Menstrual Cycle & Tests of Ovulation & Polycystic Ovarian Disease PDF

# MENSTRUAL CYCLE & TESTS OF OVULATION ## Anatomy of Female Reproductive System - Body of the uterus is known as **Corpus** | Parts | Length | |---|---| | Uterus (Nulliparous) | 7 to 8 cm | | Uterus (Multiparous) | 8 to 10 cm | | Cervix | 3.5 to 4 cm | | Short cervix | <2.5 cm | | Fallopian Tube...

# MENSTRUAL CYCLE & TESTS OF OVULATION ## Anatomy of Female Reproductive System - Body of the uterus is known as **Corpus** | Parts | Length | |---|---| | Uterus (Nulliparous) | 7 to 8 cm | | Uterus (Multiparous) | 8 to 10 cm | | Cervix | 3.5 to 4 cm | | Short cervix | <2.5 cm | | Fallopian Tube | 7 to 12 cm | | Vagina (Anterior fornix) | 7 cm | | Vagina (Posterior fornix) | 9 cm | ## Important Information - After delivery, the uterus will never come back to the prepregnant (Multiparous size uterus) ## Cervix - Nulliparous women: **Circular** - Multiparous women: **Transverse** ## Fallopian Tube - **Fallopian Tube act as a clasp** It catches the oocyte from the ovary Oocyte moves in the Fallopian tube by peristaltic movements and cilia. Uterus has the microvilli • Starting of cervix: **Internal OS** • Opening of cervix: **External OS** ## Epithelium | Parts | Epithelium | |---|---| | Fallopian tube | Ciliated columnar epithelium | | Uterus | Ciliated columnar epithelium | | Early part of the cervix (Anatomical Internal OS) | Ciliated columnar epithelium | # POLYCYSTIC OVARIAN DISEASE ## Other Name - PCOD ## Initially Diagnosed - 1930 ## Diagnosed By - Doctor Stein and Levinthal ## Women - 15% ## Most Common - Endocrine disorder of women with reproductive age - Most common cause of Hirsutism ## Diagnosis - Diagnostic criteria: **Rotterdam criteria** (2003) - **Anovulation** - **Hyperandrogenism** - **USG features of PCOD** ## Sonographic Criteria for PCOS Image - It has no cyst - Enlarged ovary with a chain of small follicles - Presence of 20 or more follicles in either ovary measuring 2 to 6 mm in diameter (Less than 9 mm): **Antral size follicles** - Thick stroma - Increased ovarian volume: >10 ml - A single ovary meeting these criteria is sufficient to affix the PCOS morphology - **PCOS Phenotypes** - Most common: **Type 1** ## Table 1.1 | PCOS Cycle | Antral | |---|---| | Multiple small size follicles are present (20 per ovary): **Antral follicles** | | • Size: 2 to 6 mm | | Follicles produces the estrogen (Increased) | | Proliferation of the endometrium due to increased estrogen | | | | ## Elevation of LH - Elevation of the LH when estrogen reaches to 200 pg - Follicles stays small after 14 days: **Anovulation** - Decrease in the production of progesterone leads to further increase in the estrogen - Hence, proliferation of the endometrium will occur continuously - **Amenorrhea:** Periods delayed for three months - Endometrium outgrows the blood supply - **Ischemia** occurs in the gland - As a result shedding occurs and it leads to ischemic withdrawal - Bleeding is continued for 10 to 15 days or more ## Syndrome of PCOS - **Anovulation** is associated with the infertility - Periods after 35 days: **Oligomenorrhea** - Missing 3 regular cycles of menstruation or no periods for 6 months: **Amenorrhea** ## Hirsutism - PCOS patients will have multiple small follicles with thick stroma - Androgens are produced in the theca cells by the LH - Increased LH and thick stroma, production of the androgens is increased - As a result, patients will develop the hirsutism ## Lab parameters - LH: FSH Ratio: (>3:1) - LH surge occurs due to increased levels of Estrogen - Testosterone: Increased - Sex hormone binding globulin (SHBG): - Released from the liver in limited amount - It results in the increased free androgens - Small Follicles are produced due to insulin resistance ## Insulin Resistance - Insulin is required in every part of the body except RBC, and brain - Insulin resistance in the ovarian receptors - As the less glucose reaches the ovarian stroma, follicular size will become less - It results in small follicles - Insulin resistance is associated with obesity ## Fasting serum insulin levels - are increased - Fasting Glucose/Insulin levels: <4.5 ## Reason for Insulin Resistance - Polygenic inheritance - Familial influence - Genetic influence - Environmental factors - Overexpression of the 17 OH lase enzyme ## Importance of the Epithelium - **Isthmus of cervix:** Between Anatomical internal OS and histological internal OS - **Length:** 0.5 cm (Non pregnant) - Full term pregnant women has upper and lower segment - **Lower segment (Isthmus):** 7 cm in size - **Upper segment** will contract - **Lower segment** will retracted ## Ovary - Has set number of follicles - **Size:** 3×3.5×2.5 cm - **Volume:** 3×3.5×2.5 x 5/9 - **Less than 10 cm³ - Normal** - **more than 10 cm³ - Enlarged** - It has one dominant follicle with oocyte every month. - **It has one egg for each month** - Many small fluid filled follicles are present 6 to 7/month - **Other Name:** Antral follicles - **Primordial follicles** (100 to 1000) - 1000 follicles are recruited every month - To give 6 or 7 Antral follicles - 1000 primordial follicles - 6 to 7 Antral follicles - 1 dominant follicle - 1 Egg ## Primordial Follicles - Follicle is the master of the uterus - 6 to 7 million primordial follicles at 20 weeks of intrauterine life - 1 to 2 million primordial follicles at birth - 3 to 4 lakhs at puberty - Menstrual life: 12 to 50 years - Around 38 years - Pregnancy: 20 to 25 years - 1000 PF per month = 12000 PF per year - 12000×38=4,56,000 (Utilized in 38 years) - **Important Information** - Chances of the pregnancy is less after 35 years and above - 40 years, chances of abortion is more ## In the ovary - There is dominant follicle with oocyte in it. - Dominant follicle has **Granulosa cells** in it. - **Granulosa cells** will produce the **estrogen** - Androgens are converted to estrogen - By aromatization - Estrogen acts on the uterus and causes the proliferation of the endometrial gland - Life of the Oocyte: 24 to 48 hours ## Ovulation - Ovulation of the follicle around 14th day of menstrual cycle - Oocyte will be released into the fallopian tube - Shrinkage of the follicle forms the **corpus luteum (Yellow color body)** - Corpus luteum will produce the **progesterone** - Progesterone will make the endometrial glands secretory - Fertilization will occur in the site of the ampulla - Embryo will reach the uterine cavity on 3rd to 4th day - Implantation occurs in the 6th day after ovulation or fertilization - It can also occur from 6th to 10th day of after ovulation (20 to 24 days of menstrual cycle) ## Explanation of the Flow Chart - **Hypothal** - **Gnrh** - **Pit** - **FSH** - **LH** - **EST** - **PROG** - **PROLIF** - **SECRT** ## Mediobasal - **(Arcuate nucleus) nucleus of the hypothalamus releases GnRH** - **Pulsatile** release of GnRH once in 60 mins in follicular phase and once in 90 minutes in luteal phase - GnRH acts on the pituitary and releases the FSH and LH - **FSH** acts on the ovaries - **Theca cells** in the ovary produces the **androgens** - Androgens get into the follicles - Androgens are converted to estrogens by **Aromatase** - Estrogen stimulates the uterus and causes the proliferation of Endometrium - Estrogen also gives negative feedback to the brain to stop the release of FSH - Required amount of Estrogen: **150 to 200 pg of estradiol** - Negative feedback of FSH causes the positive feedback of the LH - **LH** acts on the corpus luteum and makes the endometrium secretary - Purposes of FSH: Produce estrogen - Purposes of LH: Produce progesterone ## Follicular Stimulating Hormone - Normal level: **2 to 6 IU** - Purpose: **Produce Estrogen** - Suggestive of menopause: **>10 IU** - Diagnostic of menopause: **>40 IU** - Premature ovarian failure: FSH >40 IU in <40 years ## Antral Follicles - Follicles: 6 to 7 - **Investigation:** Follicular monitoring by USG - **Follicular monitoring:** 9 to 10th day of menstrual cycle - **Mature follicle:** 15 to 20 mm - **Antral follicular count:** 6 to 7 follicles per ovary - Only one will become dominant follicle ## Ovarian Reserve - **Other Name:** Capacity to Conceive | Features | Young women | Older women | |---|---|---| | Ovarian Size | 3×3.5×2.5 cm | Smaller | | Serum FSH | 2 to 6 IU | >10 IU | - **Around 38 years** - **Pregnancy:** 20 to 25 years - 1000 PF per month = 12000 PF per year - 12000×38=4,56,000 (Utilized in 38 years) - **Important Information** - **Chances of the pregnancy is less after 35 years and above** - **40 years, chances of abortion is more** ## Serum estradiol - 150 to 200 pg - <150 to 200 pg ## Antral follicular count - 6 to 7 follicles per ovary - ≤ 3 per ovary ## Anti mullerian hormone - (Granulosa) - 2 to 6 ng per ml - ≤1 ng per ml - **Poor ovarian reserve:** If a younger women has values of an older women - **Faster treatment:** IVF ## Important factors - **Serum FSH** - **Antral follicular count** - Anti mullerian hormone (Single best parameter) ## Menstrual Cycle Chart - **LH** - **FSH** Follicular Phase - **EST** - 15-20 mm - 150-200 Pg - **Luteal Phase** ## Isthmus of cervix - Between Anatomical internal OS and histological internal OS - Length: 0.5 cm (Non pregnant) - Full term pregnant women has upper and lower segment - Lower segment (Isthmus): 7 cm in size - Upper segment will contract - Lower segment will retracted ## Ovary - Has set number of follicles - Size: 3×3.5×2.5 cm - Volume: 3×3.5×2.5 x 5/9 - Less than 10 cm³ - Normal - more than 10 cm³ - Enlarged - It has one dominant follicle with oocyte every month. - It has one egg for each month - Many small fluid filled follicles are present 6 to 7/month - Other Name: Antral follicles - Primordial follicles (100 to 1000) - 1000 follicles are recruited every month - To give 6 or 7 Antral follicles - 1000 primordial follicles - 6 to 7 Antral follicles - 1 dominant follicle - 1 Egg ## Primordial Follicles - Follicle is the master of the uterus - 6 to 7 million primordial follicles at 20 weeks of intrauterine life - 1 to 2 million primordial follicles at birth - 3 to 4 lakhs at puberty - Menstrual life: 12 to 50 years - Around 38 years - Pregnancy: 20 to 25 years - 1000 PF per month = 12000 PF per year - 12000×38=4,56,000 (Utilized in 38 years) - **Important Information** - **Chances of the pregnancy is less after 35 years and above** - **40 years, chances of abortion is more** ## Other Name: Luteal Phase - **Corpus luteum** also secrete some amount of **Estrogen** ## Important Information - Secretion and stabilization of the endometrial glands are brought about by the corpus luteum ## Menstrual cycle: - of sexually active women - Implantation of the embryo will occurs in the 6th day after ovulation or fertilization - Embryo is implanted on the secretory endometrium - Corpus luteum will work only for 10 days - Early cells of the placenta: **Syncytiotrophoblasts** will produce the **hCG** - Human chorionic gonadotropin will rescue the corpus luteum from degeneration - It helps to maintain the pregnancy - Alpha unit of TSH = Alpha unit of LH = Alpha unit of hCG - Corpus luteum maintains the pregnancy for 12 weeks - Around the 6th week placenta will form - It starts to make progesterone and reduces the production of hCG. - It will maintain the pregnancy - Degeneration of the corpus luteum will occur after 6th week - **Luteoplacental shift:** 6th week - hCG will be increased till the 66th day of the pregnancy (9 weeks and 3 days) - Placenta will maintain the pregnancy till the delivery - hCG causes **hyperemesis gravidarum**. ## Tests of Ovulation - Effects of progesterone is seen - Basal body temperature raises upto 0.5 °F from baseline - Serum progesterone: >3ng per ml on day 21 of menstrual cycle - Serum or urinary LH: >15 IU - **Follicular monitoring by USG** - Usual method in OPD - Initial days, 6 to 7 Antral Follicles - 9th day the dominant follicle will become dominant - Around 14th day, one follicle will be around 15 to 20 mm in size - Transvaginal sonography is performed from 9th day - Follicular growth is assessed for every alternative days - Shrinkage of the follicle is the indication for ovulation ## Endometrial Biopsy - Effects of progesterone is seen - **Histopathology examination:** - Secretary changes - Appropriateness of the secretary changes - Mainly premenstrual endometrial biopsy is recommended - Effects of the ovulation are adequate on the endometrium - Luteal Phase defect: Lag of ≥2 days in observed and expected changes - Known cause of infertility ## Mittelschmerz - Mid cycle pain due to the ovulation - Sharp pain in the abdomen - It is unreliable test ## Laparoscopy - Best and direct evidence of ovulation ## Cervical mucus studies - Spinbarkiet and fern tree pattern is seen on 14th day - Seen due to high estrogen - Loss of spinbarkiet & fern tree pattern suggest ovulation # CARCINOMA CERVIX & CARCINOMA ENDOMETRIUM ## Screening of CA Cervix - In screening of cervix, Pap Smear-47 to 62% sensitive - Reduces mortality by Ca cervix by 70% - Most cost effective method of Ca cervix screening is Visual inspection under acetic acid (VIA) - Pap smear can be done from the transformation zone - First site where Ca Cervix starts - Located 1.7-2.3cms from external OS - Ayre's spatula, cyto brush or cyto broom can be used to take the sample - Spatula or the broom can only be turned 360° once in the cervix - Repeatedly turning leads to bleeding and obscure the cell's anatomy - Smear cells on slide and fix immediately - Fix in 95% alcohol - No drying - Store in coplin's jar - Stain with Papanicolaou stain - Liquid based cytology: Best method - Prevents sample loss - Take the sample - Wash it in the media - Media is poured into test tube - Test Tube is centrifuged - Puts the cells in sediment - Sediment has cells to be spread on the slides ## Interpretation - Asymptomatic woman - Cells are taken on the slide(polygonal cells) - Cytoplasm is clear - Smear is taken from the epithelium of the cervix - Healthy cervix, cytoplasm is clear - But in some woman, nucleus is very big - New cells on the epithelium of cervix ## They can't be seen naturally - Neoplasia in the cervical epithelium - known as, **Intra epithelial neoplasia** ## Dysplasia Classification | Dysplasia | Classification | |---|---| | <1/3rd are abnormal | CIN-1 | | >1/3rd to 2/3rd are abnormal | CIN-2 | | >2/3rd cells are abnormal | CIN-3 | | All cells are abnormal | Cis | - Cancer is present just on the epithelium - In Bethesda classification, CIN-1 is low grade squamous Intra epithelial lesion - CIN-2,3 are high grade squamous Intra epithelial lesions. ## Significance of CIN-1 - CIN-1 turns to CIN-3 in just 5 years - More vigilant - Frequent Pap smear is done - Assess HPV DNA - CIN-3 turns to Ca cervix in 10 years - Before the treatment, confirm it is only CIN-3 or invasive - If CIN-3,>60% will spontaneously regress ## For example - Smear shows >2/3rd of abnormal cells on the surface of cervix - Cells invading into the stroma - Invasive cancer of cervix - Invasive Ca cervix must be ruled out - Biopsy must be done to know the presence of invasion - For the normal cervix, biopsy can be done by colposcopy - Magnify the Vision 15-40 times - Only under the abnormal areas, invasion will be present - Done under bright illumination - Use highlighters like acetic acid or Lugol's/Schiller iodine - Acetic acid biopsies in acetowhite areas - Gives brown colour in normal cervix and remains colourless in the rapidly dividing area - lodine stains glycogen rich cells brown - Rapidly dividing areas eats up the glycogen - Colposcopy will also be held by a green filter - Shows vascular patterns of cervix - In the absence of colposcope, acetic acid must be visualised by eyes in the cervix - Known as Visual inspection under acetic acid or lugol's iodine - After the completion of biopsy, we can observe - Cells invading the stroma - Invasive Ca cervix - Radical hysterectomy is the treatment - In case of biopsy proven CIN-3, - Treatment is Loop electro surgical excision procedure (LEEP) - Best procedure - Previously, it is called as LLETZ - Now this word is not in use - Transformation area can be scribb off - Laser conization can also be done - Expensive and difficult to master - Conization can be done in women >35-40 years - Causes short cervix - Further leads to abortions, stenosis and infertility - Hysterectomy for >40 yrs of women - CIN-3/HSIL - Colposcopic biopsy ## Symptoms of Ca cervix - Most common is post coital or post menopausal bleeding - Pyometra causing dirty foul smelling discharge - Uremia: Most common cause of death - Cancer cachexia - Weight loss - Loss of appetite - Inability to thrive ## Types of Ca cervix - Invasive Ca cervix: Most commonly squamous cell carcinoma: Keratinizing type - 2nd most common, Squamous cell carcinoma: Non keratinizing type - Small cell carcinoma ## Genital Malignancies - Most common is Ca cervix - Most common tumour is fibroid - Most common malignancy is Ca breast - Second most common malignancy is Ca cervix ## Ca Cervix - 99% is due to **HPV**. - Starts in the transformation zone - Enters to transformation zone by sex - Early sex - Sex with multiple partners - Sex with people having STDS - Low socio economic status - Smoking - Also in women with monogamous relation rarely. - **HPV has E6, E7 viral proteins** - Inhibits tumour suppressor genes - E6 inhibits p53 - E7 inhibits Rb - Shows unchecked proliferation of cells - Causes cancer - **Vaccine:** Gardasil 9 nonavalent vaccine - Active against 6,11,16,18,31,33,45,52,58 serotypes - Over 50 serotypes causes Ca cervix - 15 are high risk varieties - All women and men from 9-45 years are given in 0 day, 2nd month, 6th month after the 0 day - Inhibits the occurrence of Ca cervix - Prevention is 90% if given before the exposure - 40%, if given after the exposure - Screening continues ## SAGE guidelines - One or two vaccine must be given to all girls between 9-14 years to prevent Ca cervix - SAGE: Strategic advisory group of experts on immunisation - WHO group - Screening prevents Ca cervix by 70% - Must be done in sexually active women - In our country, screening starts after 3 years of sexual activity starts. - HPV takes 3 years to exhibit - Asymptomatic women at risk - >3 years of sexual activity - Done once in three years till 30 years - Once in 5 years >30 years, if Co test is negative, (HPV DNA or Pap smear) - After the Pap smear, some fluid is taken into the slide and some is sent for DNA assessment - If both the pap smear and DNA assessment fluid are negative - Two things together - Pap smear can be done after 5 years - Only Pap smear- do after 3 years - After 65 years, no more Pap smear ## Management of Postcoital Bleeding - In a 35 yr women with 2 children, experiences bleeding after every intercourse - Rule out vulval, vaginal, gross and cervical lesions - If there is no gross lesions and Complains about post coital bleeding - Considered as symptomatic - Diagnostic test is done - Colposcopic biopsy must be done ## Staging of Ca cervix - Done clinically - Per vaginal examination - Per rectal examination for parametrium - Cystoscopy for the bladder - Proctosigmoidoscopy for the rectal and lower gut involvement - Imaging-PET CT, MRI, Ultrasound | Stage | Description | |---|---| | Stage-1 | Limited to cervix | | Stage-1A | Microscopic cancer | | Stage 1A1 | Invasion <3mm | | Stage 1A2 | Invasion 3-5mm | | Stage 1B1 | >5mm & <2cm Seen with naked eye Clinically obvious cancer | | Stage 1B2 | 2-4 cms | | Stage 1B3 | >4cms Limited to cervix | | Stage 2A | Upper vagina involved | | Stage 2B | Parametrium involved, short of pelvic wall | | Stage 3A | Lower ½ vagina | | Stage 3B | Parametrium till pelvic side wall Hydronephrosis of kidney No cancer free area between the cervix and pelvic side wall Most common stage of presentation | | Stage 3C | C1 pelvic lymph node, C2 para aortic lymph node Imaging is required | | Stage 4A | Bladder and bowel | | Stage 4B | Distant metastasis | ## Inguinal lymph nodes - are not involved in Ca cervix - External iliac group of lymph nodes > obturator LN are involved - From stage 1-2A1, radical hysterectomy is the adequate one - From Stage 2A2-ChemoRadiation - Surgery is not adequate ## High oestrogen - causes hyperplasia - **Hyperplasia** - Simple endometrial hyperplasia without atypia - Causes Ca endometrium in 1% cases - Complex endometrial hyperplasia without atypia - Causes Ca endometrium in 3% cases - Simple endometrial hyperplasia with atypia - Causes Ca endometrium in 8% causes - Complex endometrial hyperplasia with atypia - Causes Ca endometrium in 29% cases - In 1% & 3% cases progesterone therapy is given - In 8% & 29% cases hysterectomy must be done ## Symptoms of Ca Endometrium - Irregular acyclical bleeding with DM, HTN and obesity - Most common - Also known as menometrorrhagia - Ca endometrium - Cyclical bleeding beyond menopausal type - Post menopausal bleeding - Pyometra - Endometrium with cancer lining can make secretions and collected inside the uterus, leads to pus discharge - Causes dirty foul smelling vaginal discharge - Loss of weight, loss of appetite, Ca cachexia and cancer pain are not seen in Ca endometrium - Cancer pain is the late presentation - In Ca endometrium, most common type is adenocarcinoma - Endometrioid variety is the most common - Serous and clear cell <10% - Worst prognosis - More deaths - **Type-1(45-55yrs):** Unopposed **estrogens**-80% - **HRT** - Early menarche, late menopause - Tamoxifen therapy: suppress Ca breasts - Keep an eye on endometrial proliferation - Oestrogen producing tumours - Granulosa cell tumours of the ovary - Anovulatory condition - PCOS - Fat converts androgen to oestrogen by aromatase enzyme - **Corpus cancer syndrome** - Uterine body's cancer - In DM, HTN and obesity ## Abnormal LFT - Estrogens are metabolised in the liver - **LYNCH-2** - Association with hereditary nonpolyposis colon cancer syndrome - Familial predisposition - Ca Breast or Ca endometrium or Ca ovary, 1st degree female relatives can have either of this. - **Nulliparity** - No break from oestrogen action - Women with no longer menstruation has more chances of hyperplasia - **Type 2:** seen in older, thinner women - Not associated with estrogens ## Ca Endometrium - Staging is done surgical - Hysterectomy is done along with taking samples of pelvic and parotid lymph nodes | Stage | Description | |---|---| | Stage 1 | Limited to uterus | | Stage 1A | Glandular involvement | | Stage 1B | Endometrium and <½ myometrium | | Stage 1B | Myometrium ≥1/2 | | Stage 2 | Cervical stromal involvement | | Stage 3A | Uterine serosa and adnexa | | Stage 3B | Vaginal &/or parametrial involvement | | Stage 3C | C1 pelvic lymph node involvement C2 para aortic lymph node involvement | | Stage 4A | Bladder and bowel involvement | | Stage 4B | Distant metastasis including inguinal lymph nodes | ## Grading of Tumours - Shows no. Of cancer cells per slide - Cancer cells are many and clumped together - Gives solid pattern in the slide - Solid areas on the slide <5%: **Grade 1** - 5-50%: **Grade 2** - >50%: **Grade 3** ## Management - Rule out the local lesions - After the physical examinations, and observe all the local lesions - If there are no local lesions, 1st step is office endometrial biopsy using a pipelle - Easy procedure - 90% sensitive - **Fractional curettage(D&C)** - Assess all the fractions of uterus - 95-99% sensitive - Hysteroscopy biopsy - 100% sensitive - Best method - TVS: good adjunctive procedure - In postmenopausal women, endometrium≤4mm | Stage | Description | |---|---| | Stage 1 | No myometrium, grade1 Has no treatment Myometrium involved <½ with grade 1-2 Vaginal irradiation is done Myometrium involved >½ with grade3 Pelvicirradiation | | Stage 2 | Whole abdominal radiation | | Stage 3&4 | Individualized therapy Chemotherapy or radiotherapy or surgical therapy or hormonal therapy | - **Common site of the recurrence vault of the vagina** - 1st line treatment of recurrence is progesterone therapy # OVARIAN TUMOURS ## Age - 6-7th decade ## Etiology - Scars on ovarian surface - Early menarche, late menopause - Infertility treatment by ovulation induction - Nulliparity: no break from ovulation - Mutations in BRCA1, BRCA2 - Familial predisposition - Breast, endometrium, ovarian cancers ## Causes surface epithelial ovarian tumour - Most common ovarian tumour - Associated with high CA125 in ovarian tumours - Not specific - As a follow up tool, it is a good method but not as a specific diagnostic tool - Premenopausal women ≥ 200IU - Post menopausal women ≥ 35 IU ## Symptoms - Mainly due to large size - Rapid growth: likely malignant - In humanity, Biggest tumour ever removed is 136-137 kgs - Large tumours can cause bloating, distension and compression, compaction of organs and also bowel & bladder symptoms ## Diagnosis - Best imaging: MRI - Ultrasound is the 1st imaging and is usually adequate - Features s/o malignancy - Bilateral tumours - Surface irregularities - Cystic & solid areas (variegated) - Septate ≥3mm - Ascites - **Risk of Malignancy Index** | Criteria | Scoring system | |---|---| | Menopausal status (A) | | Premenopausal | 1 | | Postmenopausal | 3 | | Ultrasound features (B) | | Multiloculated | No feature = 0 | | Solid areas | One feature = 1 | | Bilateral | > 1 feature = 3 | | Ascites | | Metastases | | Serum CA 125 (C) | Absolute Level | ## Risk of Malignancy index (RMI) - =AxBxC - RMI <25-low risk - RMI 25-250-mod risk - RMI > 250-high risk ## Management - Staging laparotomy along with optimal debulking is done - Maximal cyto reduction - **Staging laparotomy and Maximal Cytoreduction (Optimal debulking)** - Vertical abdominal incision - If required, can extend it upwards - Remove the ovarian tumour intact - Left tumour must be <1cm in size - Ascites/washings sent for cytology - Cells from the ovary are coming to the abdominal surface - Clockwise exploration of the abdominal viscera - See the growth - Peritoneal biopsies - Sample the diaphragm - By scraping with the spatula - Supra colic omentectomy - To determine the growth or the staging - Abdominal scavenger or police man - First organ likely to be involved in metastasis - RPLN sampling ## Staging | Stage | Description | |---|---| | Stage 1A | Limited to the ovaries One ovary | | Stage 1B | Both ovaries | | Stage 1C | Stage 1A or 1B with C1: surgical spill C2: surface growth C3: malignant ascites or washings | | Stage 2A | Uterus and fallopian tubes | | Stage 2B | Other pelvic organs like bladder, rectum and other lymph nodes | | Stage 3 | Abdominal viscera involved | | Stage 3A1 | Retroperitoneal LN:A1(1)-<10mm A1(2)-≥ 10 mm | | Stage 3A2 | Microscopic abdominal involvement | | Stage 3B | Macroscopic involvement <2cm | | Stage 3C | Macroscopic involvement ≥ 2cm Superficial liver and spleen deposits | | Stage 4A | Malignant pleural effusion | | Stage 4B | Deep liver and spleen deposits Inguinal LN involved | - **Endometrioid neoplasia** includes all the benign demonstrations of endometriosis - **Not a common malignancy** ## Borderline Ovarian Tumours - **Low malignant potential tumours** - The criteria for the diagnosis of serous borderline tumours are as follows: - Epithelial hyperplasia - Mild nuclear atypia and mild increased mitotic activity - Detached cell clusters - Absence of destructive stromal invasion - Surgery alone is adequate management ## Germ cell tumours - Unilateral and in young women: 20% of all ovarian neoplasm - Teratoma: most common germ cell tumours - 10% malignant - 90% are benign called дерmoid or benign cystic teratoma - Derivatives of endoderm, mesoderm & ectoderm - Eg: bone, teeth, cartilage, sebaceous, endocrine glands & hair - Rokitansky protuberance-hair grows - On X-ray, radiopaque area looks like node - 10-15% can be bilateral - **Most common ovarian tumour of pregnancy and of torsion.** - **Yolk sac tumours** - Also known as endodermal sinus tumours - Characteristic is the endodermal sinus, called the Schiller duval body - Young women and girls, poor prognosis - Increases AFP, specific though is alpha 1 antitrypsin - **Embryonal tumours** - Young women and girls, poor prognosis - Increases AFP and specifically hCG. ## Dysgerminoma - Most common germ cell malignancy: 40-45% - Only B/L germ cell malignancy in 10-15% cases - Large fleshy tumour - Frequently associated with hypercalcemia - 5% associated with dysgenic gonads - Turner syndrome - **Seminoma type cells** - Large polygonal cells with clear cytoplasm and dark nucleoli and back to back arrangements - Increases LDH, placental alkaline phosphatase and even HCG, but not AFP. - Alpha feto protein ## Sex Cord Ovarian Tumours - **Granulosa cell tumours** -