VV type 2 ovarian disorders.pdf

Ovarian Disorders - Adnexa —> area between the lateral pevlic wall or the top of the uterus - Evaluate with —> TVUS/PUS; TV/US is best - Ovarian issue in menopause —> Cx until proven otherwise Functional ovarian cyst...

Ovarian Disorders - Adnexa —> area between the lateral pevlic wall or the top of the uterus - Evaluate with —> TVUS/PUS; TV/US is best - Ovarian issue in menopause —> Cx until proven otherwise Functional ovarian cyst - asym or sym that follow the menstrual cycle Categorize as high risk or low risk cancer - anechoic - low - unilocular - low - fluid filled - low - solid - high - nodular - high - thick septations - high Biomarkers for cancer suspicion - CA125 - alpha-fetoprotein - beta HCG If a cyst is large 8-10 cm, what do you do? - Sx If a cyst is recurrent, what do you do? - OCP If cysts are ruptured, - uncomplicated —> obs, pain meds, rest - stable + hemoperitoneum —> hospitalize and fluids - hemodynamically unstable and ongoing hemorrhaging —> laparoscopy and cystectomy (preserve tissue)  Follicular Corpus luteum cyst Corpus hemorrhagium Theca Lutin (must be > 3 cm) (must be > 3cm) Cause Fails to grow or rupture Fails to degenerate Fails to degenerate Pregnancy, trophoblastic disease, induced ovulation with clomiphene and gonadotrophin General characteristics Unilocular, smooth, thin slightly larger cyst with progesterone rapidly increasing cyst with bilateral pain walled release > 14 days hemorrhage complex thick walled cyst with peripheral vascularity Ovulation Does not occur Post ovulation Post ovulation Menses Amennorhea delayed days to weeks hemorrhaging Symptoms unilateral pain dull pain acute pain in luteal phase bilateral pain asymptomatic or symptomatic secondary amenorrhea potential hypovolemia if large PE Exam tender tender tender palpable mobile and cystic enlarged cystic or solid adenexal no mass adnexal mass mass hypovolemia signs or hemoperitoneum Diagnosis TVUS/PUS TVUS/PUS TVUS/PUS TVUS/PUS CT scan Treatment Repeat TVUS in 1-2 cycles Repeat TVUS in 1-2 cycles Repeat TVUS in 1-2 cycles Repeat TVUS in 1-2 cycles < 8 cm —> supportive < 8 cm —> supportive < 8 cm —> supportive < 8 cm —> supportive > 8 cm —> laparoscopy or > 8 cm —> laparoscopy or > 8 cm —> laparoscopy or laparotomy > 8 cm —> laparoscopy or laparotomy laparotomy if CA 125 elevated —>laparoscopy or laparotomy if CA 125 elevated if CA 125 elevated —>laparoscopy laparotomy if CA 125 elevated —>laparoscopy or —>laparoscopy or laparotomy or laparotomy if recurrent —> OCP or Sx laparotomy if recurrent —> OCP or Sx if recurrent —> OCP or Sx if recurrent —> OCP or Sx Ovarian Torsion - emergency where there is complete or partial rotation of the ovary on its ligaments and vascular supply Risk Factors - mobile ovarian mass > 5cm - Hx of torsion Symptoms - abrupt severe pelvic pain - radiating - diffuse or unilateral - N/V/fever - +/- palpable mass - +/- hemorrhaging (anemia and leukocytosis) Work up - Pelvic US with doppler —> heterogenous appearance and decreased blood flow - Beta hCG - CBC Diagnosis - direct visualization of torsion Tx - laparoscopy with detorsion - if cannot detorsion or concern for cancer —> salpingo-oophorectomy Prevention - OCP to supress cysts - oophoropexy PCOS - endocrine disorder - etiology unknown, but altered LH and FSH ratio - too much LH - Ovaries stimulated - releases andro-stenedione - estrogen is produced - estrogen stimulates pituitary - most common size of androgen excess and hirsutism in women Symptoms - acne - hirituism - oligiomenorrhea or amenorrhea - infertility - trunk obesity - DM2 - anxiety, depression, insomnia - characterized by - multiple cysts on ovaries - hormone imbalance - abnormal menses Physical Exam - bilateral large smooth mobile mass on exam - acanthosis nigrans Work-UP - CBC - CMP - TSH (low) - A1C - Lipid - Prolactin - LH/FSH (high) - Testosterone (high) - TVUS/PUS —> string of pearls Dx - needed to r/o causes of excess androgens - need 2 of the following - irregular menses of oligo or amenorrhea - biochemical or clincial evidence of hyperandrogenism - polycystic (12+ cysts on each ovary, sizing 2-9 mm, enlarged ovarian volume) Treatment - weight loss - OCP - statins - metformin - letrozole or clomiphene +/- metformin Goals - symptoms relief - prevent endometrial Cx - decrease DM - decrease CV - induce ovulation if wanted pregnancy Complications - increased risk of metabolic syndrome - DM - CVD - Dyslipidemia - Endometrial hyperplasia - Endometrial cancer - Pregnancy complications - abortions (20-40% higher than normal) - gestational DM - gestational HTN, Pre-eclampsia - premature delivery - C section Hyperthecosis Severe form of PCOS - hyperthecosis - where extreme levels of testosterone causes virilization - refractory to? OCPs - Do symptoms worsen in? postmenopausal years - Symptoms - balding - clit enlargement - deep voice - remodeling of limb and shoulder girdle - TX - BSO - removal of fallopian and ovaries - gnRH agonist Benign Tumors Which is more common? Benign or malignant? - benign Types of tumors? - Epithelial, Germ, Stromal Benign Epithelial Cell - serous: high rate of cancer - mucinous - endometrioid Benign Germ Cell - most common type: cystic teratoma, mature teratoma, dermoid cyst, dermoid - occurs in: reproductive years - characteristics: bone, hair, teeth, sebaceous glands - struma ovarii: functioning thyroid tissue - symptom : asymptomatic, unilateral adnexal mass, mobile, nontender - Tx: Sx and serial US Benign Stromal Cell - solid tumor from sex cord of gonad - types - sertoli-leydig —> androgen - granulosa techa —> estrogen