Ovarian Pathology Flashcards by Amy Fielding

Define Infertility

Inability of a couple to conceive after one year of regular unprotected sex

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What percentage of couples conceive within their first year of trying?

84%

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Name four risk factors for infertility

Increased Age
Extremes of weight
PCOS
Smoking

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Describe some female causes for infertility

Tubal - PID, Endometriosis

Obstruction - Polyps, Fibroids, Adhesions

Reduced ovulation - PCOS, Pathological menopause, Thyroid pathology

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Describe two male causes for infertility

Sterilisation

Reduced sperm count

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State the normal parameters for sperm analysis

Ejaculation Volume : >1.5ml

pH >7.2

Sperm count per ejaculation: Around 39 million

Motility >40%

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What initial investigations would be done to test infertility?

After an initial history and examining risk factors

Mid cycle Progesterone for female (21 day)

Sperm analysis

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If there is an abnormality in the sperm analysis, when should it be re reviewed?

3 months

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How can you test Tubal Patency?

Hysterosalpingogram

Day 5-12

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How can you test for follicular presence in infertility?

Transpelvic USS on day 2/3

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How could you estimate the response to IVF therapy using investigations?

Anti MH - High

FSH - low

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How could you treat infertility if the cause was An/Oligovilation?

Clomiphene Citrate or Letrozole

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How can you treat Infertility if the issue is structural?

Mild - surgical correction

Severe - IVF

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How can you treat infertility if the problem is the Male?

Mild - Intrauterine Insemination

Severe - IVF or Sperm Donor

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Describe the 5 step process of IVF

1) GnRH subcut for 5-10d to increase FSH
2) Once three follicles seen on USS, bHCG given and 36h later they’re harvested
3) Artificial Insemination
4) 3 days later at 6-8 cell stage, analysed
5) Implanted (may use Laproscopic drilling to enhance implantation)

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Define PCOS

Polycystic Ovarian Syndrome

Common Endocrine disorder characterised by excess androgen and immature follicles in ovaries

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Describe the pathophysiology of PCOS

Excess LH

Insulin Resistance (results in more insulin being produced, reducing SHBG therefore there are higher free circulating androgens - supress LH surge)

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Give two risk factors for PCOS

Family History

Pre - existing diabetes

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State 5 clinical features of PCOS

Oligo/Amenorrhoea
Infertility
Hirsutism
Obesity
Acne

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Describe the Rotterdam criteria for PCOS

1) Oligo/Anovulation
2) Clinical/Biochemical signs of Hyperandrogenism
3) Atleast 12 follicles on ovaries upon imaging

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How is Anovulation managed in PCOS?

Aim to induce at least 3 bleeds a year

COCP

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How is Hirsutism managed in PCOS?

Cyproterone Acetate

Spironolactone

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How is Obesity managed in PCOS?

Study These Flashcards

Weight loss encouraged, Atleast to BMI <30

Last resort - Orlistat

Name three features on examination of PCOS

Study These Flashcards

Hirsutism
Acne
Acanthosis Nigricans

How is Infertility in PCOS managed?

1) Letrozole 2) Clomiphene Citrate +/- Metformin

Describe the biochemical imbalance in PCOS

Raised : LH (at least 3:1 to FSH), Testosterone Low: Progesterone, SHBG

Ovarian cysts are derived from surface irritation (ie multiple ovulation). Give two risk factors and two protective

RF: Nulliparous, Late Menopause Protective: COCP, Breast Feeding

What is the Risk of Malignancy Index?

U x M x Ca125 ``` U = USS features M = Menopause status ``` If >250 then malignancy is very likely

Describe the USS features scoring in RMI for Ovarian Cancer

Bilateral Solid areas Metastases Ascites

How do Ovarian Tumours present?

Chronic Pain (may be cyclical, or dyspareunia) Compression (Increased Urinary Frequency and Constipation) Non specific weight loss, fatigue and change in bowel habits

What does Acute Pain in Ovarian Pathology suggest?

Ovarian Torsion Cyst Rupture Bleeding into cyst

State the three broad categories of Ovarian Cysts

Physiological Benign Germ Cell Benign Epithelial

Describe the two types of physiological Ovarian Cyst

Follicular - when dominant follicle fails to atrophy, <3cm, seen in first half of menstrual cycle Luteal - when corpus luteum fails to regress day becomes filled with fluid, <5cm, seen in second half of cycle

Name two benign germ cell cysts

Mature Cystic Teratomas (most common in under 30s, normally asymptomatic) Monodermal (normally thyroid)

Name three benign epithelial cysts

Serous Cystadenoma (mimics the most common malignant type) Mucinous (rare, can cause pseudomyxoma peritonei if ruptured) Brenner Tumour

Name the four main types of Malignant Ovarian Tumours

Surface (ie Epithelial) Germ Cell Sex Cord Metastatic

Name three subtypes of Epithelial Malignant Ovarian Tumours

Serous Cystadenocarcinoma (Psammoma Bodies) Mucinous Adenocarcinoma (Mucin secreting) Endometrioid (appears like endometrial tissue)

Name three subtypes of Germ Cell Malignant Ovarian Tumours

Immature Teratoma Dysgerminoma (associated with Turner Syndrome, secretes LDH and hCG) Choricarcinoma (form of GTD, secretes hCG, metastasises to lung early)

Name three subtypes of Sex Cord Ovarian Tumours

Granulosa (secretes oestrogen so can cause precocious puberty or hyperplasia in adults) Sertoli and Leydig (secrete androgens, benign) Fibroma (a cause of Meig’s - Pleural Effusion, Ascites)

How are Ovarian Cysts/Tumours managed in premenopausal women?

Risk stratification hCG/LDH/AFP Rescan in 6 weeks If still present - laparoscopic cystectomy

How are Ovarian Cysts/Tumours with an RMI<25 managed?

Follow up for 1 year with USS and Ca125

How are Ovarian Cysts/Tumours with an RMI 25-250 managed?

Bilateral oophorectomy

How are Ovarian Cysts/Tumours with an RMI >250 managed?

Bilateral Oophorectomy Staging If malignant - platinum chemo and 5y follow up

What is OHSS

Ovarian Hyperstimulation Syndrome A complication of ovulation induction/superovulation (more common with hCG/GnRH therapies than Clomiphene)

Describe the pathophysiology of OHSS

Ovarian Enlargement Fluid shifts from Intra vascular to extra vascular (secondary to rise in oestrogen/progesterone/VEGF) Causes pleural effusions/ascites and raked haematocrit/hypercoagulability

Name three risk factors for OHSS

Young Low BMI Previous OHSS

OHSS can be classified into mild, moderate, severe and critical. How does Mild present?

Abdominal Pain and Bloating

OHSS can be classified into mild, moderate, severe and critical. How does Moderate present?

Nausea and vomiting | Ultrasound evidence of ascites

OHSS can be classified into mild, moderate, severe and critical. How does Severe present?

Clinical ascites Oliguria Raised Haematocrit

OHSS can be classified into mild, moderate, severe and critical. How does Critical present?

ARDS | VTE

How is OHSS managed?

VTE prohylaxis | Symptomatic relief

Define Ovarian Torsion

Twisting of ovary and Fallopian tubes on its vascular and ligamentous supports, blocking adequate blood flow

Give three risk factors for Ovarian Torsion

Ovarian Mass OHSS Pregnancy

How would Ovarian Torsion present?

Abdominal Pain Nausea and Vomiting Peritoneal Signs

Name four investigations for Ovarian torsion

FBC Pregnancy Test Abdominal USS (whirlpool sign) Transvaginal USS

How is Ovarian Torsion managed?

Laparoscopy is diagnostic and therapeutic

Describe the management for infertility in PCOS

1) Clomiphene 2) Clomiphene and Metformin Clomiphene should be given on day 2-6 of cycle, for maximum 6 months If obese then metformin alone

Ovarian Pathology Flashcards

(57 cards)