Diseases of ovary / OBS and GYN

Anatomy of the Ovaries
Blood Supply of Ovaries
Ovarian Ligaments
Microscopic Anatomy
Oogenesis
Ovarian Cyst
Ovarian mass
Functional cysts
Simple ovarian cyst
Risk of Malignancy Index or RMI.
Tubo-ovarian abscess
Ovarian Endometrioma:
Benign tumor
malignant tumors

1. Diseases of The Ovary Diaa Mohammad Srahin 6 th year Medical Student Al-Quds University Obstetrics & Gynecology December/ 2018

2. Anatomy of the Ovaries The ovaries are oval, flattened, compressible organs , approximately 3 × 2 × 2 cm in size . Blood supply of ovaries : Ovarian artery (directly from aorta) Branches of uterine artery ( from internal iliac ) Ovarian vein Right : drains directly into inferior vena cava Left: drains into left renal vein Lymphatic drainage of the ovaries is through the pelvic and para -aortic lymph nodes .

3. Blood Supply of Ovaries

4. Ovarian Ligaments Several paired ligaments support the ovaries: The ovarian ligament connects the uterus and ovary. The posterior portion of the broad ligament forms the mesovarium The suspensory ligament of the ovary ( infundibular pelvic ligament) attaches the ovary to the pelvic sidewall and contains the ovarian artery and vein, as well as nerve supply to the ovary.

5. Ovarian Ligaments

6. The Cortex is where the follicles and oocytes at various stages of development and degeneration. The cortex is made of tightly packed connective tissue. The stroma of this cortical connective tissue is composed of fibroblasts. The Medulla is where the ovarian vasculature is found and is primarily loose stromal tissue. Microscopic Anatomy

7. Oogenesis 1 ° oocytes begin meiosis I during fetal life and complete meiosis I just prior to ovulation . Meiosis I is arrested in pr O phase I for years until O vulation (1° oocytes ). Meiosis II is arrested in met aphase II until fertilization ( 2° oocytes). “An egg met a sperm .” If fertilization does not occur within 1 day, the 2° oocyte degenerates.

8. Ovarian Cyst Ovarian cysts are common, with a reported clinical prevalence of 15% in premenopausal and 8% in postmenopausal women . Most of these cysts resolve over time without treatment . The causes of benign ovarian tumor will vary with age.

9. Ovarian mass

10. Functional cysts It is t he most common cause of a simple cystic mass in the reproductive age years. During the reproductive years the ovaries are functionally active, producing a dominant follicle in the first half of the cycle and a corpus luteum after ovulation in the second half of the menstrual cycle . Either of these structures, the follicle or the corpus luteum , can become fluid-filled and enlarged , producing a functional cyst.

11. Cont. COCPs reduce its risk . Diagnosis is made when the cyst measures more than 3 cm , simple unilocular in U/S.

12. Functional cysts

13. F ollicular cyst : develops when an ovarian follicle fails to rupture. C orpus luteal cyst: develop if the corpus luteum grows to over 3 cm and fails to regress normally after 14 days. Hemorrhagic cyst : form when invasion of ovarian vessels into the corpus luteal cyst 2 to 3 days after ovulation causes bleeding within the cyst.

14. Simple ovarian cyst

15. Theca Lutein Cysts : These are benign neoplasms stimulated by high levels of FSH and β- hCG . They are associated with twins and molar pregnancies and choriocarcinoma . Patients undergoing ovulation induction with gonadotropins , clomiphene, or letrozole may also develop theca-lutein cysts. The natural course of these tumors is postpartum spontaneous regression. Require only conservative management .

16. Luteoma of Pregnancy : Luteoma of pregnancy is a rare, non-neoplastic tumor-like mass of the ovary that emerges during pregnancy and regresses spontaneously after delivery. It is usually asymptomatic and is found incidentally during a cesarean section or postpartum tubal ligation . It can be hormonally active and produce androgens resulting in maternal and fetal hirsutism and virilization .

17. Polycystic ovarian syndrome : A functional disorder generally associated with chronic anovulation, hyperandrogenism , and insulin resistance, can also produce enlarged ovaries with multiple simple follicles.

18. Clinical features : U sually asymptomatic The patient may present with delayed menses abnormal uterine bleeding pelvic pain Occasionally , a functional cyst may undergo torsion (see below) or it may rupture, which may produce acute lower abdominal pain and tenderness and the differential diagnosis must include ectopic pregnancy, pelvic abscess , or adnexal torsion of an ovarian neoplasm .

19. Diagnosis: First, do B- hCG to rule out pregnancy . Bimanual examination : 5- to 8-cm cystic adnexal mass Transvaginal ultrasonography confirmed when the lesion regresses over the course of the next several cycles. In general, a functional cyst is mobile, unilateral, and not associated with ascites. To be classified a “functional cyst,” the follicle must reach a diameter of at least 3 cm .

20. Treatment: Observation: Follow-up examination should be in 6–8 weeks Alerted to the possibility of acute onset of pain OCPs can be used to prevent recurrence Laparoscopy: cyst is >7 cm Or if patient had been on prior steroid contraception for at least >= 2 months Torsion of adnexal cyst

21. Risk of Malignancy Index or RMI . A pelvic ultrasound will confirm the cystic nature of the mass, But it cannot differentiate with certainty between a functional and a neoplastic tumor .

22. RMI

23. Management: If the RMI is low < 200; wait and reexamine the patient after her next menses Low-dose contraceptive agents If the RMI is high ;surgical exploration and/or referral to a gynecologic oncologist is indicated.

24. T ubo -ovarian abscess Accumulation of pus forming an inflammatory mass of ovaries and other sites . Associated with PID . It can d eveloped from other infective causes, e.g : appendicitis or diverticular disease. Symptoms: sever lower abdominal-pelvic pain, back pain, pain with bowel movements. PE : sick, fever, tachycardia, septic shock with hypotension, peritoneal signs . + ve cervical culture, blood culture, WBC, ESR US or CT – complex mass

25. Management: Tx : Inpatient IV ATB (Clindamycin, Gentamycin) and surgical drainage. Can need TAH and BSO Definitive surgery is usually deferred : I ncreased risk of systemic infection and difficulty with inflamed and infected tissue.

26. Ovarian Endometrioma : Bening condition, ectopic endometrial tissue within the ovary. Ovary is the most common site. C hocolate cysts : the presence of altered blood within the ovary. Cause : Retrograde menstruation , coelomic metaplasia , autoimmune , lymphovascular , direct implantation. They can reach 10 cm in size H ave a characteristic ‘ ground glass ’ appearance on US. Dx: Laparoscopy

27. Management : If not surgically excised, follow-up should be at least yearly. Pregnancy, Pseudopregnancy : OCPs, or Oral MPA Pseudomenopause : Testosterone derivatives( Danocrine, danazol) GnRH analog (Leuprolide, lupron) Down regulation of Pituitary. Cx: menopausal Symptoms after 3-6 mth We can use DMPA(depoprovera): doesnt make vasomotor symptoms

28. Germ Cell Tumor : Most common ovarian tumor in young women O ccur at any age (early 20s) These are slow-growing tumors and half the tumors are diagnosed in women between 25 and 50 years of age. Most common form is mature dermoid cyst

29. Dermoid Cyst : “Cystic teratoma ” M ost common benign ovarian neoplasm in the premenopausal woman C an take on a great variety of forms with virtually all adult tissues, composed primarily of ectodermal tissue (such as sweat and sebaceous glands, hair follicles, and teeth), with some mesodermal and rarely endodermal elements. 10- 15 % teratomas are bilateral . Thyroid tissue can also be identified, and if it comprises more than 50% of the dermoid , then the condition of struma ovarii is identified

30. Diagnosis: Most commonly its an incidental finding 15% present acutely with torsion MRI is the most helpful due to high fat content .

31. Ovarian tortion : O varian cyst that has grown in size to the point at which it turns over on itself, twisting the suspensory ligament of the ovary and cutting off blood supply. I ntense, severe, sudden-onset pain in the R L Q or LLQ US - decreased or absent Doppler flow to the ovary E mergen t surgery to reverse the torsion, hopefully in time to avoid necrosis of the tissue. Untwist

32. Cystectomy . If revitalization occurs, an ovarian cystectomy can be performed with preservation of the ovary . • Oophorectomy . If the ovary is necrotic, a unilateral salpingo -oophorectomy is performed . F/o after 4 Wks  routine examination , then yearly

33. Management of dermoid cyst: D epend on the type of neoplasm , the patient’s age , and her desire for future childbearing Premenopausal: A n ovarian cystectomy with preservation of the ovary Postmenopausal : at least unilateral salpingooophorectomy The contralateral ovary should be carefully inspected to exclude a bilateral lesion

34. Epithelial Ovarian Neoplasms Derived from the mesothelial cells lining the surface of the ovary Occur more commonly in older age. Include: 1- S erous cystadenoma : the lining of the fallopian tubes. 2- M ucinous cystadenoma : cytological resembles the endocervical epithelium 3- E ndometrioid neoplasm : resembles the endometrium 4- B renner tumor : resemble transitional cells of the bladder The most common is serous cystadenoma .

35. Serous tumors: R esemble the lining of the fallopian tubes B ilateral in about 10% of cases , usually unilocular It can be : Benign about 70% . Malignant 20-25% Borderline malignant potential 5-10 % . D epending largely on the patient’s age. S erous tumors characteristically form psammoma bodies

36. Mucinous tumors C cytological resembles the endocervical epithelium. Bilateral in 10% of cases , Multiloculated O ften associated with a mucocele of the appendix. Can result in pseudomyxoma peritonei - intraperitoneal accumulation of mucinous material . 85%are benign.

37. Gross appearance of a mucinous (A) and serous (B) cystadenoma of the ovary. The mucinous type is generally multiloculated and can be quite large

38. Brenner tumor: Uncommon. Small, smooth solid ovarian neoplasm. Epithelioid cells that resemble transitional cells of the bladder. The majority are benign, but can be malignant. Often found incidentally.

39. Sex Cord–Stromal Ovarian Neoplasms F eminine differentiation , becomes a g ranulosa-cell tumor , a theca-cell tumor , or, a mixed granulosa-theca cell tumor. Masculine differentiation become Sertoli-Leydig cell tumors . (less common). O varian fibroma , developing from mature fibroblasts in the ovarian stroma .

40. Clinical findings: The granulosa -theca cell tumors promote feminizing signs and symptoms. Precocious menarche. Precocious thelarche . Premenarchal uterine bleeding during infancy and childhood. Menorrhagia. Postmenopausal bleeding. E ndometrial hyperplasia, endometrial cancer. Sertoli-Leydig cell tumors : Hirsutism . T emporal baldness0. Deepening of the voice .

41. The ovarian fibroma : Most common N ot hormonally active Often present with torsion in older women. May be associated with Meigs syndrome , ( ascites and hydrothorax in association with an ovarian fibroma ). spontaneously resolve when the fibroma has been removed.

42. Management: D epend on: the type of neoplasm , the patient’s age , and her desire for future childbearin g. Most benign-appearing ovarian cysts may be observed and followed with ultrasonography . If they are symptomatic or enlarging, laparoscopic management is usually appropriate. Laparotomy is usually indicated if the mass is suspicious for malignancy.

43. ovarian cancer

44. Ovarian cancer: 2nd most common gynecologist malignancy . 1st gynecogogist tumor causing death in females Incidence: 1.4 % mean age of presentation is 69 yrs . more in developed countries higher in caucasian .

45. Theories of cancer Incessant ovulation theory: This relates to continuous ovulation causing repeated trauma to the ovarian epithelium leading to genetic mutation and development of a cancer. This is supported by an increased incidence of EOC in nulliparous women, women with early menarche or late menopause and a reduction in incidence of EOC in multiparous women and in women who have used oral contraception. Excess gonadatrophin secretion : This promotes higher levels of oestrogen which in turn leads to epithelial proliferation and malignant transformation of the ovarian epithelium.

46. Risk Factors: D ecreased risk of ovarian cancer Increased risk of ovarian cancer Multiparity Nullparity OCPs IUD Tubal ligation Endometriosis Hysterectomy Cigarette smoking Breast-feeding Obesity Chronic anovulation Short reproductive life

47. Genetic factors in ovarian cancer: About 10-15% of ovarian cancer 3 main types of genes include: BRCA1 , BRCA2 , Lynch syndrome Usually associated with other cancers (breast, colorectal).

48. classification of Ovarian cancer: Epithelial t umor (80%) Serous Mucinous Endometroid Clear cell Undifferentiated Germ cell tumor (15%) Dysgerminoma Endodermal sinus teratoma choriocarcinoma mixed Stromal tumor (5%) Granulosa cell Sertoli cell Gynandroblastoma Metastatic tumor Including Krukenberg

49. Epithelial cell Most common type Postmenopausal women Most common malignant tumor is Serous Usually symptomatic with non specific symptoms persistent pelvic and abdominal pain; increased abdominal size/persistent bloating; difficulty eating and feeling full quickly.

50. Germ cell tumor: Predominantly occurs in teenagers, large Most common malignant form is dysgerminoma Uniquley X ray sensitive

51. Stromal tumors: Functionally active Granulosa -theca cell tumor secret estrogen , so bleeding from endometrial hyperplasia Sertoli - leyding cell tumor secrete testosteron . So produce musculinization syndrome Pt Usually come early Tx : Oophorectomy of involved adnexa( desire for fertility) TAH or BSO( nodesire ) If mets (rarely): it requires Chemotherapy (vincristine, actinomycin , cytoxan )

52. Metastatic disease: Most common sources is : Endometrium, GI, Breast Krukenberg tumors : are mucin producing tumor from stomach to ovaries.

53. Clinical Features : Pelvic and abdominal examination: Fixed hard pelvic mass Ascites : Highly indicative Chest examination: Pleural fluid Neck and groin: palpable LNs.

54. Investigations: CBC, urea, electrolyte, LFT, Tumor markers US: most useful non invasive test for suspected malignancy others: Paracentesis if ascites present. CT, MRI of abdomen barium enema and colonoscopy Biopsy

55. Tumor markers: Tumor marker Tumor type Uses Ca 125 Epithelial ovarian cancer (serous), borderline ovarian tumors Preoperative, follow up Ca 19-9 Epithelial ovarian cancer (mucinous), borderline ovarian tumors Preoperative, follow up Inhibin Granulosa cell tumours Follow up B - hCG Dysgerminoma, choriocarcinoma Preoperative, follow up AFP Endodermal yolk sack, teratoma Preoperative, follow up Estrogen, Testosteron Stromal tumors Preoperative, follow up

56. Serous CEA , CA-125 Mucinous Ca19-9 Dysgerminoma LDH , B- hCG Sertoli-Leydig Testosterone Granulosa Estrogen , Inhibin Endodermal sinus (Yolk Sac), T eratoma AFP Choriocarcinoma B- hCG

57. staging: Staging is surgical . Stage I : Spread limited to the ovaries IA. Limited to one ovary, capsule intact, negative cytology IB. Limited to both ovaries, capsules intact, negative cytology IC. One or both ovaries but ruptured capsule, positive cytology Stage II: Extension to the pelvis IIA. Extension to uterus or tubes IIB. Extension to other pelvic structures IIC. Extension to pelvis with positive cytology

58. Stage III: Peritoneal metastases or positive nodes. This is the most common stage at diagnosis. IIIA. Microscopic peritoneal metastases IIIB. Macroscopic peritoneal metastases ≤2 cm IIIC. Macroscopic peritoneal metastases >2 cm Stage IV: Distant metastases IVA. Involves bladder or rectum IVB. Distant metastasis

59. Management: .A surgical exploration should follow preoperative studies and medical evaluation At the time of surgery, a unilateral salpingo -oophorectomy (USO) is done and sent for frozen section If abdominal or pelvic CT scan shows no evidence of ascites or spread to the abdominal cavity, and if the surgeon is an experienced laparoscopist , evaluation could be performed laparoscopically

60. Benign Histology If the patient is not a good surgical candidate or the patient desires to maintain her uterus and contralateral ovary, a USO is sufficient treatment. If the patient is a good surgical candidate, then a TAH and BSO

61. Malignant Histology D ebulking procedure ( cytoreduction ) . TAH and BSO, omentectomy , and bowel resection, if necessary. Postoperative chemotherapy (carboplatin and Taxol ) should be administered.

62. Prognostic factors in ovarian cancer Stage of disease Volume of residual disease post-surgery Histological type and grade of tumour Age at presentation FIGO Stage 5-year survival (%) I 70–90 II 80 III 30 IV 10–20

63. Follow-Up If the final pathology report was benign : the patient can be followed up in the office yearly for regular examination. If the pathology report was carcinoma, follow up every 3 months for the first 2 years then every 6 months for the next 2 years with follow-up of the CA-125 tumor marker

64. Borderline Cancers A lso known as tumors of low malignant potential. N o invasion of the basement membrane Tx : Conservative surgery. A patient desires further fertility with a unilateral borderline cancer of the ovary can be treated with a USO with preservation of the uterus and the opposite adnexa. • Aggressive surgery. patient has completed her family then treatment would be a TAH and BSO. • Chemotherapy. Not requires unless metastasis, and this is a rare occurrence.

65. Adnexal Mass With Ascites A bdominal accumulation of fluid in the peritoneal cavity c auses of ascites: heart, kidney , liver disease and ovarian cancer. Meigs syndrome is the triad of ascites, pleural effusion, and benign ovarian fibroma.

66. A n abdominal pelvic CT scan should be ordered for evaluation of the upper abdomen . The most common method of ovarian carcinoma spread is by peritoneal dissemination (exfoliation) . commonly metastatic to the omentum and to the GI tract. Most common cause of death in advanced ovarian carcinoma is bowel obstruction . Treatment as mentioned.