BENIGN DISEASES OF OVARY

CYSTIC / NEOPLASTIC ENLARGEMENTS IN

OVARY
FUNCTIONAL CYSTS METAPLASTIC

• FOLLICULAR CYSTS INFLAMMATORY • ENDOMETRIOMA

• LEUTIN CYSTS
• MULTIPLE • SALPHINGO
FUNCTIONAL CYSTS OOPHORITIS
• CORPUSLUTEAL NEOPLASTIC
CYST • PUERPERAL/
• PCOS ABORTAL/IUCD • BENIGN
RELATED • BORDRLINE
• MALIGNANT
FOLLICULAR CYST
• Formed as a result of failure of absorption of fluid in incompletely developed follicle/failure of
ovulation
• Single/multiple size not more than 5cm
• Unilateral/bilateral
• Usually asymptomatic
Pelvic pain/dyspareunia/irregular bleeding in case of large size cysts/multiple cysts
• Complications: hemorrhage/rupture/torsion
• D/D
• Endometriosis
• Ovarian neoplasms
• Inflammatory adnexal enlargements
MANAGEMENT OF FOLLICULAR CYST
• Usually disappear spontaneously within 4 - 8 weeks
• In amenorrhoea patients
Oral MPA 10mg bd *5 days (or)
Norethistrone tablet 5mg tid *5 days
• 3cycles of OCPs in case of persistent cysts
• In case of persistent cyst >3months /size increases >7cm need to be evaluated for
neoplastic cyst

• FOLLICULAR HEMATOMA/FOLLICULAR CYST WITH HEMATOMA

Is of no significance unless a rupture cyst presents with acute abdomen –ruptured ectopic to be
ruled out.
LEUTIN CYSTS OF OVARY
• GRANULOSA LEUTIN CYSTS (CORPUS
LEUTEUM CYSTS)

• Formed due to corpus leuteum overactivity.

• Usually resolves spontaneously.

• Persistent cysts may cause pain/delayed

periods.

• D/D:unruptured ectopic pregnancy –ruled out

by TVS &Serum BHcg.
THECA LEUTIN CYSTS
• Larger in size compared to other functional cysts of ovary.
• Usually bilateral & filled withstraw coloured fluid.
• Seen in:
• Hydatiform mole.
• Choriocarcinoma.
• Ovulation induction by HCG & clomiphene citrate.
• These cysts regress after the evacuation of mole.
• Should avoid HCG Inj if multiple follicles noted in ovary in patients on ovulation induction
with gonadotropin/clomiphene citrate.
MULTIPLE FUNCTIONAL CYSTS
• FSH SECRETING PITUITARY ADENOMA

• OHSS

• PCOS
FSH SECRETING PITUITARY ADENOMA

• Characterised by ↑ FSH , ↑ oestrogen levels, low

LH.
• Amenorrhoea/oligomenorrhoea/infertility.
• Usually the ovarian cysts are >1cm.
• Management may require trans-sphenoidal excision
of adenoma.
• The cysts eventually resolve after treating the
tumour perse.
OHSS
• OHSS is triggered by the ovarian
response to hormones used in fertility
treatments, particularly HCG (human
chorionic gonadotropin).

• Excessive ovarian stimulation leads to

the release of large amounts of vascular
endothelial growth factor (VEGF), which
increases vascular permeability.

• Fluid Accumulation
•Fluid leaks into the abdominal cavity
and other spaces (e.g., chest,
pericardium), leading to edema and
ascites.
 At risk individuals for OHSS
• Young women and those with PCOS (Polycystic
Ovary Syndrome) are at higher risk.

• Previous history of OHSS.

• High number of ovarian follicles at stimulation

GRADING OF OHSS
Degree Grade Clinical Features
Mild Hyperstimulation (10 % - 30 %) Grade - I Abdominal distension, Pain.
Grade – I + Nausea Vomiting, diarrhoea, ovarian enlargement
less than 5 cm.
Grade - II Weight gain < 3 kg
Moderate ( 3 % - 4 %) Grade – III Features of mild OHSS + ultrasonic
evidence of ascites, hyponatraemia,
hypoalkalaemia, hypoproteinaemia.
Reduce renal output, ovarian size up to 10
cm, weight gain of 10 pound.
Severe (0 % - 5 %) Grade – IV Features of moderate stimulation + Clinical
ascites and/or hydeothorax, adult
respiratory diseases, ovarian size > 12 cm,
weight gain > 5 kg.
Critical Grade – V Grade IV + hypovolaemia, hyponatraemia,
hyperkalaemia, increased blood viscosity,
hypercoagulability, decreased renal
perfusion, oliguria, hypotension,
hypoproteinaemia, thrombosis, coagulation
failure, electrolyte imbalance, leucocytes >
15,000/m3, hepatic, renal failure
Haematocrit > 55 % and serum creatinine >
1.6 mg%
MANAGEMENT
•Mild OHSS
•Conservative management with hydration and close monitoring.
•Symptomatic relief with antiemetics, pain relief.
•Moderate OHSS
•Paracentesis for fluid removal.
•Electrolyte and fluid balance correction.
•Severe OHSS
•Hospitalization for intensive monitoring and care.
•Management of complications (renal failure, thromboembolic events).
•Use of albumin infusions and diuretics to manage fluid balance.
PCOS
Genetic, familial, environmental factors, obesity
CYP21a gene mutation, AD/sex linked inheritance

Insulin resistance, Hyperinsulinemia

Increased LH secretion

Stimulates Theca cell hyperplasia

HYPERANDROGENISM → PCOS
PATHOGENESIS OF PCOS
• Hyperandrogenism suppress the growth of dominant
follicle & prevent apoptosis of smaller follicles
resulting in PCOS and anovulation.
• Persistent atretic follicles / theca cell hyperplasia &
stromal hyperplasia results in increase in size to
>10mm3.

Hence gross appearance

• Both ovaries are mildly enlarged.
• Ovary shows thick white capsule of tunica
albugenia.
• Lobulated ovarian surface but peritoneal surface
free of adhesions.

• PCOS predisposes to Metabolic syndrome / syndrome X

in later life – hypertension, Diabetes, hyperlipidemia,
cardiovascular disease.
FEATURES OF PCOS
HORMONAL
↑E2
CLINICAL
↑ LH
LONG TERM
↑ FSH/LH ratio
• Young woman SEQUELAE
↑ Androgens
• Central obesity
↑Testosterone,
• (BMI > 30,Waist • Diabetes
Epiandrostenedione, DHEA
line > 88cm) • Hypertension
17 a hydroxyprogesterone>
• Oligomenorrhoea, • Hyperlipidaemias
300 ng/dL
amenorrhoea. • Endometrial cancer
Testosterone >2ng/mL
• Infertility (20 %) • Breast cancer
↑ Prolactin
• Hirsuitism • Premature ovarian failure
↓SHBG
• Acanthosis nigricans following surgery
↑ Fasting Insulin>10 mIU/L
↓ Fasting glucose/fasting
insulin ratio < 4.5
DIAGNOSTIC CRITERIA
• Rotterdam criteria – Atleast 2 out of the 3 is required for
diagnosis

• Oligomenorrhoea / Amenorrhoea / Anovulation.

• Hyperandrogenism / Hirsutism / Acne.

• Ultrasound features of PCO – pearl Necklace

appearance.
INVESTIGATIONS
• Ultrasound –very useful in PCOS diagnosis (preferably performed in early follicular phase).

• Enlarged ovaries – size > 10mm3.

• ≥ 12 small follicles each of 2-9 mm peripherally placed in subcapsular region of ovaries.

• Helps to rule out ovarian neoplasms.

• Also detects endometrial hyperplasia.

• TFT in obese woman.

• DHEA,17OH hydroxyprogesterone acetate in case of suspicion of adrenal tumour /

hyperplasia.
TREATMENT
AIM

• Address menstrual disorders.

• Treat hirsutism.

• Treat infertility.

• Prevent long term effects such as metabolic syndrome.

• Weight loss

• 5-10% over previous weight alone works in mild PCOS.

• Increases SHBG, reduces insulin level & testosterone level.

• Lifestyle changes

• Cigarette smoking increases E2 level, DHEA, androgen levels hence stopping it is

beneficial.
MENSTRUAL REGULATION
• ORAL CONTRACEPTIVE PILLS (OCP)

• Estrogen in oral pills

• suppresses androgens & adrenal DHEA.
• ↑SHBG hence reduces free testosterone.
• Suppresses LH.

• It is best given as combined pills with progesterone of lesser androgenic effect - 4 th gen
combined pills are best for PCOS.
• Prevents water retention, reduces weight & maintains lipid profile.
• Progestogen is required to induce menstruation in amenorrhic woman prior to initiation of
OCP.
• OCP with cypropterone acetate is preferred in Hirsutism woman.
HIRSUTISM
• Cypropterone acetate

• Potent antiandrogen & competes with intracellular

receptors of DHT thus preventing its action.

• 50-100mg with Ethynyl Estradiol (EE2)of 30mcg in

1st 10 days of cycle cyclically for 3 weeks every
month.

• Then 5-10 mg with EE2 for long period as

maintenance therapy.
Spironolactone
• Antiandrogenic & inhibits 17a hydroxylase
lowering serum testosterone and androstenedione.

• 150 mg daily dose with EE2 then 50mg of

maintenance dose after 6-12 months of initial
therapy.

• Elflornithine cream topical application prevents

hair growth

ACNE
• Clindamycin lotion 1%,Erythromycin gel 2% for
topical use.

• Isotretinoin for severe acne & pregnancy should be

avoided d/t teratogenicity.
INFERTILITY
• Clomiphene citrate is the 1st line of treatment

• Letrozole

• FSH, LH

• GnRH
METFORMIN
• Reduces plasma insulin levels ,delays glucose absorption, increases production of
glucose in liver ,increases peripheral utilization of insulin.
↓
Overall it reduces the insulin resistance treating the root cause.

• Reduces total & free testosterone & ↑SHBG.

• Initially started as 500mg/day then increased to 500mg tid.

• Side effects : Lactic acidosis ,GI disturbances.

• Avoided in liver & renal disorders

Acarbose
• Dose - 300mg daily.

• MOA - inhibits growth hormone &insulin release.

• Enhances ovulation in clomiphene resistant cases.

• N-Acetyl cysteine which is an Insulin sensitizer with micronutrients has been used now

a days.
SURGICAL MANAGEMENT
• INDICATIONS

• Failure of medical therapy

• Hyperstimulation of ovaries occurs during ovulation

stimulation
• Infertile women

• Previous pregnancy losses

• Includes laparoscopic drilling of not more than 4

cysts in each ovary
• Improves fertility over 6-12 months
APPROACH IN ADNEXAL MASSES
THANK YOU