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Ovarian Cysts
- Common findings and are often part of a normal menstrual cycle including follicular and corpus luteum cysts.
- The most common types of benign cysts found are serous and mucinous adenomas and teratomas or dermoid cysts.
- Postmenopausal cysts are presumed to be malignant until proven otherwise.
Clinical Presentation
- Pain
- Abnormal menstrual changes
- Incidental finding
Physical exam
- It is possible, but unlikely to palpate a very large cyst.
Labs and studies
- U/S for diagnosis
- Exploratory Laparoscopy
Treatment
- Watchful waiting. Follow with U/S in a premenopausal women with a small cyst
- Cystectomy
Ovarian Cancer
Risk factors
- 45+ years old with the majority being over 60
- Woman with increased ovulation
- Early menarche
- Nulliparous
- Late menopause
- Caucasian
- Family history of endometrial cancer
- Family history of ovarian cancer
Clinical presentation
- Patients typically present late as symptoms are subtle and vague
- Nondescript GI symptoms
- Pelvic pain
- Pelvic pressure
Physical Exam
- Pelvic exam may demonstrate a palpable mass
- Ascites
Labs and studies
- CA 125 is used to monitor treatment but is not useful for a screening test. It is most helpful for postmenopausal women as premenopausal women may have elevated CA 125 with benign disease.
- U/S both transvaginal and abdominal
- Laparoscopy
- CAT scan
Treatment
- Removal of fallopian tubes may help prevent ovarian cancer
- Total abdominal hysterectomy and bilateral salpingo oophorectomy and lymphadenectomy
- Chemotherapy
- Radiation
- 5 year survival rates are about 45%
Polycystic Ovarian Syndrome
Clinical presentation
- Oligomenorrhea
- Amenorrhea
- Infertility
Physical exam
- Obese
- Hirsutism
- Virilization
Labs and Studies
- FSH, LH – used to check for premature ovarian failure & hypogonadotropic hypogonadism
- Thyroid stimulating hormone (TSH) – thyroid problems may cause menstrual irregularities
- DHEAS – used to test for adrenal neoplasm
- Glucose tolerance test
- Pelvic u/s may show polycystic ovaries
- Endometrial aspiration
Treatment
- Weight loss
- Metformin 500 mg daily
- Patient desires pregnancy
- Clomiphene – used to stimulate ovulation
- Dexamethasone 0.5 mg po at bedtime with clomiphene increases ovulation rates
- Patient does not desire pregnancy
- Medroxyprogesterone acetate 10 mg daily for the first 10 days of each month. This causes the regular shedding of the endometrial lining.
- Oral contraception
- To treat Hirsutism spironolactone, flutamide and finasteride may be given
Pelvic Inflammatory Disease
- A polymicrobial infection of the the fallopian tubes and pelvis
Risk factors
- Most cases are caused by the sexually transmitted organisms Gonococcus and Chlamydia
Clinical presentation
- Fever
- Nausea and vomiting
- Purulent vaginal discharge
- Bilateral pelvic or abdominal pain
Physical exam
- Pelvic exam
- Cervical motion tenderness
- Uterine tenderness
- Adnexal tenderness
- Friable cervix
- Mucopurulent discharge
Labs and Studies
- Cervical Gram stain and culture. Often Gonococcus and Chlamydia
- U/S
- Culdocentesis – Placing a needle into the rectovaginal space in order to culture the fluid there
- MRI
- Laparoscopy – If no improvement with 48 hours in order to visualize abdominal and pelvic structures as well as obtain cultures.
- Rule out appendicitis, ectopic pregnancy or ovarian torsion
Treatment
- Mild cases may be treated with oral or intramuscular antibiotics
- Ceftriaxone IM + 14 days of doxycycline with or without metronidazole
- Severe cases will require hospitalization with IV antibiotic
- 2nd generation cephalosporin + doxycycline
- Cefotetan + doxycycline
- Cefoxitin + doxycycline
- Another option is gentamicin + clindamycin
- 2nd generation cephalosporin + doxycycline
- – The CDC website has a great table if you’re looking for more information.
- Surgery is indicated for unresponsive disease or a pelvic abscess
- All sexual partners should be treated!
Study tip
Trust your brain. It’s the secret behind your gut feelings.
<< Click here to get 26 ObGyn questions straight from my book, The Final Step >>