Ovarian Disorders
- Ovary is attached to the broad ligament by the mesovarian, attached to the pelvic wall by the infundibulopelvic ligament and to the uterus by the ovarian ligament
- Outer cortex is covered in germinal epithelium (from which the most common carcinoma is derived)
- Inner medulla contains CT and vessels
Acute presentations
- Rupture of ovarian cyst – causes intense pain
- Haemorrhage of an ovarian cyst – may cause hypovolaemic shock
- Torsion of the pedicle cause infarction and pain
Disorders of ovarian function
- Polycystic ovary syndrome – cysts are small multiple poorly developed follicles
- Premature menopause – when the last period is reached before the age of 45
Ovarian Tumours
Primary neoplasms
- May be benign or malignant
- A benign cyst may undergo malignant change
Epithelial tumours
- Derived from the epithelium covering the ovary
- Most common in most menopausal women
- Histology may demonstrate borderline malignancy where histological features are present but invasion isn’t
Germ cell tumours
- Originate from undifferentiated primordial cells of the gonad
- Examples include teratomas, dysgerminoma (female equivalent of seminoma)
Sex cord tumours
- Originate from the stroma of the gonad
- Granulosa cell tumours are generally malignant but slow growing
- Rare, normally round in post menopausal women
- Secrete oestrogen, which stimulates the endometrium causing bleeding, endometrial hyperplasia and even malignancy
- Thecomas are very rare and usually benign, they also secrete oestrogen
- Fibromas are rare and benign. They can cause Meigs’ syndrome where ascites and a right pleural effusion accompany a small ovarian mass
Secondary malignancies
Ovary is a common site for metastic spread particularly from the breast and GI tract
Secondaries account for 10% of malignant ovarian masses
Carcinoma of the Ovary
- Presents late and therefore overall prognosis is poor
- Causes more deaths than cervical and uterine cancer together
- Most common between the ages of 60-70
- 90% are epithelial carcinomas
- In the rare event a women under 30 is affected it is likely to be a germ cell tumour
Aetiology
- Benign cysts can undergo malignant change but a premalignant phase is not normally recognised
- Risk factors related to the number of ovulations – early menarche, late menopause and nulliparity are risk factors
- Lactation, multiparity and the contraceptive pill are protective
- 5% are familial via the BRCA1 and 2 gene mutations
Clinical features
- Abdominal distension, pain or abnormal vaginal bleeding
- Ask about breast and GI symptoms because as mass could be metastic from these sites
- An ovarian mass is likely to be malignant if
Spread/Staging
- Ovarian adenocarcinoma generally spreads directly with the pelvis and abdomen
- Lymphatic and blood born spread can occur
- Stage 1 disease macroscopically confined to the ovaries
- Stage 1a one ovary is affected, capsule is intact
- Stage 1b both ovaries affected, capsule in intact
- Stage 1c one/both ovaries affected, capsule not intact or malignant cells in the abdominal cavity
- Stage 2 disease is beyond ovaries but confined to the pelvis
- Stage 3 disease is beyond pelvis but confined to abdomen
- Stage 4 disease is beyond abdomen
Investigations
- Ultrasound – features suggestive of malignancy are solid or septate tumour, high vascularity and ascites
- CA125
- Liver function tests
- CXR