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If a malignant mass is suspected, surgical evaluation should be performed by a gynecologic oncologist
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Bhoola S et al Diagnosis and management of epithelial ovarian cancer Obstet Gynecol 2006 Jun;107(6):1399 410 [PMID: 16738170] Guppy AE et al Epithelial ovarian cancer: a review of current management Clin Oncol (R Coll Radiol) 2005 Sep;17(6): 399 411 [PMID: 16149282]
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TVS is useful for screening high-risk women but has inadequate sensitivity for screening low-risk women Ultrasound is helpful in differentiating ovarian masses that are benign and likely to resolve spontaneously from those with malignant potential Color Doppler imaging may further enhance the specificity of ultrasound diagnosis
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Once an ovarian mass has been detected, it must be categorized as functional, benign neoplastic, or potentially malignant Predictive factors include age, size of the mass, ultrasound configuration, CA 125 levels, the presence of symptoms, and whether the mass is unilateral or bilateral In a premenopausal woman, an asymptomatic, mobile, unilateral, simple cystic mass less than 75 cm may be observed for 4 6 weeks Most will resolve spontaneously If the mass is larger or unchanged on repeat pelvic examination and TVS, surgical evaluation is required Most ovarian masses in postmenopausal women require surgical evaluation However, a postmenopausal woman with an asymptomatic unilateral simple cyst less than 5 cm in
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Clinical or biochemical evidence of hyperandrogenism Oligoovulation or anovulation Polycystic ovaries on ultrasonography
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Polycystic ovary syndrome (PCOS) is a common endocrine disorder affecting 4 7% of women of reproductive age and is a common source of chronic anovulation The underlying etiology is unknown, although most of these women have an
CMDT 2008
500 mg three times daily, rosiglitazone 4 mg daily, or pioglitazone 30 45 mg daily may bring resumption of regular cycles and ovulation These agents reduce the hyperinsulinemia and hyperandrogenemia in PCOS If the patient does not desire pregnancy, medroxyprogesterone acetate, 10 mg/d for the first 10 days of each month, should be given to ensure regular shedding of the endometrium and avoid hyperplasia If contraception is desired, a low-dose combination oral contraceptive can be used; this is also useful in controlling hirsutism, for which treatment must be continued for 6 12 months before results are seen Hirsutism may be managed with epilation and electrolysis Dexamethasone, 05 mg each night, is helpful in women with excess adrenal androgen secretion Spironolactone, an aldosterone antagonist, is also useful for hirsutism in doses of 25 mg three or four times daily Flutamide, 250 mg daily, and finasteride, 5 mg daily, are also effective for treating hirsutism Because these three agents are potentially teratogenic, they should be used only in conjunction with secure contraception
aberration of gonadotropin stimulation This is manifested by an increased release of luteinizing hormone (LH) relative to follicle-stimulating hormone (FSH), resulting in an increased production of androstenedione and testosterone by ovarian theca cells The androstenedione undergoes aromatization to estrone and converted to estradiol in the ovarian granulosa cells The high estrone levels are believed to cause suppression of pituitary FSH and constant LH stimulation of the ovary results in anovulation, multiple cysts, and theca cell hyperplasia with excess androgen output Women with Cushing s syndrome, congenital adrenal hyperplasia, and androgen-secreting adrenal tumors also tend to have high circulating androgen levels and anovulation with polycystic ovaries; these disorders must be ruled out in women with presumed PCOS
Clinical Findings
PCOS is manifested by hirsutism (50% of cases), obesity (40%), and virilization (20%) Fifty percent of patients have amenorrhea, 30% have abnormal uterine bleeding, and 20% have normal menstruation In addition, they show insulin resistance and hyperinsulinemia, and these women are at increased risk for early-onset type 2 diabetes The patients are generally infertile, although they may ovulate occasionally They have an increased long-term risk of cancer of the breast and endometrium because of unopposed estrogen secretion
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