obstetrics and gynecology

1. OVARIAN CYST IN
POSTMENOPAUSAL

2. CASE SCENARIO
Maryam Othman

3. Case scenario
■ Monera is 60 year old post menopausal female P8+0 referred to KAMC as borderline ovarian
cyst for clinical assessment.
■ 10 month ago she presented to ER at MCH complaining of intermittent vaginal bleeding
associated with left lower abdominal pain for 7 days prior to her presentation. The bleeding
was bright red in color without clots . She change her pads 2 time/day (medium size pad) and
they filled with blood. No dizziness, sweating and palpitations, no fever , vaginal discharge and
no dyspareunia The abdominal pain is dull in nature, not aggravating by movement and not
radiating to other site , she has abdominal bloating and feel fullness. She feel early satiety, no
significant weight loss, no loss of appetite and no night sweat.
■ No GI symptoms (nausea, dyspepsia, constipation, melena). No urinary symptoms (frequency,
dysuria and hematuria) . No respiratory symptoms ( SOB, cough, hemoptysis ) . Other systemic
review unremarkable
■ Past obstetric & gynecological history: she has 2 boys 6 girls all SVD without complications.
Never using any contraceptive methods She's post menopause 10 year ago , -ve pap smear
■ Past medical & surgical history: she's diabetic on insulin well controlled and hypertensive on
Amlodipine . Surgical history unremarkable
■ She denied taking any anticoagulant medications or exogenous Estrogen
■ No family history of ovarian and breast cancer.

4. Physical Examination
On examination
■ Patient look well , normal body weight I have to confirm by BMI , normal color not
pale or cyanosed and not distressed
■ Vital signs: BP 155/70, Temperature:37.5 , Heart rate:98 , Respiratory rate:20 , O2
saturation:97%
■ Abdominal examination:
distended abdomen, no scars , symmetrical movement with respiration, umbilicus inverted.
there is single solid fixed pelvic mass in the left side, not tender. Bowel sound present not
exaggerated
Digital Vagino-rectal examination should performed
■ Respiratory examination: equal bilateral air enter
■ CVS examination: S1 + S2 + 0
■ CNS examination: oriented, cranial nerve intact with normal tone , power , reflex in
bilateral upper and lower limb

5. DIFFERENTIAL DIAGNOSIS
Elham Al-saedi

7. Differential diagnosis
1. Ovary: ovarian cyst
2. Uterus: uterine carcinoma
3. Myometrium: fibroid
4. Endometrium: atrophic changes , polyps and hyperplasia
5. Cervix: atrophic changes and malignancy
6. Vagina: atrophic changes
7. Medication: Exogenous use of Estrogen

8. INVESTIGATION
Wijdan Zamzami

9. Lab investigation
7.65 × 109/LWBC
CBC & coagulation
4.67 × 1012/LRBC
28.1 pgMCH
86.5 FLMCV
32.4 g/dLMCHC
13.1g/dLHGB
266 × 109
/LPlatelet count
0.86INR
28.2 secPTT
20 U/mlCA 125
Tumor marker
40.26 U /mlCA 19-9
1.86 ng /dlCEA
153 U/LLDH
B +veBlood Group

10. Lab investigation
7.4 g/dLA/G ratio
Chemistry
22 U/LAlanine AminoTransferase
3.4 g/dLAlbumin
12 U/LAspartate AminoTransferase
8 mg/dLBlood Urea Nitrogen
10.38 corrected CaCalcium
100 mmol/LChloride
0.602 mg/dLCreatinine
4 mmol/LPotassium
7.4 g/dLProtein
136 mmol/LSodium
136 mg/dLUric acid

11. Transvaginal sonography (TVS)
Multilocular complex solid mass measured around 6 cm ,Thick septations =3 mm.
No Other pelvic/omental masses.
No other U/S abnormalities.

12. Radiology
CT scan of the abdomen and pelvis with IV contrast
A large cystic lesion in pelvic arising from left ovary.
multiple internal septation associated with skunky calcification and heterogeneous enhancing soft
tissue.
The liver, gallbladder, pancreas, spleen ,adrenals and kidney appear unremarkable apart from left
cortical renal cyst .
The major vascular structure are patent. No enlarged lymph node are noted
No free fluid or air
No obvious bone lesions are noted
Conclusion :
Complex left ovarian cystic lesion which could represent malignant epithelial neoplasm of the
ovary or metastasis for histopathology correlation
Thickened endometrium for clinical evaluation

13. ■ MA Mammogram :
■ No obvious suspicious micro- calcification ,architectural distortion ,skin thickening or
nipple retraction
■ No enlarged lymph node at visualizes axilla
Radiology
Conclusion :
No mammographic evidence of malignancy

14. Radiology
Chest X-ray :
Cardio-mediastinal contour within normal limit
No pleural effusion , No obvious airspace opacity

15. DIAGNOSIS
1. Ovary: ovarian cyst
2. Uterus: uterine carcinoma
3. Myometrium: fibroid
4. Endometrium: atrophic changes , polyps and hyperplasia
5. Cervix: atrophic changes and malignancy
6. Vagina: atrophic changes
7. Medication: Exogenous use of Estrogen

16. OVARIAN CYST IN
POSTMENOPAUSAL

17. RMI= 3(PM) x 3(TVS) x 20(CA125) = 180
RMI= 180
ScoreScoring systemCriteria
A ( 1 or 3 )1
3
Menopausal status
Pre-menopausal
Post-menopausal
B ( 0,1,3 )
No feature = 0
One feature = 1
More than 1 feature = 3
Ultrasonic feature
Multiloculate
Solis areas
Bilaterally
Ascites
Metastasis
CAbsolute levelSerum CA125
Risk of Malignancy Index A*B*C

18. MANAGEMENT
Sara Alqethami

19. Management options
According to the RMI:
■ Surgical management :
■ -(TAH-BSO) Total Abdominal Hysterectomy- Bilateral Salpingo-oopherectomy and
omentectomy.
■ -Intra-Operative Frozen Section (Serous Cystadenoma )
■ Patient-controlled by analgesia.
■ Chemotherapy.

20. HOW ARE OVARIAN CYSTS
DIAGNOSED IN
POSTMENOPAUSAL WOMEN
AND WHAT INITIAL
INVESTIGATIONS SHOULD BE
PERFORMED?
Malak Alfaifi

21. - How are ovarian cysts diagnosed in postmenopausal women and what initial investigations should
be performed?
■ Ovarian cysts in postmenopausal women could present in one of three ways
o Acute pain.
o Identified during gynecological investigations.
o Incidentally in postmenopausal women undergoing investigations by other specialties for non-
gynecological conditions
■ It is recommended that ovarian cysts in postmenopausal women should be initially assessed by
measuring serum cancer antigen 125 (CA125) level and transvaginal ultrasound scan. (A)
■ In order to triage women and guide further management, assess the risk that the ovarian cyst is
malignant.

22. WHAT BLOOD TESTS SHOULD
BE PERFORMED IN
POSTMENOPAUSAL WOMEN
WITH OVARIAN CYST?
Haneen Almasoudi

23. CA125
 CA125 should be the only serum tumour marker used for primary evaluation as it
allows the RMI of ovarian cysts in postmenopausal women to be calculated. (B)
 CA125 levels should not be used in isolation to determine if a cyst is malignant.While a
very high value may assist in reaching the diagnosis, a normal value does not exclude
ovarian cancer due to the nonspecific nature of the test. (B)
 The use of serum CA125 is well established, being raised in over 80% of epithelial
ovarian cancer cases, but not in most primary mucinous ovarian cancers. If a cut-off of
30 iu/ml is used,the test has a sensitivity of 81% and specificity of 75%. However,
CA125 values can show wide variation, with lower levels (20 iu/ml) found in healthy
postmenopausal women
 Non-malignant gynaecological conditions such as pelvic inflammatory disease,
fibroids, acute events in benign cysts (e.g. torsion or haemorrhage) and endometriosis
can all result in an increased CA125 level.
 Numerous benign nongynaecological conditions that cause peritoneal irritation
(tuberculosis,cirrhosis, ascites, hepatitis, pancreatitis, peritonitis, pleuritis) and other
primary tumours that metastasise to the peritoneum (breast, pancreas, lung, and
colon cancer) can also cause an elevated CA125
Evidence
level 1–
Evidence
level 2+
Evidence
level 2++

24. HE4 , CEA, CDX2, CA72-4, CA19-9, α -
FP, LDH and B-hCG
 There is currently not enough evidence to support the routine clinical use of other
tumour markers, such as human epididymis protein 4 (HE4), carcinoembryonic
antigen (CEA), CDX2, cancer antigen 72-4(CA72-4), cancer antigen 19-9 (CA19-9),
alphafetoprotein (α -FP), lactate dehydrogenase (LDH) or beta-human chorionic
gonadotrophin (B -hCG), to assess the risk of malignancy in postmenopausal ovarian
cysts , All of these markers show low sensitivity and wide variation in specificity when
used in isolation or in combination with CA125 (B)

25. WHAT IMAGING SHOULD BE
EMPLOYED IN THE
ASSESSMENT OF OVARIAN
CYSTS IN POSTMENOPAUSAL
WOMEN?
Razan Sulaimani

31. INITIAL ASSESSMENT AND
ESTIMATION OF THE RISK OF
MALIGNANCY
Shatha Haroun

32. Which RMI should be used?
■ The ‘RMI I’ is the most utilized, widely available and validated effective triaging system
for women with suspected ovarian cancer. (A)
■ Although a RMI I score with a threshold of 200 (sensitivity 78%, specificity 87%) is
recommended to predict the likelihood of ovarian cancer and to plan further
management, some centers utilize an equally acceptable threshold of 250 with a lower
sensitivity (70%) but higher specificity (90%). (A)
■ CT of the abdomen and pelvis should be performed for all postmenopausal women
with ovarian cysts who have a RMI I score greater than or equal to 200, with onward
referral to a gynecological oncology multidisciplinary team. (B)
What other scoring systems are available ?
■ Other scoring systems are described.OVA1® and Risk of Malignancy Algorithm
(ROMA)require specific assays which may make routine use impractical. The IOTA
classification, which is based on specific ultrasound expertise, has comparable
sensitivity and specificity to RMI and forms an alternative for those experienced in this
technique. (A)

34. THANK YOU