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Ovarian Cysts

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Ovarian Cysts

Basics

Description

Found in 2.5 " 6.6% of pre- and postmenopausal women in screening studies.

Physiologic cysts occur related to normal ovulation process. High levels of gonadotropins/androgens may cause ovarian cysts, especially in women in their first few years after menopause.

Watchful waiting for functional cysts. Oral contraceptives appeared to be no benefit in resolution of the size of cyst (1)[A].

1Grimes DA, Jones LB, Lopez LM. Oral contraceptives for functional ovarian cysts. Cochrane Database Syst Rev. 2009;2:CD006134. [View Abstract]2Im SS, Gordon AN, Buttin BM. Validation of referral guidelines for women with pelvic masses. Obstet Gynecol. 2005;105:35 " 41. [View Abstract]

1Castillo G, Alcazar JL, Jurado M. Natural history of sonographically detected simple unilocular adnexal cysts in asymptomatic postmenopausal women. Gynecol Oncol. 2004;92:965 " 969. [View Abstract]2Gransberg S, Wikland M, Jansson I. Macroscopic characterization of ovarian tumors and the relation to the histological diagnosis: Criteria to be used for ultrasound evaluation. Gynecol Oncol. 1989;35:139 " 144.

  • Ovarian cysts are benign cystic tumors of the ovary.
  • Usually asymptomatic, or may cause pain or pressure sensation.
  • Physiologic (functional) cysts: Follicular, corpus luteum cysts
  • Pregnancy-related: Theca lutein cysts, corpus luteum cysts
  • Others: Dermoid cysts, endometriotic cysts

Epidemiology

  • Follicular cystsRare in childhood, frequent in reproductive age, never occur in postmenopausal women
  • Corpus luteum cystsOccasionally occur in reproductive age
  • Theca lutein cystsOccur in adolescence and reproductive age, association with gonadotropin or clomiphene therapy, and also with hydatidiform mole/choriocarcinoma or normal pregnancy
  • Endometriotic cystsMost common in women at age 20 " “40, never seen in preadolescent and postmenopausal women
  • Dermoid cystsCommon in women aged 20 " “40, arising from ovarian germ cells; may contain teeth, hair, or fat
  • Rare in childhood, frequent in reproductive age, never occur in postmenopausal women
  • Occasionally occur in reproductive age
  • Occur in adolescence and reproductive age, association with gonadotropin or clomiphene therapy, and also with hydatidiform mole/choriocarcinoma or normal pregnancy
  • Most common in women at age 20 " “40, never seen in preadolescent and postmenopausal women
  • Common in women aged 20 " “40, arising from ovarian germ cells; may contain teeth, hair, or fat

Risk Factors

Pathophysiology

Etiology

  • InfantsUsually follicular cysts, resulting from ovarian stimulation by maternal hormones
  • PrepubescentPhysiologic cysts are uncommon.Suspect malignancy when adnexal mass is found in this age group.Recurrent, large, multiple ovarian cysts with signs of early sexual development may result from precocious puberty.
  • AdolescentsMajority are physiologic cysts related to normal ovarian activity.
  • Reproductive ageThe majority of physiologic cysts are related to normal ovarian activity or pregnancy.Consider polycystic ovary syndrome when patient has multicystic ovaries; other characteristics include obesity, hirsutism, prolonged amenorrhea, and infertility.
  • Postmenopausal womenHigh gonadotropin levels may cause ovarian cysts.Always consider the possibility of malignancy.
  • Usually follicular cysts, resulting from ovarian stimulation by maternal hormones
  • Physiologic cysts are uncommon.
  • Suspect malignancy when adnexal mass is found in this age group.
  • Recurrent, large, multiple ovarian cysts with signs of early sexual development may result from precocious puberty.
  • Majority are physiologic cysts related to normal ovarian activity.
  • The majority of physiologic cysts are related to normal ovarian activity or pregnancy.
  • Consider polycystic ovary syndrome when patient has multicystic ovaries; other characteristics include obesity, hirsutism, prolonged amenorrhea, and infertility.
  • High gonadotropin levels may cause ovarian cysts.
  • Always consider the possibility of malignancy.

Diagnosis

History

  • Usually asymptomatic
  • Mid-cycle pain in premenopausal women (physiologic cysts)
  • Occasional anovulation (follicular cysts)
  • Chronic pain during intercourse (endometriotic cyst)
  • Pain immediately after intercourse (ruptured cyst)
  • Severe lower abdominal pain associated with nausea and vomiting, when cyst is torsed

Physical Exam

Tests

  • Serum CA-125 for excluding epithelial ovarian carcinoma in postmenopausal women. In premenopausal women, CA-125 is not useful as a diagnostic test for cancer in evaluation of a simple cyst.
  • Alpha-fetoprotein (AFP), lactate dehydrogenase (LDH), and human chorionic gonadotropin (hCG) for excluding germ cell tumors of ovary
  • Pregnancy test if ectopic pregnancy is suspected
  • Physiologic cysts are generally solitary, thin walled, unilocular, and <10 cm diameter.Follicular cysts: <6 cm, often bilateralCorpus luteum cysts: 4 " “10 cm, can be large, unilateralTheca lutein cysts: 4 " “5 cm, multiple, bilateral
  • Endometriotic cysts: 10 " “12 cm, may have thicker walls, may be multilocular, and may be occasionally bilateral.
  • In one study, only 0.3% of unilocular cysts were malignant, whereas the rate of malignancy was 8% in multilocular cysts.
  • Follicular cysts: <6 cm, often bilateral
  • Corpus luteum cysts: 4 " “10 cm, can be large, unilateral
  • Theca lutein cysts: 4 " “5 cm, multiple, bilateral

Differential Diagnosis

  • Malignant ovarian/fallopian tube/colon tumors
  • Ectopic pregnancy
  • Diverticular abscess
  • Appendiceal abscess/appendicitis
  • Tuboovarian abscess
  • Paraovarian cyst
  • Retroperitoneal cyst
  • Polycystic ovary syndrome

Treatment

Medication

Surgery

  • Postmenopausal women (2)[B]Symptomatic cystUltrasound image appears suspicious for malignancyElevated CA-125 levelMultilocular cystFamily history of breast or ovarian cancer in the first-degree relatives
  • Premenopausal womenCyst size >10 cm diameter and/or symptomaticAn increase in size of cyst during the period of observation
  • Ruptured or torsed cyst
  • Symptomatic cyst
  • Ultrasound image appears suspicious for malignancy
  • Elevated CA-125 level
  • Multilocular cyst
  • Family history of breast or ovarian cancer in the first-degree relatives
  • Cyst size >10 cm diameter and/or symptomatic
  • An increase in size of cyst during the period of observation

Ongoing Care

Follow-Up Recommendations

  • Infants and prepubescentWhen physiologic cyst is suspected, follow up with serial ultrasound every 4 " “8 weeks. If there is no increase in size of cyst, ultrasound characteristic is assuring and the patient remains asymptomatic, continue observation.
  • AdolescentsAn asymptomatic simple follicular cyst <6 cm diameter can be followed with ultrasound examination. If the size increases, or the cyst is >6 cm or symptomatic, perform laparoscopic cystectomy.An asymptomatic corpus luteum cyst without intraperitoneal bleeding can be observed. There is no size limit for observation. Surgery is rarely needed in the absence of torsion.
  • Reproductive ageAn asymptomatic small (<10 cm) cyst can be observed. If it increases in size, surgical exploration is indicated.
  • Postmenopausal womenPatients who have asymptomatic, simple unilateral cyst with normal Pap smear and CA-125 level can be observed with serial ultrasound examination and CA-125 measurement. Most of these cysts resolve spontaneously within 12 " “24 months. Otherwise, surgical exploration should be performed.
  • When physiologic cyst is suspected, follow up with serial ultrasound every 4 " “8 weeks. If there is no increase in size of cyst, ultrasound characteristic is assuring and the patient remains asymptomatic, continue observation.
  • An asymptomatic simple follicular cyst <6 cm diameter can be followed with ultrasound examination. If the size increases, or the cyst is >6 cm or symptomatic, perform laparoscopic cystectomy.
  • An asymptomatic corpus luteum cyst without intraperitoneal bleeding can be observed. There is no size limit for observation. Surgery is rarely needed in the absence of torsion.
  • An asymptomatic small (<10 cm) cyst can be observed. If it increases in size, surgical exploration is indicated.
  • Patients who have asymptomatic, simple unilateral cyst with normal Pap smear and CA-125 level can be observed with serial ultrasound examination and CA-125 measurement. Most of these cysts resolve spontaneously within 12 " “24 months. Otherwise, surgical exploration should be performed.

Prognosis

Complications

  • Ovarian torsion
  • Rupture of cyst with intraperitoneal hemorrhage
  • Bleeding into cyst

References

Additional Reading

Codes

ICD9

  • 220 Benign neoplasm of ovary
  • 620.1 Corpus luteum cyst or hematoma
  • 620.2 Ovarian cyst

ICD10

  • D27.9 Benign neoplasm of unspecified ovary
  • N83.1 Corpus luteum cyst
  • N83.20 Unspecified ovarian cysts

SNOMED

  • 79883001 cyst of ovary (disorder)
  • 386762009 corpus luteum cyst (disorder)
  • 60878004 theca-lutein cyst of ovary (disorder)
  • 119424003 mature cystic teratoma of ovary (disorder)

Clinical Pearls

  • Most common adnexal mass in reproductive age and adolescence
  • Ovarian cysts are rare in prepubescent and postmenopausal women; should consider neoplastic tumors when adnexal mass is found in these age groups.
  • Etiology of cystic lesion of ovary varies by age group.
  • Diagnosis can be made based on history, physical examination, and characteristic ultrasound findings.