Basics
Description
- 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 cysts
- Rare in childhood, frequent in reproductive age, never occur in postmenopausal women
- Corpus luteum cysts
- Occasionally occur in reproductive age
- Theca lutein cysts
- Occur in adolescence and reproductive age, association with gonadotropin or clomiphene therapy, and also with hydatidiform mole/choriocarcinoma or normal pregnancy
- Endometriotic cysts
- Most common in women at age 20 " 40, never seen in preadolescent and postmenopausal women
- Dermoid cysts
- Common in women aged 20 " 40, arising from ovarian germ cells; may contain teeth, hair, or fat
Prevalence
Found in 2.5 " 6.6% of pre- and postmenopausal women in screening studies.
Risk Factors
Theca lutein cysts occur with gonadotropin or clomiphene therapy, also can occur with hydatidiform mole/choriocarcinoma.
Pathophysiology
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.
Etiology
- Infants
- Usually follicular cysts, resulting from ovarian stimulation by maternal hormones
- Prepubescent
- 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.
- Adolescents
- Majority are physiologic cysts related to normal ovarian activity.
- Reproductive age
- 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.
- Postmenopausal women
- High gonadotropin levels may cause ovarian cysts.
- Always consider the possibility of malignancy.
Diagnosis
History
Signs and symptoms:
- 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
Adnexal mass on pelvic examination
Tests
Lab
- 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
Imaging
Ultrasound:
- Physiologic cysts are generally solitary, thin walled, unilocular, and <10 cm diameter.
- Follicular cysts: <6 cm, often bilateral
- Corpus luteum cysts: 4 " 10 cm, can be large, unilateral
- Theca 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.
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
Watchful waiting for functional cysts. Oral contraceptives appeared to be no benefit in resolution of the size of cyst (1)[A].
Surgery
Indications for cystectomy:
- Postmenopausal women (2)[B]
- 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
- Premenopausal women
- Cyst size >10 cm diameter and/or symptomatic
- An increase in size of cyst during the period of observation
- Ruptured or torsed cyst
Ongoing Care
Follow-Up Recommendations
Patient Monitoring
- Infants and prepubescent
- 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.
- Adolescents
- 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.
- Reproductive age
- An asymptomatic small (<10 cm) cyst can be observed. If it increases in size, surgical exploration is indicated.
- Postmenopausal women
- 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
Spontaneous resolution: May occur in physiologic cysts. Malignancy is rare in premenopausal women with simple cyst.
Complications
- Ovarian torsion
- Rupture of cyst with intraperitoneal hemorrhage
- Bleeding into cyst
References
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]
Additional Reading
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.
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.