Topic List

OVARIAN CYST
Supervised by : dr. Pim Gonta, Sp.OG

Created by :
Shella 201806010025
Maria Angelia 201806010083
Definition of Ovarian Cysts
- Ovarian cyst is a larger fluid-filled sac (more than 3 cm in diameter)
that develops on or in an ovary. (RCOG 2013).

- Ovarian cyst can be categorized as:

- Simple cyst : thin walled and only contain fluid
- Complex cyst : containing thick fluid, blood or solid areas.
Incidence of ovarian cysts
- The incidence varies only slightly with patient demographic (5-15%)
- Most of the cases are classified into functional ovarian cyst, followed
by benign neoplasms.
- Benign cyst usually occur during reproductive age
- Ovarian carcinoma occurs 15 cases per 100.000 per year in USA
- Race related demographic : most frequently Europe and North
America, less frequently in Asia, Africa and Latin America.
Pathogenesis of ovarian cyst
- The exact mechanisms leading to cyst formation are unclear.
- Angiogenesis is the essential component of both follicular and luteal
phase of the ovarian cycle.
- This component also played a role in various pathologic ovarian
process, including follicular cyst formation, PCOS, and benign or
malignant ovarian neoplasms.
Classification of Ovarian Cyst
Based on histologic examination, ovarian cysts are divided into:

- Ovarian cystics neoplasms, those derived from neoplastic growth.

- Functional ovarian cysts those created by disruption of normal
ovulation.
Functional Ovarian Cyst

Follicular Cyst

Corpus Luteum Cyst

Theca lutein cyst

Functional Ovarian Cysts
- Common ovarian cysts, originated from ovarian follicle & created
during follicle maturation and ovulation.
- Subtypes : follicular cyst, corpus luteum cyst, theca lutein cyst.
- Risk factor for developing functional ovarian cyst:
- Oral contraceptives
- Tamoxifen usage for breast cancer therapy
- Body mass index
- Smoking

.
Pathogenesis & Characteristics of Follicular Cyst
Pathogenesis :

Failure in ovulation due to disturbance in the release of pituitary

gonadotrophine → the fluid from incompletely developing follicle is not
absorbed.

Characteristics:

- Diameter of cyst are about 3 to 8 cm.

- Histologic → this cyst lined by inner layer of granulosa cells and outer
layers of thecal cells.
- Mostly asymptomatic & disappear spontaneously within 60 days.
Diagnosis of Follicular Ovarian Cyst

Typical follicular cyst :

Rounded anechoic lesions
with thin, regular walls.
Pathogenesis of Corpus Luteum Cyst
- Normal ovulation → granulosa cells lining the follicle become
luteinized
- In stage of vascularization → blood accumulates in the central cavity
→ corpus hemorrhagicum → resorption of blood → corpus luteum →
when it grows > 3 cm → Cyst
- Characteristics → thin walled unilocular cyst, 3 -10 cm in size.
Diagnosis of Corpus Luteum Cyst
Corpus luteum cyst → varied sonographic characteristics :

- Diffuse low level echoes → hemorrhage throughout smooth

walled cyst.
- lacy reticular pattern → evolution of the clots
- As the clot hemolyzed → formed distinct line and clot may appear
as intramural nodules.
Varied Sonographic Findings in Corpus Luteum Cyst
Theca Lutein Cyst
- Uncommon type of follicular cyst
- Characteristics : bilateral, multiple smooth walled cysts, range from 1 -
4 cm in size, filled with clear, straw colored fluid
- Termed hyperreactio lutealis→ induced by elevated LH or Beta hCG
levels → causing luteinization and hypertrophy of their theca interna
layers.
Theca Lutein Cyst
- Associated conditions :
- Gestational trophoblastic disease
- Multifetal gestation
- Hydatidiform mole
- Ovarian hyperstimulation during assisted reproductive techniques.
- The cyst disappear spontaneously following removal of the stimulating
hormone source
BENIGN NEOPLASTIC OVARIAN CYSTS

Epithelial-stromal tumors

Germ cell tumors

Sex cord-stromal tumors

 BENIGN NEOPLASTIC OVARIAN CYSTS
Originate from surface epithelial-stromal

1. Benign serous tumors

Thin-walled, unilocular, filled with serous fluid, lined by cells similar to those
lining the fallopian tube.

2. Benign mucinous tumors

Thicker-walled, filled with mucous fluid.

 BENIGN NEOPLASTIC OVARIAN CYSTS
Originate from germ cell

1. Immature teratoma

Malignant, immature tissue from one, two, or all 3 germ cell layers.

2. Mature teratoma (dermoid cyst)

Benign, Contain mature forms of the three germ cell layers.

3. Monodermal teratoma
Complications :

1. Ovary torsion → sharp lower abdominal pain with sudden onset that worsen
intermittently over several hours.

Localized to the involved side, with radiation to the flank, groin, or thigh.

2. Cyst rupture → rare, due to it’s thick wall ; if rupture → acute peritonitis.

Treatment :

1. Surgical excision
History Taking
- Symptoms of ovarian cysts
- Most women with ovarian cyst are asymptomatic.
- If the symptoms occurs, pain is common symptoms
- Pressure or ache → result from ovarian capsule stretching.
- Acute severe pain may indicate cyst rupture or tuboovarian abscess.
- If intermittent or acute pain occurs with vomiting → torsion.
- Sign of malignancy
- Persistence bloating, generalized abdominal pain, early satiety
- Family history of ovarian, bowel, or breast cancer
- Menstrual cycle
- Dysmenorrhea → indicated endometriosis with associated endometrioma
Physical Examination
- Palpable mass
- Characteristic of ovarian cysts are vary, but typical masses are mobile,
cystics, nontender, and found lateral to the uterus.
- Malignancy : Irregular, firm, fixed, nodular, bilateral, and associated
ascites.
Diagnosis
- Found incidentally on routine pelvic examination or during imaging studies for
another indication.
- Tumour markers → CA-125, LDH, inhibin A & B
- Sonography → first line tool
- CT scan or MR imaging
 Lactate dehydrogenase (LDH), aFP, and hCG

- should be measured in all women under 40 with a complex ovarian mass for a
suspect for germ cell tumours.

CA-125

- Not specific
- Raised in → fibroids, endometriosis, adenomyosis, and pelvic infection.
 RISK OF MALIGNANCY (RMI)
RMI = U x M x CA125
sensitivity 78%, specificity 87%

Ultrasound (U) RMI > 200

Menopausal Status (M)
- Multilocular cysts (1) Increase risk of malignancy
M = 1 (Premenopausal)
- solid areas (1)
M = 3 (postmenopausal)
- metastases (1)
- ascites (1)
- bilateral lesions (1)
Serum CA125
U = 0 (ultrasound score 0)
measured in IU.mL
U = 1 (ultrasound score 1)
U = 3 (ultrasound score 2-5)
IOTA GROUP ULTRA SOUND
differentiate benign and malignant ovarian mass
sensitivity was 95%, specificity 91%
Ultrasonography
- Ultrasonography (Transvaginal)

SIMPLE CYST
COMPLEX CYST
1. Round or oval shape
1. Complete septation (multilocular
2. Thin or imperceptible wall
cyst)
3. Posterior acoustic enhancement
2. Solid nodules
4. Anechoic fluid
3. Papillary projection
5. Absence of septations or nodules
Management
- Observation
- Prepubertal and reproductive aged woman → functional ovarian
cyst & spontaneously regress after 6 months.
- Surgery
- two types of surgical techniques : cystectomy or oopherectomy.
- Surgical route → laparoscopic or laparotomy incision.
 Reference
1. The American College of Obstetricians and Gynecologists. 2016. Evaluation
and Management of Adnexal Masses.
2. Royal College of Obstetricians & Gynaecologists. 2016. The Management of
Ovarian Cysts in Postmenopausal Women.
3. Beckmann, Charles R.B.2010. Obstetrics and Gynecology. Baltimore, MD :
Wolters Kluwer Health/Lippincott Williams & Wilkins.