Ovarian Masses I

“Ovarian Cysts”

Alaa M. Ismail, MD, JBOG, ArBOG

Assistant Prof. at Islamic University
Ovarian Cysts in Premenopausal
 Overview

- Up to 10% of women will have some form of surgery during their lifetime for the
presence of an ovarian mass

- In premenopausal women almost all ovarian masses and cysts are benign

- Preoperative differentiation between the benign and the malignant ovarian mass
in the premenopausal woman can be problematic with no test or algorithm being
clearly superior in terms of accuracy

- Ten percent of suspected ovarian masses are ultimately found to be non-ovarian in

origin
- Many ovarian masses in the premenopausal woman can be managed
conservatively

- Functional or simple ovarian cysts (thin-walled cysts without internal structures)

which are less than 5 cm maximum diameter usually resolve over 2–3 menstrual
cycles without the need for intervention

- If surgery is indicated, a laparoscopic approach is generally considered to be the

gold standard for the management of benign ovarian masses
Types of adnexal masses
 Presentation

- Lower abdominal/Pelvic pain

- Low bachacke
- Menstrual/Premenstrual or dyspareunia
- Unscheduled bleeding
- Hormonal changes: Weight gain, breast changes
- Urinary symptoms: frequency, incomplete emptying
- Acute presentation: acute abdominal pain, dizziness and faintness, nausea and
vomiting,
 Assessment

- A thorough medical history with specific attention to risk factors or protective

factors for ovarian malignancy and a family history of ovarian or breast cancer

- Symptoms suggestive of endometriosis should be specifically considered along

with any symptoms suggesting possible ovarian malignancy: persistent abdominal
distension, appetite change including increased satiety, pelvic or abdominal pain,
increased urinary urgency and/or frequency

- A careful physical examination of the woman is essential and should include

abdominal and vaginal examination and the presence or absence of local
lymphadenopathy

- In the acute presentation with pain the diagnosis of accident to the ovarian cyst
should be considered (torsion, rupture, haemorrhage)
 Investigations

Tumor Markers
- A serum CA-125 assay does not need to be undertaken in all premenopausal
women when an ultrasonographic diagnosis of a simple ovarian cyst has been
made

- Lactate dehydrogenase (LDH), α-FP and hCG should be measured in all women
under age 40 with a complex ovarian mass because of the possibility of germ cell
tumours
 Imaging

- A pelvic ultrasound is the single most effective way of evaluating an ovarian mass
with transvaginal

- The combined use of the TVS in combination with colour doppler may improve
sensitivity, particularly in complex masses

- MRI and CT: should be individualized. Not routinely requested

 Risk of malignancy?

- An estimation of the risk of malignancy is essential in the assessment of an ovarian

mass by calculating the risk of malignancy index (RMI)

- RMI = Ultrasound features x Menopausal status x CA-125

- Another tool that is highly sensitivity is benign (B-rules) or malignant (M-rules)

 Management

- Women with small less than 5 cm simple ovarian cysts generally do not require
follow-up as these cysts are very likely to be physiological and almost always
resolve within 3 menstrual cycles

- Women with simple ovarian cysts of 5-7 cm in diameter should have yearly
ultrasound follow-up and those with larger simple cysts should be considered for
either further imaging (MRI) or surgical intervention

- Ovarian cysts that persist or increase in size are unlikely to be functional and may
warrant surgical management

- Aspiration of ovarian cysts, either vaginally or laparoscopically, is less effective and

is associated with a high rate of recurrence
Postmenopausal Ovarian Cysts
- A thorough medical history should be taken from the woman, with specific
attention to risk factors and symptoms suggestive of ovarian malignancy, and a
family history of ovarian, bowel or breast cancer

- Where family history is significant, referral to the Regional Cancer Genetics service
should be considered

- In postmenopausal women presenting with acute abdominal pain, the diagnosis of

an ovarian cyst accident should be considered (e.g. torsion, rupture, haemorrhage)

- Appropriate tests should be carried out in any postmenopausal woman who has
developed symptoms within the last 12 months that suggest irritable bowel
syndrome, particularly in women over 50 years of age or those with a significant
family history of ovarian, bowel or breast cancer
- A transvaginal pelvic ultrasound is the single most effective way of evaluating
ovarian cysts in postmenopausal women

- CA125 should be the only serum tumour marker used for primary evaluation as it
allows the Risk of Malignancy Index (RMI) of ovarian cysts in postmenopausal
women to be calculated

- MRI, CT or PET scan should not be used routinely as the primary imaging tool for
the initial assessment of ovarian cysts in postmenopausal women
- Asymptomatic, simple, unilateral, unilocular ovarian cysts, less than 5 cm in
diameter, have a low risk of malignancy. In the presence of normal serum CA125
levels, these cysts can be managed conservatively, with a repeat evaluation in 4–6
months. If cyts are larger or symptomatic, consider surgery

- Initial findings that suggest malignancy, refer the patient to nearest oncologist
center

- Laparoscopic management of ovarian cysts in postmenopausal women should

comprise bilateral salpingo-oophorectomy rather than cystectomy
 Ovarian Masses in Pregnancy

 Adnexal masses in pregnancy are common, they are mostly benign.

 Most benign masses either resolve spontaneously or can be managed conservatively during pregnancy

 Ultrasound scan can reliably characterize most benign and malignant masses. MRI can be used to
characterize indeterminate or suspicious lesions

 The main predictors of persistence are a cyst diameter of greater than 5 cm and complex morphology at
imaging

 Surgery is indicated in cases of an acute abdomen or high suspicion of malignancy

 Laparoscopic surgery is appropriate in most cases depending on the tumour diameter, gestational age
and surgical expertise
1. Corpus luteal cyst
- Corpus luteal cysts produce progesterone and support pregnancy in the early first trimester

- Usually, they spontaneously regress by the 8th week of pregnancy when the placenta takes over
progesterone production inadvertent surgical resection may lead to miscarriage

- These cysts are highly vascular and prone to spontaneous haemorrhage or rupture miscarriage
Follicular cyst
2. Follicular cyst
- A physiologically mature follicle is typically less than 2 cm in diameter

- Failure of involution, or failure of a mature follicle to spontaneously rupture, results in a follicular cyst,
which is usually 2.5–6 cm in diameter

- Recognizing a follicular cyst enables a conservative management approach as it typically resolves

before 16 weeks of gestation
Follicular cyst
3. Haemorrhagic cyst
- Acute haemorrhage into an ovarian cyst presents as sudden abdominal pain, which usually resolves
within a few days

- Haemorrhagic cysts are usually benign but have varied sonographic appearances, and may be difficult
to distinguish from malignant lesions

- The presence of a clot, for example, may be confused for a solid nodule

- Colour Doppler will show no vascularity within the clot, whereas blood flow may be evident in a solid or
papillary lesion
Haemorrhagic cyst
4. Hyperstimulated ovaries
- Bilateral enlarged ovaries may be part of ovarian hyperstimulation syndrome (OHSS)

- In severe cases, the ovaries may be enlarged to greater than 12 cm, and as such are at high risk of
torsion and haemorrhage

- OHSS is self‐limiting and requires supportive management while awaiting resolution

- Cyst drainage is not normally recommended, and surgery is only indicated in women with associated
adnexal torsion or ovarian rupture

- Hyperstimulated ovaries are highly vascular and liable to damage on handling

Hyperstimulated ovaries
5. Luteoma of pregnancy
- This is a rare and benign condition in which luteinized stroma cells replace the ovarian parenchyma

- These cells produce androgens causing maternal virilisation in 25–30% of cases

- When maternal virilization occurs, there is a 50% risk of virilisation of a female fetus
Luteoma of pregnancy
6. Heterotopic pregnancy
- This is a rare event in pregnancy, but women who have undergone assisted reproductive techniques have
a 1–2% risk of heterotopic pregnancy

- There should be a high index of suspicion in patients with an adnexal mass

Heterotopic pregnancy
7. Mature cystic teratoma (dermoid cyst)
- Dermoid cysts are the most common adnexal cystic lesions diagnosed after 16 weeks of gestation

- Dermoid cysts less than 6 cm in diameter are generally asymptomatic in pregnancy. Dermoid cysts
greater than 6 cm are prone to torsion

- Where ultrasound scans reveal indeterminate lesions, MRI is useful for identifying features that suggest
‘fat content’, which are typical of a mature dermoid cyst
Dermoid cyst