Ovarian Cysts

Lim Su-Ying
Women’s Health EJR Group 5
 Definition
• Fluid-filled sac (that is more than 3cm in
diameter)
• Develops on or in an ovary
• Ovarian cysts may be thin-walled and contain
only fluid (simple cyst) or may be more
complex, containing thick fluid, blood or solid
areas
 Types of Ovarian Cysts

Inflammatory Endometrioma
Follicular cyst

Benign
Germ cell
Teratoma
Pathological
Functional Cyst Corpus luteal cyst
Cyst
Epithelial Cystadenoma

Theca luteal cyst Sex cord

Thecoma
stromal
 Follicular Cyst

Pathophysiology May result from lack of physiological release of ovum due to

excessive FSH stimulation or lack of normal LH surge at
midcycle just before ovulation.

Typically larger than 2.5cm (normal ovulatory follicles

measure up to 2.5cm)

Rarely grow larger than 10cm and appear as simple

unilocular cyst on USS
 Corpus Luteal Cyst
Pathophysiology In the absence of pregnancy, lifespan of corpus luteum is 14
days.

If ovum is fertilised, corpus luteum continues to secrete

progesterone for 5-9 weeks, until its eventual dissolution in
14 weeks time.

Failure of dissolution may result in a corpus luteal cyst.

Definition: Corpus luteum that grows to 3cm in diameter

Can cause dull, unilateral pelvic pain an may be complicated

by rupture, which causes acute pain, typically in the late
menstrual cycle.
 Theca Luteal Cyst

Pathophysiology Associated with pregnancy, particularly multiple pregnancy

Caused by luteinisation and hypertrophy of the theca interna

cell layer in response to stimulation from the human
chorionic gonadotropin (hCG)
 Pathological Cyst
• Inflammatory (Endometrioma)
– Blood-filled cysts arising from the ectopic endometrium.
– Often known as ‘chocolate cyst’ due to presence of altered blood within the
ovary
– Causes classic triad of painful and heavy periods and dyspareunia
– Have a characteristic “ground glass” appearance on USS
• Germ cell (Teratoma)
– Contain elements from all 3 embryonic germ layers, ie, ectoderm, endoderm
and mesoderm
– Any mature tissue type may present e.g. hair, muscle, bone
– High in fat content
– Most common tumours in young women
• Sex Cord Stromal tumours (Thecoma)
– Groups of tumors composed of granulosa cells, theca cells, Sertoli cells, Leydig
cells, and fibroblasts of stromal origin
• Thecoma: Benign oestrogen-secreting tumours
Often present post-menopause with manifestation of excess
oestrogen production such as post-menopausal bleeding
 Signs and Symptoms
Most ovarian cysts are diagnosed by chance, e.g. during a routine
examination or an ultrasound scan. Therefore you may have no
symptom at all.
However, you may experience one or more of
the following:
• Pain or discomfort in the lower abdomen
• Severe pain form torsion or rupture
• Discomfort with intercourse
• Pressure symptoms
• Irregular menstrual cycle
• Abdominal fullness and bloating
• Endometriomas – These are associated with endometriosis, which
causes a classic triad of painful, heavy periods and dyspareunia
• PCOS – This includes hirutism, infertility, oligomenorrhoea, obesity
and acne
 Risk Factors
• Infertility treatment
Patients being treated for infertility by ovulation induction with
gonadotrophins may develop cysts as part of ovarian hyperstimulation
syndrome
• Pregnancy
Ovarian cysts may form in the second trimester, when hCG levels peak
• Hypothyroidism
May stimulate ovarian and cysts growth due to similarities between alpha
subunit of TSH and hCG
• Maternal gonadotrophins
The transplacental effects of maternal gonadotrophins may lead to the
development of neonatal and fetal ovarian cysts.
 Complications
In most cases, ovarian cyst is benign and asymptomatic, requires no further
management and will resolve on its own.

• Torsion
Higher incidence in ovarian cyst >4cm.
Ovarian torsion involves rotation of ovarian vascular pedicle, causing obstruction
to venous, and eventually arterial flow that can lead to infarction
Most cases occur in premenopausal women of childbearing age
More common on the right side(sigmoid colon restricting mobility of the left
ovary)
Most common ovarian mass associated with torsion is DERMOID CYST

• Rupture
Commonly occurs with CORPUS LUTEAL CYST
USS may demonstrate free fluid in the pouch of Douglas
 Investigation
• Ultrasound scan
– A pelvic ultrasound is the single most effective way of evaluating an
ovarian mass with transvaginal ultrasonography being preferable due
to its increased sensitivity over transabdominal ultrasound.
– Masses are classified as benign (B-rules) or malignant (M-rules).
Women with an ovarian mass with any of the M-rules ultrasound
findings should be referred to a gynaecological oncological service.

M-rules
Irregular solid tumours
Ascites
Irregular multilocular solid tumour with diameter
>100mm
Very strong blood flow
 Other tests
• CA-125
– May be conducted in women with high risk of ovarian
cancer, e.g. family history or mutations in the BRCA1 and
BRCA2 genes
– Not specific, may be elevated in other conditions
– Commonly used to monitor response to cancer treatment
– Normal value <35U/ml
• Other marker
– Lactate dehydrogenase (LDH), alpha-feto protein and hCG
should be measured in women under age 40 with a
complex ovarian mass because of the possibility of germ
cell tumours
 Other tests
• Risk of malignancy Index I (RMI I)

Risk RMI Risk of cancer (%)

Low <25 <3
Moderate 25 – 250 20
High >250 75
 Premenopausal Management
• A simple cyst that measures less than 5cm in diameter
Normally, treatment is not necessary. These cysts usually
disappear on their own after a few months.
• A simple cyst that measures 5-7cm in diameter
Follow-up ultrasound scan a year later
• A simple cyst that measures more than 7cm in diameter
May be offered further tests, such as MRI and/or surgery

Surgical intervention
Laparoscopic (keyhole)surgery
Laparotomy (open surgery) may be recommended if the cyst
is very large or if there is a suspicion of cancer
Postmenopausal Management
 Differential Diagnosis
Conditions Signs
Ovarian cancer Suspect in post-menopausal
women (>65 years); family
history of BRCA1 and BRCA2
gene malignancy;
unexplained weight loss,
ascites
Polycystic Ovarian History of menstrual
Syndrome irregularity, hirutism, weight more follicles in each ovary
gain, acne and infertility
Endometriosis History of painful period
(dysmenorrhoea) or heavy
period (menorrhagia)
Test
Ultrasound findings of
irregular multilocular solid
tumour >10cm with strong
blood flow
Perform histopathology to
confirm the diagnosis
Ultrasound findings: 12 or
measuring 2 to 9 mm in
diameter or increase in
ovarian volume (>10ml)
Transvaginal ultrasound may
detect a ‘ground glass’
appearance: ovarian
endometrioma
 List of reference
• Management of Suspected Ovarian Masses in Premenopausal
Women (2011) 1st edn. [Online]. UK: Royal College of Obstetricians and
Gynaecologists. Available at:
https://www.rcog.org.uk/globalassets/documents/guidelines/gtg_62.pdf.
(Accessed: 9 February 2016).
• Nhs.uk, (2016) Ovarian cyst - NHS Choices. [Online]. 2016. Available at:
http://www.nhs.uk/conditions/ovarian-cyst/pages/introduction.aspx.
(Accessed: 9 February 2016).
• Ovarian cysts before the menopause (June 2013) . UK:Royal College of
Obstertricians and Gynaecologist. Available at:
https://www.rcog.org.uk/globalassets/documents/patients/patient-
information-leaflets/gynaecology/ovarian-cysts-before-the-
menopause.pdf (Accessed: 9 February 2016).
• Medscape (13 Feb 2015) Ovarian Cysts. Available at:
http://emedicine.medscape.com/article/255865-overview#a3 (Accessed:
9 February 2016).