BENIGN OVARIAN DISEASES

BY DR FG MHLANGA
fmhlanga@uzchs-ctu.org
+263772335232
 Benign Ovarian Diseases

• Are common in the reproductive age group

and are caused by;

– physiologic cysts
– benign neoplasm
– inflammatory conditions
 Functional Ovarian Cysts
• arise from temporary pathologic variations
of a normal physiologic process during a
woman's menstrual life
• Tumours result from
– failure of a dominant mature follicle to rupture
– failure of an immature follicle to undergo the
normal process of atresia
THE IVF PROCESS
• Cyst without any histologic evidence of
participation in ovulation are termed follicular
cysts
• If significant luteinization present, called theca
lutein cysts.
• If site of an ovulation, they are named corpus
luteum cysts.
– Luteinization in simple terms refers to an increased
amount of cytoplasm in cells producing steroid
hormones.
 ..
2. Follicular Cysts
• Commonly occur in neonatal, childhood and
reproductive years
• Most commonly seen cystic enlargements of the
ovary and can reach 8 – 9cm in diameter
• In menstruating women
– Are a sign of ovulatory failure
– Also seen in hyperstimulation of ovaries from use of
fertility drugs
• May be multiple, recurrent or bilateral
• Most common functional cyst rarely exceeding
4cm in diameter. Walls are lined with granulose
cells producing high E2 levels.
• Persistently enlarged cysts require further
investigation such as laparatomy or laparoscopy
• Ovarian cystectomy with conservation of ovarian
tissue is the treatment of choice
 Theca lutein cysts
• Occur in association of high levels HCG
therefore seen in hydatidiform mole. Cysts
may grow to as large as 15cm in diameter
• After evacuation of the uterus for a molar
pregnancy or after pregnancy, theca luteal
cysts regress.
• Surgery reserved for cases with
complications such as torsion or
haemorrhage
•
 Functional Cysts
1. Corpus luteal cyst
• are thin walled
• measure 3 to 11cm
• Mainly result from intra cystic haemorrhage
• filled with serous or serosanganinous fluid
• May grow bigger in pregnancy
• Usually incidental finding
 ..
• Will regress spontaneously in 1 to 2 months
• May complicate and present with
haemorrhage, torsion or rupture
• Management usually conservative, but
surgical when it complicates - laparoscopic
approach ideally
 Granulosa lutein cysts
• occur in 2nd half of menstrual cycle –
persistent production of progesterone may
result in amenorrhea or delayed
menstruation.
• These are functional cysts of the corpus
luteum – may rupture to result in
haemoperiotoneum spontaneous regression
usually occurs.
 Hyperplasic conditions

• Polycystic ovarian syndrome

– Also known as Stein-Leventhal Syndrome
– 3.5% to 7% of females have this
– May present with;
• anovulation, obesity, secondary amenorrhoea,
• infertility or hirsuitism
– Usually involves both ovaries
– May be 2 to 5 times original size
 – USS will show follicles 6 – 8mm in diameter
around the periphery of the ovary
”string of pearl” appearance
Diagnosis-2 of 3 criteria
• Polycystic ovaries
• Signs of androgen excess;
– acne, hirsuitism, temporal balding, male pattern hair loss,
cliteromegaly, etc
 • Menstrual irregularity-oligo or polymenorrhoea.
Many struggle with sub fertility due to anovulation
or oligo ovulation.
– Rx
• Oral contraceptive
• Danazol
• GnRHa
• Ovulation inducing agents+/- metformin
 Iuteoma of pregnancy
– Occurs in pregnancy
– Ovaries may be large up to 20cm in diameter
– Often associated with maternal virilisation
– Due to HCG stimulation
 Rx –conservative
 Ovarian Neoplasms

• A variety of neoplasms can result from ovary

• Can be divided into:
• Epithelial
• Germ cell
• Stromal tumours
 Benign cystic Epithelial Tumours

account for ~ 60% of all true ovarian neoplasms

• serous cystadenoma
• a/c for 50 - 70% of all benign ovarian tumours,
usually women in 40-50s
• bilateral in ~15-20% of cases
• usually multilocular
• Rx . pre-menopausal – cystectomy
• Post menopausal – salpingo-oopherectomy
• mucinous Cystedenoma
• may grow to large sizes, +/_30cm
• about 75-85% are benign, usually 30-50s
• multilocular and unilateral
• may contain benign, borderline and malignant
changes in one tumour
• May rupture to cause pseudomyxoma peritonei.
• Other benign epithelial tumours are clear cell,
endometroid and transitional cell tumours
• Treatment-as for serous
 Solid benign tumours
1.Sex Cord –Stromal Cells
• Thecomas
– May present with post menopausal bleeding in
endometrial cancer because of oestrogen
production
– Never malignant
– Rx TAH and BSO in post menopausal
– Salpingo-oopherectomy or cystectomy in others
Fibroma
• can be associated with a hydrothorax, ascites
and pelvic mass (Meig’s syndrome)
• Common in post menopausal
• Unilateral, at least 3 cm in diameter
2.Germ cell tumours
• Most common ovarian tumour in children
and young women
• Accounts for 90% of pre-pubertal tumours
and 60% of tumours in young women
younger than 20.
• Patients usually complain of abdominal pain
and have an abdominal mass.
• A/c for 25% of ovarian neoplasms
Mature cystic teratoma
• Also known as dermoid cysts
• Most common benign solid ovarian neoplasm
• peak incidence from ages 20 to 40 years, though can
be seen in infancy or menopausal years
• 5 to 10cm in diameter and bilateral in 8 – 15% of
cases
• Usually unilocular but may be multi locular
• Filled with a fatty material and hair. A solid portion may
occur at one place where hair, teeth, bone may be
found.
• In the past diagnosis by abdominal X-ray which easily
visualises teeth
• Torsion is a frequent complication
• Cystic rupture may result in a chemical peritonitis due to
spillage of cyst contents causing dense adhesions
• Rx -ovarian cystectomy with preservation of the ovary
 Inflammatory
1.Tubo-ovarian Abscesses
• Seen in 14-38%patients with PID
• Presents with pain, discharge, fever, chills,
genitourinary symptoms
• On exam abd. tender with guard and rebound, bil
adnexal tender with CET
• Raised wcc and esr
• On scan- fluid with internal echoes.
Treatment-iv antibiotics,
-surgery
2.Endometriosis
• ~10-15% of reproductive-aged women have it.
• common symptoms of endometriosis are pelvic pain,
dysmenorrhea, dyspareunia, and infertility
• May present with bilateral endometrial cysts, known
as endometriomas- complex ovarian masses with
blood inside - chocolate cysts
• Endometriomas -Often bilateral
-range in size from small to
medium (5-6 cm).
Treatment
• Lap’scope excision or diathermy
• Coc,nsaids,GnRHa,danazol
• TAH & BSO
 Evaluation of Adnexal Masses
1) USS
• TVS gives best visualization
• Assess
: Size
: Location (unilateral or bilateral)
: Internal characteristics
:+ fluid in PID
• Be wary of cysts
» Predominantly solid
» > 10 cm in size
» Thick and numerous septae
» Internal papillae or nodules
 • Small amount of fluid on PID is expected
- Too much suspicious of malignancy

2) Doppler USS
• Allows assessment of ovarian blood flow
• Used to detect neoangiogenesis often associated with ovarian
cancers
3) CT Scan

4) MRI