2.13 Ovarian Cysts

Question 1

What might a “string of pearls” appearance on the ovaries raise suspicion of?

Answer 1

PCOS

Question 2

When there is a “string of pearls” appearance what else is needed to make a diagnosis of PCOS

Answer 2

PCOS Dx requires:

• anovulation
• hyperandrogenism
• polycystic ovaries on US

Question 3

How do most ovarian cysts present?

Answer 3

usually asymptomatic and found on US incidentally

occasionally Sx of:

• pelvic pain
• bloating
• abdo fullness
• palpable pelvic mass (esp large eg mucinous cystadenomas)

Question 4

Name 3 types of Functional / physiological ovarian cysts?

Answer 4

Follicular cysts

Corpus luteum cysts

Theca-lutein cysts (pregnancy only)

(PCOS cysts too)

Question 5

How do follicular and corpus luteum cysts end up forming? US appearance?

Answer 5

Follicular:

• developing follicle fails to rupture and release egg
• empty cyst, no internal structures

Corpus luteum:

• corpus luteum fails to break down and fills with fluid
• pelvic pain and delayed menstruation
• spider web / lace like pattern
• ring of fire on doppler
• aka haemorrhagic cysts

Question 6

How would you manage a simple / functional ovarian cyst?

Answer 6

PREMENOPAUSAL:

<5cm will usually resolve in 3 cycles, no followup

5-7cm referral to gynae and yearly US

> 7cm consider MRI or surg evaluation as can be difficult to characterise on US

POSTMENOPAUSAL:

do CA125:

• if raised –> 2 week wait referral
• if low –> monitor with US every 4-6months

Question 7

Other than function cysts, name 6 other types of ovarian masses?

Answer 7

Serous cystadenoma

Mucinous cystadenoma

Endometrioma

Dermoid cyst / aka Germ cell tumour / aka Teratoma

Sex cord stromal tumour

Fibromas

Question 8

Compare Serous cystadenoma and Mucinous cystadenoma?

Answer 8

Serous cystadenoma:

• common 30 - 40yrs
• 30% bilateral
• 30% malignant

Mucinous cystadenoma:

• 30-50yrs
• commonest LARGE ovarian tumour
• 5% malignant
• remove appendix at the same time

Question 9

What are endometriomas? What is another name for them?

Answer 9

aka chocolate cysts

endometrial tissue in the ovary, fill with blood as cycles go on.

Question 10

What is a Dermoid cyst / aka Germ cell tumour / aka Teratoma made of? Associated with?

Answer 10

made from germ cells so can contain various types of tissue: skin, teeth, hair, bone

associated with OVARIAN TORSION

Question 11

What types of sex cord stromal tumours are there?

Answer 11

several including:

Sertoli-Leydig cell tumours

Granulosa cell tumours

(rare, can be benign or malignant)

Question 12

What symptoms might suggest a cyst is malignant rather than benign?

Answer 12

• Bloating
• Eating less
• Abdo pain
• Trouble with bladder
• ascites
• lymphadenopathy

Question 13

What are some risk factors for ovarian malignancy?

Answer 13

• age
• postmenopause
• increased number of ovulations
• HRT
• smoking
• obesity
• FHx and BRCA1 and BRCA2

(breast feeding is protective)

Question 14

What are the tumour markers for a germ cell tumour?

Answer 14

• LDH
• aFP
• hCG

(all women under 40 with couples mass)

Question 15

What is the scoring system for ovarian cancer risk?

Answer 15

Risk of malignancy index (RMI)

Question 16

What goes into the RMI score calculation?

Answer 16

RMI = U x M x Ca125

M = menopausal status; pre=1 post=3

U = US score; 1-2 points for:

• multilocularity
• solide areas
• metastasis
• ascites
• bilaterality of lesions

SCORE:
<25 = <3% Cx risk
25-250 = 20% Cx risk
>250 = 75% Cx risk

Question 17

What are three complications of cysts?

Answer 17

• torsion
• haemorrhage (into the cyst)
• rupture with bleed into peritoneum

(acute onset pain)

Question 18

What is an ovarian fibroma associated with?

Answer 18

Meig’s syndrome

Question 19

What is the triad of Meig’s syndrome?

Answer 19

• ovarian fibroma (benign)
• pleural effusion
• ascites

(ovarian mass, typically in older women, removal of tumour is resolution)