Benign condition of the ovary and pelvis

Question 1

What is a functional ovarian cyst?

Answer 1

This is a group of ovarian cysts that includes:

• Follicular cyst
• Corpus luteum cyst
• Theca Lutein

The aetiology is not fully known. Follicular cyst is when ovulation doesnt occure and the follicle keeps growing. Corpus luteum cysts follow ovulation. Theca lutein cysts are associated with pregnancy, growing in response go hCG.

Question 2

How might a women with a benign ovarian mass present?

Answer 2

Symptoms:

• Pelvic discomfort
• Pressure on bowel/bladder

On examination:

• Pelvic/abdominal mass that is seperate from the uterus

If the pain is acute, torsion or rupture are possible!

Question 3

What are the different types of ovarian cysts?

Answer 3

An ovarian cyst is any fluid-filled sac within the ovary. They can be:

• Non-neoplastic ovarian cysts. These include functional cysts and inflammatory cysts.
• Benign neoplastic ovarian cysts (may have some malignant potential but are benign - basically like the word ‘tumour’). These include epithelial tumours, benign germ cell tumours and sex-cord stromal tumours.
• Malignant neoplastic ovarian cysts - referred to as ovarian cancers basically.

Question 4

How are follicular cysts managed?

Answer 4

• It is called a follicular cyst if they are ≥3cm on TVUSS (cf. 2.5cm for normal follicle)
• If asymtpomatic: reassure patient and repeat scan later to check for resolution
• If symptomatic: can perform laparoscopic cystectomy

Question 5

How are corpus luteal cysts managed?

Answer 5

• These occur following ovulation, can can present with pain due to rupture/haemorrhage (more commonly than follicular cyst).
• Treatment is expectant ± analgesia
• If there is significant peritoneal bleeding: wash out pelvis and cystectomy

Corpus luteal cysts are common in the first trimester of pregnancy, and will usually self-ressolve by the second trimester, so important to reassure the mother (as maternal stress is bad).

Question 6

What are inflammatory ovarian cysts?

Answer 6

Inflammatory ovarian cysts are associated with PID.

They are inflammatory masses, sort of like abscesses.

Endometriomas can (according to 10 teachers) be classified an inflammatory ovarian cyst.

Question 7

What is endometriosis?

Answer 7

• Endomatriosis is a disease in which endometrial glands and stroma implant and grow in areas outside of the uterine endometrial layer
• These are most commonly found in the pelvis, but can occur at distant sites, incl. pleural cavity, kidney, gluteal muscles, bladder etc.

Question 8

Summarise the epidemiology of endometriosis.

Answer 8

• Affects ~5-10% of woman of reproductive age (but probably underdiagnosed)
• As it if dependant on ovarian hormones, endometriosis resolves following menopause

Question 9

What are theories explaining the aetiology of endometriosis?

Answer 9

1. Retrograde menses and peritoneal implantation (Sampson’s theory)
2. Coelomic metaplasia: ie. that the peritoneal cells differentiate into endometrial cells (same embryogenal origin)
3. Vascular/lymphatic spread
4. Genetic/immunologic defects?

Question 10

What are clinical features a women with endometriosis might present with?

Answer 10

• Severe Pelvic Pain:
  
  • Can be cyclical or all the time (acyclic) if there are adhesions.
  • Associated with heavy menstrual bleeding (HMB)
  • Inlcudes deep dyspareunia, dysuria and dyschezia (which indicates endometriosis in pouch of Douglas)
  • Pain can also be in distant site

Irritable-bowel like symptoms include constipation and bloating.

• Subfertility:
  
  • Due to adhesions, which distort the normal anatomy -> Prevent sperm-egg interaction
  • Mild subfertility occurs in mild disease even without anatomical distortion . mechanism unknown
  • 30-40% of women with endometriosis complain of problems conceiving

Question 11

What might you find on physical examination in a woman with endometriosis?

Answer 11

Examination is of limited use in diagnosis of endometriosis as is often normal and so should not exclude endometriosis. Signs of endometriosis on examination include:

• General tenderness and tenderness in the pouch of Douglas
• Thickening or nodularity of the uterosacral ligaments
• An adnexal mass
• Fixed retroverted uterus

Question 12

What investigations would you like to perform in a woman with suspected endometriosis?

Answer 12

• TVUSS: can detect ovarian endometriosis (aka. endometriomas) and adhesions, but oterwise of limited use
• MRI: can detect lesions >5mm in size
• Laparoscopy is gold standard. Also allows for simultaneous biopsy for histological confirmation

Question 13

How is endometriosis staged?

Answer 13

There are 4 stages to endometriosis:

1. Minimal
2. Mild
3. Moderate
4. Severe

This is based on extent of spread of the tissue, involvement of other pelvic structures, extent of adhesions, and blockage of Fallopian tubes.

Question 14

How would you manage a woman with endometriosis?

Answer 14

Patients with endometriosis are difficult to treat, not only from a physical view, but also because of associated psychological issues associated with heir pain. Medical management should be started before confirmation of diagnosis with laparoscopy even if the clinical examination and TVUSS are normal.

All women should be provided with information on their condition and signposted to websites such as Endomertiosis UK (www.endo.org.uk) and The Endometriosis SHE Trust UK (www.shetrust.org.uk/). Medical management includes:

• Analgesic therapy is only for symptom control and should only involve NSAIDs such as ibuprofen, naproxen or mefenamic acid. Offer paracetamol if contraindicated to NSAIDs.
• If a woman does not want to conceive, a trial of COCP can be taken. It has been shown to reduce endometriosis associated dyspareunia, dysmenorrhea and non-menstrual pain as well as providing cycle control. More effective if taken back to back instead of having pill free bleeds, inducing amenorrhea.
• If the woman does not want to take combined hormonal contraceptive, or is contraindicated, then progestogens should be used to induce amenorrhea. This can be in form of the LNG-IUS, depot, implant etc.

Review the woman in 3-6 months and if symptoms have not improved, refer to a gynecologist.

Gynecologists may consider:

• GnRH agonists
• Aromatase inhibitors (e.g. letrozole)

Surgical:

• Fertility sparing:
  
  • Ablation of endometrial implants
  • Adehsiolysis
  • Endometrioma resection
• Hysterectory/oophorectomy

Assissted reproductive technology (Ovulation indcution/IVF) can be used if pregnancy is desired.

Question 15

What is chronic pelvic pain?

Answer 15

RCOG defines chronic pelvic pain as:

• Intermittent or constant pain
• in lower abdomen/pelvis of a woman
• of at least 6 months duration
• not exclusively occuring with mensturation
• or intercourse
• or pregnancy.

Question 16

What are possible causes for chronic pelvic pain?

Answer 16

CPP is multifactorial is most cases unlike acute pelvic pain. The effect of chronic pelvic pain on the patient themselves is affected by other physical factors, psychological and social factors. Depression ands leep disorders are common. A substantial number give a childhood or ongoing history of sexual or physical abuse.

Common contributing factors include:

• Endometriosis and adenomyosis
• Adhesions including chronic PID
• Irritable bowel syndrome symptoms are very common including cramping, abdominal pain, increased gas, bloating, altered bowel symptoms.
• Psychosocial issues

Oestrogen activity seems to be important, as suppression of ovarian activity cures 2/3 of cases. Other causes include:

Gynaecological:

• Endometriosis/adenomyosis
• Adhesions (incl. PID)
• Fibroids
• Ovarian cysts

GI:

• IBS
• Constipation
• IBD
• Coeliac’s

Urological:

• Recurrent UTIs
• Stones

Pain arising from pelvic muslces or joints, nerve entrapment/neuropathic pain or psychological/social issues.

Question 17

What investigations might you consider in a woman with chronic pelvic pain or a pelvic mass?

Answer 17

Always exclude pregnancy!

Diagnosis often takes time. The patient’s own ideas on the cause of the pain needs to be elicited and discussed. There is frequently more than one component to the pain. Psychosocial evaluation is very important in CPP.

An abdominal and pelvic examination should look for areas of tenderness and pelvic masses. Common investigations for CPP include:

• Genital tract swabs for all sexually active women screening for STIs such as Chlamydia and Gonorrhoea which may help diagnose PID.
• TVUSS but Abdo USS if a virgin
• CT/MRI, especially where potentially malignant
• Laparoscopy where pelvic masses, endometriosis or adhesions are suspected. Used to be considered the ‘gold standard’ but 40% of diagnostic laparoscopies fail to show any cause for the CPP symptoms.

Bloods:

• CRP/WCC to look for signs of inflammation (PID?)
• Tumour markers (if malignancy suspected)

Question 18

What are good resources you might point a woman with endometriosis to?

Answer 18

• Endometriosis UK (endo.org.uk)
• Endometriosis SHE Trust (Shetrust.org.uk)

Question 19

What are possible complications of ovarian cysts?

How would you manage them?

Answer 19

They can rupture or lead to torsion.

Management torsion:

• Urgent surgery to detort the ovary

Management rupture:

• ABC approach (as it might bleed lot)
• Suregical repair
• Supportive measurements such as blood transfusions if required

Question 20

Describe ovarian tortion and it’s aetiology

Answer 20

Ovarian torsion is where rotation of the vascular pedicle supplying the ovary compresses and cuts it’s blood supply. If the fallopian tube is also involved then it is referred to as adnexal torsion.

Torsion is more likely to be seen with enlargement of the ovary as is seen with ovarian cysts, torsion is very unlikely in normal ovary. Up to 15% of dermoid cysts present with Ovarian torsion.

Question 21

What are the clinical features of ovarian tortion?

Answer 21

Patients present with acute onset colicky lower abdominal pain associated with vomiting, nausea and distress.

Question 22

Describe the diagnosis and management of ovarian tortion

Answer 22

Ultrasound may show free fluid and presence of a cyst. Doppler measurement of blood flow may be useful in the diagnosis.

Management:

Emergency surgical treatment to untwist the ovary and the ovarian cyst should be removed at the same time. If the torsion was not recognised in good time, removal of necrotic material will be necessary.

Question 23

What are the symptoms of an ovarian cyst?

Answer 23

In general women with benign ovarian masses are asymptomatic but can present with pelvic discomfort and may have symptoms secondary to pressure on bowel or bladder. On examination, there is pelvic/abdominal mass that is separate from the uterus.

If pain is acute, suspect torsion or rupture.

Question 24

How do endometriomas appear on ultrasound tests?

Answer 24

Patients may present with endometriomas, often known as chocolate cysts due to the presence of altered blood within the ovary. They have characteristic ground glass appearance on USS.

Question 25

What are the types of benign neoplastic ovarian cysts?

Answer 25

These present as ovarian cysts. Benign ovarian cysts/tumours include:

• Epithelial tumours including serous cystadenomas, mucinous cystadenomas and Brenner tumours.
• Benign germ cell tumours - of the germ cell tumours, mature cystic teratomas also called dermoid cysts are the benign ones. See here for malignant germ cell tumours.
• Sex-cord stromal tumours such as a fibroma.

Question 26

What are the types of benign epithelial ovarian tumours?

Answer 26

Benign epithelial tumours increase in frequency with age and are most common in perimenopausal women. The most common epithelial tumours are serous cystadenomas, accounting for 20-30% of tumours in women under 40. They are typically unilateral.

Mucinous cystadenomas are the second most common benign epithelial tumour. They are typically large multiloculated cysts and bilateral in 10% of cases.

Brenner tumours are also a thing some female humans suffer from.

Question 27

What are dermoid cysts?

Answer 27

Mature cystic teratomas also called dermoid cysts are a type of teratoma. This happens when a germ cell differentiates into embryonic germ cells before becoming neoplastic. They are the most common ovarian tumour in young women aged 20-40, accounting for more than 50% of ovarian tumours in this age.

Dermoid cysts contain tissue from all three embryonic layers and therefore hair, teeth, skin, muscle, cartilage and bone are commonly found. Teratomas are bilateral in 10%, and the risk of malignant transformation is rare so they usually do not invade.

Question 28

How are ovarian teratomas diagnosed and managed?

Answer 28

Diagnosis is confirmed with pelvic USS and because of the high fat content present in dermoid cysts, MRI may also be useful where there is uncertainty.

In general, ovarian cystectomy is indicated because spontaneous resolution is unlikely. Surgical treatment is indicated if the dermoid cyst is symptomatic or is more than 5cm in diameter or is enlarging.