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Year 5 - Obstetrics and Gynaecology > Ovarian cyst > Flashcards

Ovarian cyst Flashcards

1
Q

Define ovarian cyst.

A

Ovarian cyst is a surgical, imaging, or examination finding of an enlarged, fluid-filled ovary or portion of ovarian tissue.

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2
Q

List the different types of ovarian cysts.

A
  • Phsyiological cysts
  • Benign epithelial tumours
  • Benign germ cell tumours
  • Benign sex cord stromal tumours
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3
Q

How do ovarian cysts present?

A
  • acute pelvic pain
  • chronic pelvic pain
  • presence of an abdominal mass/adnexal mass
  • incidental finding on gynae examination or pelvic USS

Differentials: tumours of adjacent structures (uterus, bladder, bowel) and pregnancy.

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4
Q

How do you diagnose ovarian cysts?

A

USS - TVUSS is better resolution for pelvic masses, trans-abdominal USS indicated in those who have not been sexually active or in combination with TVUSS to explore large ovarian masses beyond the pelvis.

+/- CT/MRI - if thought to be malignant

Serology - for tumour markers to differentiate benign and malignant neoplasms

Pregnancy test - excluse pregnancy

CRP, WCC - exclude appendicitis or tubo-ovarian abscess etc

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5
Q

What is the management of a simple ovarian cyst?

A

If incidental finding on US + simple and…

Small (<50mm diameter): Expectant management - likely physiological and will resolve within 3 menstrual cycles; do not follow up

Medium (50-70mm diameter): Follow up - yearly US scan

Large (>70mm diameter): Imaging/Removal - further imaging required i.e. MRI or laparoscopic removal

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6
Q

What is the management of an ovarian cyst in a patient who is symptomatically unwell?

A

Laparoscopy or laparotomy - urgent surgical exploration required to manage possible ovarian torsion/cyst rupture or haemorrhage + reusus + broad spectrum antibiotics

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7
Q

What is the management of ovarian cyst in a post-menopausal patient with solid/complex ovarian cyst?

A

Treat as suspicious for malignancy:

  • TVUSS - determine risk of malignancy index (RMI)
    • RMI = US features of cyst + menopausal status + Ca125
  • Laparotomy
  • Gynae oncology review
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8
Q

What are the differentials for a pelvic mass?

A
  • Gynaecological: benign or malignant ovarian cyst; torsion; para-ovarian cyst; ectopic pregnancy; hydrosalpinx; pyosalpinx; tubo-ovarian abscess; tubal malignancy; pregnancy; fibroids; uterine malignancy.
  • Gastrointestinal: small or large bowel obstruction; diverticular/appendicular abscess; intussusception; malignancy.
  • Urological: hydronephrosis; pelvic kidney; renal/bladder malignancy.
  • Other: pelvic lymphocele; peritoneal cyst; psoas muscle abscess; lymphoma; neuroblastoma; aortic aneurism.
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9
Q

List 5 ovarian tumour markers.

A
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10
Q

Name 3 types of physiological ovarian cysts.

How can you decrease risk of developing these cysts?

A
  1. Follicular cyst - most common cyst type
  2. Corpus luteum cyst
  3. Theca luteal cyst

Functional cyst development risk is reduced by COCP use.

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11
Q

Describe the pathophysiology of a follicular ovarian cyst. What is the prognosis?

A
  • Pathophysiology: Occurs due to non-rupture of the dominant follicle OR failure of atresia in a non-dominant follicle
  • Prognosis: Commonly regress after several menstrual cycles
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12
Q

How do you diagnose a functional/physiological cyst? What size are they usually?

A

Diagnosed when cyst size is >3cm (normal ovulatory follicles measure up to 2.5cm). Aetiology is largely unknown.

Rarely grow >10cm

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13
Q

Describe the pathophysiology of a corpus luteum cyst. How does it more commonly present?

A

Pathophysiology: if pregnancy doesn’t occur in a menstrual cycle, the corpus luteum cyst usually breaks down and disappears. If this doesn’t occur, it may fill with blood or fluid and form a corpus luteal cysts.

Presentation: more likely to present with intraperitoneal bleeding than a follicular cyst and may need wash out and ovarian cystectomy if there is significant bleeding

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14
Q

What is the management of functional/physiological ovarian cysts?

A

Depends on symptoms:

Asymptomatic - reassure + repeat USS to check for resolution or non-enlargement

Symptomatic - laparoscopic cystectomy

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15
Q

What is the pathophysiology of theca luteal cysts? What is the prognosis?

A

Theca luteal cysts are associated with pregnancy, esp multiple pregnancy. Often bilateral

Prognosis - most resolve spontaneously during pregnancy

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16
Q

What are inflammatory ovarian cysts most commonly associated with?

A

PID and are most common in young women - can affect the tube, ovary, bowel or develop from other infective causes like appendicitis or dicerticular disease

17
Q

What is the management of inflammatory ovarian cysts?

A
  1. Antibiotics
  2. Surgical drainage or excision - after the acute infection has resolved due to risk of perioperative systemic infectoin and bleeding from handling acutely inflamed and infected tissue
18
Q

Which types of inflammatory cysts are known as ‘chocolate cysts’? How do these appear on USS?

A

Endometriomas - they have altered blood within the ovary making it look like a ‘chocolate cyst’.

USS - ‘ground glass’ appearance

NB: Removal or endometriomas must be balance against damage to the ovarian tissue. Overall medical treatment of endometriosis does not improve fertility but surgical does.

19
Q

Name a type of benign germ cell tumour of the ovary.

A

Dermoid cyst aka mature cystic teratomas

20
Q

Describe some characteristics of a dermoid cyst. How do they present? What is a common complication?

A

Lined with epithelial tissue and so may contain skin appendages, hair and teeth i.e. differentiated tissue types derived from all three embryonic germ cell layers (mesenchymal, epithelial and
stroma).

Presentation: Usually asymptomatic, bilateral in up to 10%

Complication: torsion is more likely than with other ovarian tumours, risk of malignant transformation (<2%, usually aged >40yrs)

21
Q

What is the commonest benign ovarian tumour in women <30 years?

A

Dermoid cyst

22
Q

When are dermoid cysts usually diagnosed? How?

A

Median age of diagnosis is 30 years

Pelvic USS but MRI also useful due to high fat content in dermoid cysts.

23
Q

What is the management of dermoid cysts?

A

Ovarian cystectomy - spontaneous resolution is unlikely. Especially indicated if symptomatic or if the cyst is >5cm or enlarging. This prevents ovarian torsion .

24
Q

What cyst appearance makes it suspicious for malignancy?

A

Multiloculated

25
Q

Name two benign epithelial tumours of the ovary. Which is the most common benign epithelial tumour of the ovaries?

A
  1. Serous cystadenoma - most common benign epithelial tumour
  2. Mucinous cystadenoma
  3. Brenner tumour
26
Q

What can a serous cystadenoma look like?

A

Bears a resemblance to the most common type of ovarian cancer (serous carcinoma). They are typically unilocular and unilatera.

Bilateral in 20%

27
Q

Which type of benign epithelial tumour of the ovary is the second most common and may become especially large?

A

Mucinous cystadenoma - are large multiloculated cysts that are bilateral in 10% of cases

28
Q

What is a complication of mucinous cystadenoma rupture?

A

Causes pseudomyxoma peritonei (PMP) - this is a rare type of cancer which begins in the appendix with polyp growth

29
Q

What is a Brenner tumour?

A

Type of epithalial ovarian tumour which contains urothelilal-like eithelium and may rarely secrete oestrogen

30
Q

Name two oviarian sex cord stromal tumour. Which cells do they consist of?

A
  • Ovarian fibroma - solid ovarian tumours composed of stromal cells.
  • Thecomas - benign oestrogen-secreting tumours
31
Q

What are the complications of ovarian fibromas and thecomas?

A

Ovarian fibromas - present in older women

  • Torsion - due to heaviness
  • Meig syndrome - pleural effusion, ascites and ovarian fibroma

Thecomas - benign oestrogen secreting tumours. Often present after the menopause with manifestations of excess oestrogen production, usually postmenopausal bleeding.

  • Post-menopausal bleeding
  • Endometrial carcinoma.
32
Q

What is Meig syndrome?

A
  1. pleural effusion
  2. + ascites
  3. + ovarian fibroma.

Removal of ovarian fibroma usually causes resolution of the pleural effusion

33
Q

Other ovarian cysts:

  • Fimbiral cysts
  • Paratubal cysts
  • Paraovarian cysts of Morgani - embryologically derived paraovarian cysts, appear like grape-like cysts derived from the paraoopheron
A
34
Q

What are the complications of ovarian cysts?

A

Cyst rupture - catastrophic bleeding may occur from rupture of corpus luteal cysts esp if patient is on anticoagulants or has a bleeding disorder. May be triggered by exercise, sexual intercourse or pelvic examination. Dermoid cyts can also rupture and cause a peritonitis due to inflammatory response

Ovarian torsion - emergency aparoscopy needed if this occurs.

Dyspareunia - common in PID and with cysts

Ovarian cancer - some emdometriomas may undergo malignant change

35
Q

What is the prognosis with ovarian cysts?

A
  • Simple cyst pre-menopause - 50% spontaneous resolution at 6 months in <6cm cysts, 75% at 75 months. But recur in 40%.
  • Complex cyst pre-menopause - only 8% spon resolution and 7% recurrence
  • Complex cyst post-menopause - risk of malignancy in solid cysts is ~40%
  • Pregnancy - most resolve sponteneously
36
Q

What main factors govern whether a cyst should be removed or not?

A

Whether treatment is needed will depend on:

  • cyst size and appearance
  • whether symptomatic
  • whether post-menopause – if postmenopausal there is a slightly higher risk of ovarian cancer
37
Q

How is ovarian cystectomy done?

A

Laparoscopy - several small incisions in the abdomen

Laparotomy - bigger incision in the abdomen; done if the cyst is large

38
Q

What must you warn patients about regarding cystectomy?

A

In some cases the ovary may also need to be removed which may affect fertility, especially if the other ovary is not functioning

39
Q

What are the immediate, short- and long-term complications of ovarian cystectomy?

A

Immediate:

  • Risks of anaesthetic
  • Bleeding requiring blood transfusion
  • Damage to other organs

Short-term:

  • Pain for 7-10 days following procedure
  • Infection of the wound
  • VTE
  • Vaginal discharge

Long-term:

  • Reduced fertility if oophrectomy
  • Recovery can take 3-4 weeks

Year 5 - Obstetrics and Gynaecology (87 decks)

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