Ovarian Cyst Flashcards
Define ovarian cyst
An enlarged fluid filled sac on or in the ovarian tissue
> 3cm diameter
The cyst may be UNILOCULAR or MULTILOCULAR
What are the types of ovarian cyst
Physiological/functional
- Follicular (most common)
- Corpus luteal cyst
Benign germ cell
- Dermoid cyst/mature cystic teratoma
Benign epithelial
- Serous cystadenoma
- Mucinous cystadenoma
What is the difference between simple and complex cysts
Simple = thin walled without internal structures
- Normal cyclical development of follicles disrupted
- <50mm diameter
- Resolves ofer 2-3 menstrual cycles without intervention
Complex = abnormal reproduction of cells in or on the ovaries (neoplastic)
- >10cm
- Irregular borders
- Internal septations - multi-locular appearance
- Fluid is heterogenous (may contain solid components)
What are the risk factors for ovarian cysts
Pre-menopausal women
Early menarche
1st trimester of pregnancy
PCOS
Endometriosis
Treatment for fertility
Tamoxifen therapy
What are the symptoms of ovarian cysts
Dull, aching, lower abdominal/ pelvic pain (usually chronic)
- Can be intermittent, unilateral
Bloating and early satiety
Deep Dyspareunia
Compression: Urinary frequency and frequent bowel movements
Dysmenorrhoea (endometriomas)
What are the signs of ovarian cysts on examiantion
Abdominal mass if large cyst
Palpable adnexal mass
Low BP, high HR
Speculum: peritonitic can cause cervical excitation (Rupture, torsion, and haemorrhage)
What are the symptoms of ruptured ovarian cysts
Sudden, sharp, severe pain
- unilateral
- Deep pelvic pain
- Precipitated by intercourse or strenuous activity
Low BP, high HR
What investigations should be done for ovarian cysts
Bloods: FBC, CA-125, b-hCG, aFP*
Other: TV-USS
- Ruptured = free fluid in pelvic cavity
- Torsion = enlarged, oedematous ovary with impaired blood flow
If indicated:
Colour power Doppler USS of abdomen/ pelvis
MRI/ CT of abdomen/ pelvis
Karyotyping analysis
Calculate Risk malignancy index (RMI) score: USS features of cyst + menopausal status + Ca-125
*If simple cyst then bloods and serum CA-125 are NOT needed
How are cysts classified on TVUSS
IOTA criteria: benign (‘B rules’) or malignant (‘M rules’)
M rules:
- Irregular, solid tumour.
- Ascites.
- At least 4 papillary structures.
- Irregular multilocular solid tumour with largest diameter ≥100 mm.
- Very strong blood flow.
What is the management for premenopausal women with a simple cyst
< 50mm: Usually do NOT need follow up (often resolves within 2-3 cycles)
50-70mm: Yearly USS, if increasing in size → refer
> 70mm: gynae referral → Considered for further imaging (MRI) or surgical intervention
What is the management for complex cysts
Should be treated as malignant until proven otherwise
Serum CA-125, aFP, and b-hCG should be performed in all premenopausal women
Cystectomy may be required
What are the indications for conservative management for ovarian cysts
Unilateral
Unilocular (no solid parts)
Pre-MP (3-10cm)
Post-MP (2-6cm)
Normal CA125
No free fluid
What is the management for post-menopausal ovarian cysts
RMI <200: asymptomatic, simple cyst, <5cm, unilocular, unilateral → repeat USS, Ca-125i n 4-6m:
(1) Resolved
(2) Unchanged → repeat USS, Ca-125in 4-6m
(3) Changed → laparoscopic cystectomy
Symptomatic, non-simple features, >5cm, multilocular, bilateral → gynae referral →BSO
RMI >200: CT-AP → MDT management
What is the management for ovarian cysts in pregnant women
Most simple ovarian cysts disappear as pregnancy progresses
If the cyst is large or complex, can be offered further scans during pregnancy and postpartum
What is the surgical management for ovarian cysts
Ovarian cystectomy
- Diagnostic (and exclude ovarian cancer)
- Removal of symptomatic cysts
- Cyst ≥7.6cm
- Cysts hat do not resolve after 2-3 months
- Bilateral lesions
- USS finding that deviate from simple functional cyst
TVUSS before surgery is VITAL to characterise the mass and determine the risk malignancy index (RMI)
Torsion → immediate cystectomy
