Ovarian Cysts

Question 1

What are the types of ovarian cysts?

Answer 1

• Functional
  
  • Follicular
  • Corpus luteal
  • Theca lutein
• Inflammatory
  
  • Tubo-ovarian abscess
  • Endometrioma
• Germ Cell
  
  • Dermoid
• Epithelial
  
  • Serous cystadenoma
  • Mucinous cystadenoma
  • Brenner’s tumour
• Sex Cord Stromal
  
  • Fibroma
  • Thecoma
  • Granulosa cell

Question 2

Describe follicular ovarian cysts.

Answer 2

• Cyst = >3cm - >5cm is at risk of torsion
• USS
  
  • Thin walled
  • Unilocular
  • Anechoic
• MOST COMMON ovarian cyst

Question 3

Describe corpus luteal ovarian cysts.

Answer 3

• Occur after ovulation
  
  • May rupture at the end of the menstrual cycle
• USS
  
  • Diffusely thick wall
  • <3 cm
  • Lacey pattern

Question 4

Describe theca lutein ovarian cysts.

Answer 4

• Features:
  
  • Can cause hypertension
  • Often bilateral
  • Resolve spontaneously
• Associated with pregnancy/high circulating gonadotrophins
• USS
  
  • Bilaterally enlarged
  • Multicystic ovaries
  • Thin-walled and anechoic

Question 5

Describe tubo-ovarian abscess.

Answer 5

• Features of PID
• Tender adnexal mass
• USS
  
  • Ovary and tube cannot be distinguished from mass

Question 6

Describe endometrioma.

Answer 6

• Chocolate cyst
• Associated with endometriosis
• USS
  
  • Unilocular with ground-glass echoes (50% of cases)

Question 7

Describe dermoid ovarian cysts.

Answer 7

• Mature = benign, solid or cystic
  
  • USS
    
    • Unilocular
    • Diffusely or partially echogenic
    • May contain teeth, no internal vascularity
• Immature = embryonic elements, malignant

Question 8

Describe epithelial ovarian cysts.

Answer 8

• Serous Cystadenoma - most common ovarian neoplasm
  
  • Usually unilocular
  • Often bilateral
  • USS
    
    • Unilocular
    • Anechoic
    • No flow on colour Doppler
• Mucinous Cystadenoma
  
  • Usually Large
  • USS
    
    • Multi-loculated
    • Many thin separations
    • Low echogenicity due to mucin
• Brenner’s Tumour
  
  • Small
  • Contain urothelial-like epithelium
  • USS
    
    • Hypoechoic
    • Occasionally calcifications may be seen

Question 9

Describe sex cord stromal ovarian cysts.

Answer 9

• Fibroma
  
  • Benign
  • No endocrine production
  • USS
    
    • Solid
    • Hypoechoic mass
• Thecoma
  
  • Benign
  • May produce oestrogens
  • USS
    
    • Variable – echogenic mass, hypoechoic or anechoic
• Granulosa Cell
  
  • Produce oestrogen
  • USS
    
    • Variable – may appear solid or cystic

Question 10

Define Ovarian Cyst.

Answer 10

Fluid-filled sac in ovarian tissue - 8% prevalence in premenopausal

Question 11

What are the risk factors for ovarian cysts?

Answer 11

• PCOS
• Endometriosis
• Pregnancy

Question 12

What are the signs and symptoms of ovarian cysts?

Answer 12

• Lower abdominal pain
• Swelling with pressure symptoms - i.e. urinary symptoms
• Deep dyspareunia
• Acute abdomen = torsion/haemorrhagic -severe right or left iliac fossa pain ± vomiting in torsion

Question 13

What are the appropriate investigations for suspected ovarian cysts?

Answer 13

• Pregnancy test
• CA-125
• TVUSS
  
  • Pre-menopausal - simple = manage depending on size; complex (<40yo) → LDH, aFP, b-hCG levels
  • Post-menopausal - simple or complex = CA-125 level → RMI calculation

Question 14

What is the management of pre-menopausal ovarian cysts?

Answer 14

• Simple/unilocular cyst
  
  • <5cm → no follow-up required
  • 5-7cm → repeat USS yearly
  • >7cm → MRI ± surgery
• If recurrent or unresolved → medical = COCP → preventing ovulation will prevent recurrent cysts
• If recurrent, sustained >5cm, suspicious/multiloculated = surgical → laparoscopic cystectomy

Question 15

What are the indications for watchful waiting in ovarian cysts?

Answer 15

• Unilateral
• Unilocular (no solid parts)
• Pre-menopausal and 3-10cm
• Post-menopausal and 2-6cm
• Normal CA125
• No free fluid

Question 16

What is the management of post-menopausal ovarian cysts?

Answer 16

• RMI <200
  
  • • All of:
      
      • Asymptomatic
      • Simple cyst
      • <5cm
      • Unilocular
      • Unilateral
  • = Repeat USS, Ca-125 in 4-6m
    
    • Resolved
    • Unchanged = repeat USS, Ca-125 in 4-6m
    • Changed = laparoscopic cystectomy
  • Any of symptomatic, non-simple features, >5cm, multilocular, bilateral = BSO
• RMI >200 = CT-AP → MDT management:
  
  • TAH, BSO ± omentectomy

Question 17

What are the complications of ovarian cysts?

Answer 17

• Ovarian cyst rupture
  
  • Most common with functional cysts
  • Conservative (pain relief) + watchful waiting
  • Laparoscopy ± cautery (if evidence of active bleeding)
• Ovarian torsion (if >5cm; most common in dermoid)
• Subfertility
• Malignant change
• Oophorectomy