Ovarian Cysts Flashcards
What are functional ovarian cysts?
Functional ovarian cysts (fluid-filled sacs) related to the fluctuating hormones of the menstrual cycle, and are very common in premenopausal women
Are ovarian cysts usually malignant?
The vast majority of ovarian cysts in premenopausal women are benign. Cysts in postmenopausal women are more concerning for malignancy and need further investigation.
Is “string of pearls” appearance of the ovaries diagnostic of PCOS?
Patients with multiple ovarian cysts or a “string of pearls” appearance to the ovaries cannot be diagnosed with polycystic ovarian syndrome unless they also have other features of the condition. A diagnosis of PCOS requires at least two of (Rotterdam criteria):
Anovulation
Hyperandrogenism
Polycystic ovaries on ultrasound
What are follicular cysts?
Corpus luteum cysts?
Follicular cysts represent the developing follicle. When these fail to rupture and release the egg, the cyst can persist. Follicular cysts are the most common ovarian cyst, they are harmless and tend to disappear after a few menstrual cycles. Typically they have thin walls and no internal structures, giving a reassuring appearance on the ultrasound.
Corpus luteum cysts occur when the corpus luteum fails to break down and instead fills with fluid. They may cause pelvic discomfort, pain or delayed menstruation. They are often seen in early pregnancy.
What are other types of ovarian cysts other than follicular and corpus luteum cysts?
Serous Cystadenoma
These are benign tumours of the epithelial cells.
Mucinous Cystadenoma
These are also benign tumour of the epithelial cells. They can become huge, taking up lots of space in the pelvis and abdomen.
Endometrioma
These are lumps of endometrial tissue within the ovary, occurring in patients with endometriosis. They can cause pain and disrupt ovulation.
Dermoid Cysts / Germ Cell Tumours
These are benign ovarian tumours. They are teratomas, meaning they come from the germ cells and may contain various tissue types, such as skin, teeth, hair and bone. They are particularly associated with ovarian torsion.
Sex Cord-Stromal Tumours
These are rare tumours, that can be benign or malignant. They arise from the stroma (connective tissue) or sex cords (embryonic structures associated with the follicles). There are several types, including Sertoli–Leydig cell tumours and granulosa cell tumours.
What features suggest an ovarian cyst may be malignant rather than benign?
Abdominal bloating Reduce appetite Early satiety Weight loss Urinary symptoms Pain Ascites Lymphadenopathy
Assess for risk factors for ovarian malignancy:
Age Postmenopause Increased number of ovulations Obesity Hormone replacement therapy Smoking Breastfeeding (protective) Family history and BRCA1 and BRCA2 genes
What has a positive correlation with the risk of ovarian cancer?
The number of times a woman has ovulated during her life correlates with her risk of ovarian cancer. More ovulations increases the risk of ovarian cancer. Factors that will reduce the number of ovulations are:
Later onset of periods (menarche)
Early menopause
Any pregnancies
Use of the combined contraceptive pill
Blood tests for ovarian cysts?
Premenopausal women with a simple ovarian cyst less than 5cm on ultrasound do not need further investigations.
CA125 is the tumour marker to remember for ovarian cancer. It contributes to the overall impression of whether an ovarian cyst is related to cancer
Women under 40 years with a complex ovarian mass require tumour markers for a possible germ cell tumour:
Lactate dehydrogenase (LDH) Alpha-fetoprotein (α-FP) Human chorionic gonadotropin (HCG)
Is raised CA125 always indicative of ovarian cancer?
CA125 is a tumour marker for epithelial cell ovarian cancer. It is not very specific, and there are many non-malignant causes of a raised CA125:
Endometriosis Fibroids Adenomyosis Pelvic infection Liver disease Pregnancy
What tool can be used to estimate the risk of an ovarian mass being malignant?
The risk of malignancy index (RMI) estimates the risk of an ovarian mass being malignant, taking account of three things:
Menopausal status
Ultrasound findings
CA125 level
How are ovarian cysts managed?
Possible ovarian cancer (complex cysts or raised CA125) requires a two-week wait referral to a gynaecological oncology specialist.
Possible dermoid cysts require referral to a gynaecologist for further investigation and consideration of surgery.
Simple ovarian cysts in premenopausal women can be managed based on their size:
<5cm cysts will almost always resolve within three cycles. They do not require a follow-up scan.
5cm-7cm: require routine referral to gynaecology and yearly ultrasound monitoring.
> 7cm: consider an MRI scan or surgical evaluation as they can be difficult to characterise with ultrasound.
Cysts in postmenopausal women generally require correlation with the CA125 result and referral to a gynaecologist. When there is a raised CA125, this should be a two-week wait suspected cancer referral. Simple cysts under 5cm with a normal CA125 may be monitored with an ultrasound every 4 – 6 months.
Persistent or enlarging cysts may require surgical intervention (usually with laparoscopy). Surgery may involve removing the cyst (ovarian cystectomy), possibly along with the affected ovary (oophorectomy).
Complications of ovarian cysts?
onsider complications when patients present with acute onset pain. The main complications are:
Torsion
Haemorrhage into the cyst
Rupture, with bleeding into the peritoneum
Meig’s syndrome?
Treatment?
Meig’s syndrome involves a triad of:
Ovarian fibroma (a type of benign ovarian tumour)
Pleural effusion
Ascites
Meig’s syndrome typically occurs in older women. Removal of the tumour results in complete resolution of the effusion and ascites.
TOM TIP: It is worth remembering Meig’s syndrome for your MCQ exams. Look out for the woman presenting with a pleural effusion and an ovarian mass.
