Ovarian cysts

Question 1

Define

Answer 1

Fluid-filled sac in ovarian tissue; risk factors: N.B. overlap with ovarian tumours

o Prevalence = 8% of premenopausal women have large cysts

o 90% of all ovarian tumours are benign (but this varies with age)

Question 2

Types

Answer 2

Types of Ovarian Cyst (Benign)

Physiological / functional cysts:

1. Follicular -> failed rupture (of dominant Graafian follicle or nondominant follicles to degenerate)

· Lined by Granulosa cells

· May occasionally continue to produce oestrogen and lead to EH

2. Luteal -> following rupture, follicle reseals, distends with fluid à NORMAL in early pregnancy *

· Lined by Luteal cells

3. Haemorrhagic -> bleeding into a functional cyst

Benign germ cell:

1. Dermoid cyst / mature cystic teratoma à most common benign tumour in those <30yo

· Lined by epithelial cells

· Often asymptomatic but most likely to tort

· Rokitansky protuberances = multiple or single white shiny masses that protrude out

Benign epithelial:

1. Serous cystadenoma
2. Mucinous cystadenoma -> typically very large

· If ruptures à pseudomyxoma peritonei (mucin in abdomen)

Question 3

Signs and symptoms

Answer 3

Lower abdominal pain

o Swelling with pressure symptoms (i.e. urinary symptoms)

o Deep dyspareunia

o Acute abdomen (torsion/haemorrhagic) – severe right or left iliac fossa pain (± vomiting in torsion)

Question 4

Investigations

Answer 4

Pregnancy test

o TVUSS -> outcome dependant on menopause status:

Pre-menopausal; simple -> manage depending on size; complex (<40yo) à LDH, aFP, b-hCG levels

Post-menopausal; simple or complex -> CA-125 level -> RMI calculation

Question 5

Premenopausal management

Answer 5

(premenopausal):

Simple/unilocular cyst:

• <5cm -> no follow-up required
• 5-7cm -> repeat USS yearly
• > 7cm -> MRI ± surgery

o Indications for watchful waiting:

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

o If recurrent or unresolved à medical (COCP à preventing ovulation will prevent recurrent cysts)

o If recurrent, sustained >5cm, suspicious/multiloculated à surgical (laparoscopic cystectomy; usually curative)

Question 6

Postmenopausal bleeding

Answer 6

(postmenopausal) – n.b. an RMI will already be calculated and management is based on this:

o RMI <200:

• All of… asymptomatic, simple cyst, <5cm, unilocular, unilateral à repeat USS, Ca-125 in 4-6m à

· (1) Resolved

· (2) Unchanged à repeat USS, Ca-125 in 4-6m

· (3) Changed à laparoscopic cystectomy

Any of… symptomatic, non-simple features, >5cm, multilocular, bilateral à BSO

o RMI >200 à CT-AP à MDT management:

§ TAH, BSO ± omentectomy

Question 7

Complications

Answer 7

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