Ovarian cysts

Question 1

What is an ovarian cyst?

Answer 1

• ovarian cysts are fluid-filled sacs on the ovaries
• if functional, they are related to the fluctuating hormones in the menstrual cycle and very common in premenopausal women
• mostly benign in premenopausal women but more concerning for malignancy in postmenopausal

Question 2

What are the different types of ovarian cysts?

Answer 2

• functional cysts -> follicular and corpus luteum cysts

- serous cystadenoma -> benign tumours of epithelial cells

Question 3

CA 48 year old woman presents to hospital with rapidly progressive shortness of breath and abdominal distension following a recent blood test that showed raised CA125.

On examination, tense ascites is present.

A chest x-ray demonstrates bilateral pleural effusions.

What type of benign ovarian tumour is classically associated with the above presentation?

A. Cystic teratoma

B. Serous cystadenoma

C. Fibroma

D. Brenner Tumour

E. Mucinous cystadenoma

Answer 3

C. Fibroma

Fibromas are a stromal type of benign ovarian tumours which are classically associated with Meig’s syndrome. This patient shows the pathognomic features of pleural effusion (typically right sided, but can be bilateral) and ascites, in the context of an ovarian tumour. Removal of the tumour reverses the symptoms.

Question 4

what is the most common type of ovarian cyst?

Answer 4

follicular cyst

Question 5

what are the 2 types of functional (physiological) cysts?

Answer 5

1. 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.
2. 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.

Question 6

what benign epithelial tumours can cause pseudomyxoma peritonei?

Answer 6

mucinous cystadenoma

Question 7

what are the 2 types of benign epithelial tumours? differences?

Answer 7

1. Serous cystadenoma
   the most common benign epithelial tumour which bears a resemblance to the most common type of ovarian cancer (serous carcinoma)
   bilateral in around 20%
2. Mucinous cystadenoma
   second most common benign epithelial tumour
   they are typically large and may become massive
   if ruptures may cause pseudomyxoma peritonei

Question 8

How are complex cysts defined?

Answer 8

cysts containing a solid mass, or those which are multi-loculated

Question 9

42 yr old woman with gradual masculinisation (increased body hair, deepening of voice & clitoral enlargement). Ultrasound revealed tumour in left ovarian hilus. Elevated 17-ketosteroid excretion. Diagnosis of hilus cell tumour made (based on histopathology) and it revealed large, lipid-laden tumour cells. To which cells in the male reproductive system are the affected cells homologous?

Answer 9

Leydig cells (other name: pure Leydig cell tumour)
-this kind of tumour sometimes arises in pregnant women, producing similar masculinising effects in mother & female foetuses

Question 10

what is the female homologue of the sertoli cells?

Answer 10

granulosa cell in ovarian follicle

Question 11

epididymis equivalent in females

Answer 11

Epoophoron, Gartner’s duct

Question 12

spermatocytes equivalent in females

Answer 12

oocytes & polar bodies

Question 13

investigations for women <40 yrs with complex ovarian mass:

Answer 13

tumour markers for a possible germ cell tumour:

1. Lactate dehydrogenase (LDH)
2. Alpha-fetoprotein (α-FP)
3. Human chorionic gonadotropin (HCG)

Question 14

what constitutes RMI (risk of malignancy index):

Answer 14

The risk of malignancy index (RMI) estimates the risk of an ovarian mass being malignant, taking account of three things:

1. Menopausal status
2. Ultrasound findings
3. CA125 level

Question 15

what can cause raised CA125>

Answer 15

1. ovarian cancer
2. Endometriosis
3. Fibroids
4. Adenomyosis
5. Pelvic infection
6. Liver disease
7. Pregnancy

Question 16

how do multiple ovarian cysts appear on USS?

Answer 16

“string of pearls” appearance to the ovaries

Question 17

symptoms of ovarian cysts:

Answer 17

Most ovarian cysts are asymptomatic. Cysts are often found incidentally on pelvic ultrasound scans.

Occasionally, ovarian cysts can cause vague symptoms of:

1. Pelvic pain
2. Bloating
3. Fullness in the abdomen
4. A palpable pelvic mass (particularly with very large cysts such as mucinous cystadenomas)

Ovarian cysts may present with acute pelvic pain if there is ovarian torsion, haemorrhage or rupture of the cyst.

Question 18

what are dermoid cysts/germ cell tumours:

Answer 18

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.

Question 19

what are endometriomas: description:

Answer 19

These are lumps of endometrial tissue within the ovary, occurring in patients with endometriosis. They can cause pain and disrupt ovulation.

• “chocolate cysts,” on USS: cysts filled with menstrual blood

Question 20

what are sex cord-stromal tumours:

Answer 20

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.

Question 21

questions to ask in ovarian cyst history/examination:

Answer 21

1. Abdominal bloating
2. Reduced appetite
3. Early satiety
4. Weight loss
5. Urinary/bowel symptoms (compression)
6. Pain

Examination:
7. Ascites
8. Lymphadenopathy

Question 22

RFs for ovarian malignancy vs protective factors:

Answer 22

1. Age
2. Postmenopause
3. Increased number of ovulations (nulliparity)
4. Obesity
5. Hormone replacement therapy (oestrogen-only HRT )
6. Smoking
   7.Family history and BRCA1 and BRCA2 genes

Protective factors:
-Breastfeeding
-Later onset of periods (menarche)
-Early menopause
-Any pregnancies
-Use of the combined contraceptive pill

Question 23

complications of ovarian cysts:

Answer 23

1. Torsion (especially dermoid)
2. Haemorrhage into the cyst
3. Rupture, with bleeding into the peritoneum

Question 24

Investigations for possible ovarian cancer (complex cysts or raised CA125):

Answer 24

two-week wait referral to a gynaecological oncology specialist

Question 25

meig’s syndrome triad:

Answer 25

1. Ovarian fibroma (a type of benign ovarian tumour)
2. Pleural effusion
3. Ascites

Question 26

possible dermoid cysts investigations:

Answer 26

referral to a gynaecologist for further investigation and consideration of surgery.

Question 27

how are simple ovarian cysts managed (size):

Answer 27

Less than 5cm cysts will almost always resolve within three cycles. They do not require a follow-up scan.

5cm to 7cm: Require routine referral to gynaecology and yearly ultrasound monitoring.

More than 7cm: Consider an MRI scan or surgical evaluation as they can be difficult to characterise with ultrasound.

Question 28

how are cysts in postmenopausal women investigated/managed:

Answer 28

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).