Ovarian Cysts Flashcards
What are the different classes of benign ovarian cysts?
Benign ovarian cysts are extremely common. They may be divided into physiological cysts, benign germ cell tumours, benign epithelial tumours and benign sex cord stromal tumours.
What’s the difference between a simple and a complex cyst?
Simple – contains only fluid
Complex – irregular, contain solids, blood or have septations or vascularity - multilocular
What are the two main types of physiological cysts?
- Follicular cysts – Most common type of ovarian cyst occurring due to non-rupture of the dominant follicle or failure of atresia in a non-dominant follicle. These often regress after several menstrual cycles. These are usually less than 3cm
- Corpus luteum cyst – Failure of the corpus luteum to break down may result in it filling with blood or fluid and forming a corpus luteal cyst. More likely to present with intraperitoneal bleeding than follicular cysts. Normally less than 5cm.
Which gynaecological pathologies can present with or cause a cyst?
- Endometrioma – Called chocolate cysts because of the chocolate coloured blood on the inside. These present due to endometriosis.
- Polycystic ovaries – More than 12 antral follicles or ovarian volume > 10ml. Does not necessarily indicate PCOS.
- Theca lutein cyst – These occur as a result of high levels of BhCG such as in molar pregnancies. Will regress once the molar pregnancy has been resolved.
- Ovarian oedema – Usually secondary to ovarian torsion – enlarged and boggy but must exclude germ cell tumour in young women
What are the 3 types of epithelial benign cysts?
- 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 30%
- Mucinous cystadenoma – Second most common benign epithelial tumour, they are typically large and may become massive. If ruptured may cause pseudomyxoma peritonei. Usually unilateral.
- Brenner tumour – Unilateral with a solid grey or yellow appearance
What is the most common benign germ cell tumour?
• Dermoid cyst – Also called mature cystic teratomas. Usually lined with epithelial tissue and hence may contain skin appendages, hair and teeth. Most common benign ovarian tumour in woman under the age of 30 years or in pregnancy and can be bilateral in 10%. Usually asymptomatic. Torsion is more likely than with other ovarian tumours
What are the most common benign sex cord stromal tumours?
• Fibroma – most common stromal tumour. Up to 40% present with Meig’s syndrome, associating these tumours with ascites and pleural effusion.
How do cysts usually present?
Chronic pain – pressure on organs e.g. bladder and bowl
Dyspareunia and cyclical pain – especially with chocolate cysts in endometriosis
Acute pain due to rupture, bleeding or torsion
Per vaginal bleeding
What investigation should all cysts have?
Transvaginal USS and always rescan after 6 weeks and monitor if persistent
Most will resolve spontaneously so manage with analgesia
How should adolescents be investigated and followed up with cysts?
Same as premenopausal but pay particular attention for germ cell tumours especially with ovarian torsion.
How should pre-menopausal women with cysts be investigated and followed up?
CA125 – can be raised in anything that irritates the peritoneum
USS of cyst
Calculate RMI
Lactate dehydrogenase, Alpha fetoprotein and BhCG for possibility of germ cells tumour
If persistent or over 5cm monitor with USS and CA125
Then cystectomy via laparotomy or laparoscopy
How should post-menopausal women with cysts be investigated and followed up?
Postmenopausal depends on RMI:
If lower than 25: follow up in 1 year with USS and CA125 every 4 months (<3% cancer risk). If persistent and changes noted in CA125 or USS – bilateral oophorectomy
Moderate 25-250: bilateral oophorectomy and if malignant then staging (20% cancer risk)
If above 250 then should be referred for staging laparotomy (75% cancer risk)
What are the complications that can occur from cysts?
Rupture and/or Torsion
Urgent diagnostic laparotomy or laparoscopy. Send for tumour markers to aid follow-up.
What are the risks of torted/rupture ovarian cysts in pregnancy and how should this be managed?
If pregnant
Increased risk of miscarriage, urinary retention, discomfort and pain and failure of foetus to engage leading to malpresentation or position.
Management should be conservative if possible Cystectomy advised if: • Torsion, rupture or bleed • Large >8cm • Suspicion of malignancy
Elective surgery should take place at 16-20 weeks but not greatly increased risk of miscarriage. If cyst is obstructing labour then deliver by C-section.
What is ovarian torsion?
Ovarian torsion may be defined as the partial or complete torsion of the ovary on its supporting ligaments that may in turn compromise the blood supply. If the fallopian tube is also involved, then it is referred to as adnexal torsion.
