Ovarian Cysts

Question 1

Are ovarian cysts common?

Answer 1

Yes

Question 2

What different types are there?

Answer 2

Physiological (functional) - follicular and corpus luteum cysts
Benign germ cell tumours - dermoid
Benign epithelial tumours - serous cystadenoma and mucinous cystadenoma
Benign sex cord stromal tumours

Question 3

What is the commonest type of ovarian cyst?

Answer 3

Follicular cyst

Question 4

What causes follicular cysts?

Answer 4

Non rupture of the dominant follicle (ie due to failure of normal LH surge) or failure of atresia in non dominant follicle

Question 5

Because physiological cysts are so common, they are considered normal if they are less than what size?

Answer 5

Less than 5cm

Question 6

When do follicular cysts tends to regress?

Answer 6

After several menstrual cycles

Question 7

What causes a corpus luteum cyst?

Answer 7

During menstrual cycle if pregnancy does not occur, the corpus luteum usually breaks down and disappears. If this doesn’t occur it may fill with blood or fluid and form a corpus luteal cyst

Question 8

Is a follicular or corpus luteal cyst more likely to present with intraperitoneal bleeding?

Answer 8

Corpus luteum cyst

Question 9

What benign germ cell tumour can occur?

Answer 9

Dermoid cyst - also called mature cystic teratoma

Question 10

Who are dermoid cysts more common in?

Answer 10

Younger women

Mean age = 30

Question 11

Dermoid cysts are bilateral in what percentage?

Answer 11

10-20%

Question 12

What are dermoid cysts usually lined with?

Answer 12

Epithelial tissue - may contain skin appendages, hair and teeth

Question 13

Is torsion more or less likely with dermoid cysts compared to other ovarian tumours?

Answer 13

More likely

Question 14

What do dermoid cysts arise from?

Answer 14

Primitive germ cells

Question 15

What do benign epithelial tumours arise from?

Answer 15

The ovarian surface epithelium

Question 16

Describe serous cystadenomas

Answer 16

Most common benign epithelial tumour
Develop papillary growths that may be very prolific, so cyst appears solid 
Commonest in women between 30-40 
30% bilateral 
30% malignant

Question 17

Describe mucinous cystadenomas

Answer 17

Typically large - may become massive
If rupture can cause pseudomyxoma peritonei
Filled with mucinous material
5% malignant

Question 18

How do they present?

Answer 18

Asymptomatic - incidental finding
Chronic pain with dull ache, dyspareunia, cyclical pain, pressure effects - frequent urination or bowel movement
Acute pain due to bleeding into cyst, ovarian torsion or rupture
Irregular bleeding
Hormonal effects e.g development of adrogenic features
Abdominal swelling or mass

Question 19

What ligaments hold the ovary in place?

Answer 19

Broad ligament
Ovarian
Suspensory - ovarian artery, vein and nerve plexus run through it

Question 20

What syndrome has multiple follicular cysts?

Answer 20

PCOS

Question 21

What complications can occur with ovarian cysts?

Answer 21

Become haemorrhagic - more common with follicular and corpus luteal cysts
Can rupture - release contents into peritoneal cavity causing irritation
Ovarian torsion - ovary twists around the suspensory ligament

Question 22

Ovarian torsion can cut off blood supply to…

Answer 22

The ovary

Question 23

What other symptoms are associated with a ruptured cyst?

Answer 23

Low blood pressure
Fast HR
Upper abdominal or shoulder pain due to diaphragm irritation

Question 24

How does ovarian torsion present?

Answer 24

Severe lower abdominal pain (may be sudden and sharp)
Radiating to loin or thigh
May start to improve after 24 hours as ovary starts to die
Vomiting, nausea
Low grade fever

Question 25

Describe what happens during torsion

Answer 25

The venous return from ovary is occluded, causing ovary to be oedematous and eventually interrupts arterial supply

Question 26

What examination findings occur?

Answer 26

May be normal if cyst small or woman obese If acute presentation - signs of shock Abdominal - mass in pelvis, tenderness, localised guarding, rebound tenderness at site of torsion if present Bimanual - discharge or bleeding, cervical excitation, adnexal mass and tenderness Nodular uterosacral ligaments and fixed retroverted uterus = features of endometriosis

Question 27

What investigations should be done?

Answer 27

FBC, U and E, CRP - dehydration and raised inflammatory markers Tumour markers depending on patient age CA125 if over 40 Check AFP, CA19-9, LDH, hCG and CEA

Question 28

What imaging is required?

Answer 28

TVUS most appropriate initially - useful in distinguishing benign from malignant masses Cyst extending out of pelvis: abdominal USS Cysts more than 7cm consider MRI

Question 29

What is a typical USS picture for ovarian torsion?

Answer 29

Dense stroma Reduced follicles seen Reduced blood flow through ovary

Question 30

What is the scoring system for identifying women with adnexal torsion?

Answer 30

``` 1 - unilateral lumbar/abdominal pain 2- pain duration >8 hours 3- vomiting 4- absence of leucorrhoea/metrorrhagia 5- ovarian cyst >5cm by US ```

Question 31

How is adnexal torsion treated?

Answer 31

IV fluids Pain relief Surgery

Question 32

If the cyst is under 5cm with no torsion/rupture, how are they managed?

Answer 32

Functional and benign neoplasms: observation = mainstay | If over 5cm, usually laparoscopic removal done

Question 33

What features warrant cyst removal?

Answer 33

Over 5cm Symptomatic Appear malignant

Question 34

What risk factors are there for ovarian torsion?

Answer 34

Ovarian mass - present in around 90% of cases Reproductive age Pregnancy Ovarian hyper stimulation syndrome