Ovarian Cysts Flashcards
Are ovarian cysts common?
Yes
What different types are there?
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
What is the commonest type of ovarian cyst?
Follicular cyst
What causes follicular cysts?
Non rupture of the dominant follicle (ie due to failure of normal LH surge) or failure of atresia in non dominant follicle
Because physiological cysts are so common, they are considered normal if they are less than what size?
Less than 5cm
When do follicular cysts tends to regress?
After several menstrual cycles
What causes a corpus luteum cyst?
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
Is a follicular or corpus luteal cyst more likely to present with intraperitoneal bleeding?
Corpus luteum cyst
What benign germ cell tumour can occur?
Dermoid cyst - also called mature cystic teratoma
Who are dermoid cysts more common in?
Younger women
Mean age = 30
Dermoid cysts are bilateral in what percentage?
10-20%
What are dermoid cysts usually lined with?
Epithelial tissue - may contain skin appendages, hair and teeth
Is torsion more or less likely with dermoid cysts compared to other ovarian tumours?
More likely
What do dermoid cysts arise from?
Primitive germ cells
What do benign epithelial tumours arise from?
The ovarian surface epithelium
Describe serous cystadenomas
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
Describe mucinous cystadenomas
Typically large - may become massive
If rupture can cause pseudomyxoma peritonei
Filled with mucinous material
5% malignant
How do they present?
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
What ligaments hold the ovary in place?
Broad ligament
Ovarian
Suspensory - ovarian artery, vein and nerve plexus run through it
What syndrome has multiple follicular cysts?
PCOS
What complications can occur with ovarian cysts?
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
Ovarian torsion can cut off blood supply to…
The ovary
What other symptoms are associated with a ruptured cyst?
Low blood pressure
Fast HR
Upper abdominal or shoulder pain due to diaphragm irritation
How does ovarian torsion present?
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
Describe what happens during torsion
The venous return from ovary is occluded, causing ovary to be oedematous and eventually interrupts arterial supply
What examination findings occur?
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
What investigations should be done?
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
What imaging is required?
TVUS most appropriate initially
- useful in distinguishing benign from malignant masses
Cyst extending out of pelvis: abdominal USS
Cysts more than 7cm consider MRI
What is a typical USS picture for ovarian torsion?
Dense stroma
Reduced follicles seen
Reduced blood flow through ovary
What is the scoring system for identifying women with adnexal torsion?
1 - unilateral lumbar/abdominal pain 2- pain duration >8 hours 3- vomiting 4- absence of leucorrhoea/metrorrhagia 5- ovarian cyst >5cm by US
How is adnexal torsion treated?
IV fluids
Pain relief
Surgery
If the cyst is under 5cm with no torsion/rupture, how are they managed?
Functional and benign neoplasms: observation = mainstay
If over 5cm, usually laparoscopic removal done
What features warrant cyst removal?
Over 5cm
Symptomatic
Appear malignant
What risk factors are there for ovarian torsion?
Ovarian mass - present in around 90% of cases
Reproductive age
Pregnancy
Ovarian hyper stimulation syndrome
