ovarian cysts Flashcards
Ovum production
All women are being born with primordial follicles sitting in the ovaries waiting to be kickstarted. As one primary follicles develop, it gets to a point where it is a graffian folicle and ultimately releases the egg at the time of ovulation.
the bit left being once the egg is released then forms the corpus luteum (yellow body) and that becomes a corpus Albicans (white body).
-If you look at the early ovulation/egg release, if it gets it wrong, it may not release an egg and at that point it can form a FOLLICULAR CYST.
-Having released the ovum, it is possible for the corpus luteum to form a cystic body and this will be a _LUTEAL CYST._
-Both follicular and luteal cyst are _functional cyst,_ part of the normal functioning of a woman whose ovary is functioning. hence, functional cysts are common.
Simple follicular cysts
What causes follicular cysts? Follicular cysts develop as the result of normal menstrual cycles. If you’re a fertile woman of reproductive age, your ovaries develop cyst-like follicles every month. These follicles produce the important hormones, estrogen and progesterone. They are benign.
Luteal cysts
The corpus luteum at the top has had bleeding to it and this can be fresh after ovulation. what is clear is that there is a cystic component adjacent to this and this would have caused a corpus luteal or luteal cyst.
Are ovarian cysts common?
- 10% of women in the community have an ovarian cyst. 1 in 10 of them so very common. most menopausal women and those on the pill will not be making functional cysts.
- 4th most common cause of gynae.admission
- 4% of all women in U.K. will be admitted with this by age 65 years.
Ovarian Cysts cont
- Ovarian cysts may be non-neoplastic (functional) or neoplastic (abnormal growth)
- of the neoplastic cysts, 90% are benign
- The proportion of patients that have malignant cysts or tumours on their ovaries are much higher in the post-menopausal group.
- 13% of all surgically managed tumours/ cysts in pre menopausal women are malignant.
- whereas in the post-menopausal group, 45% of them are malignant.
Symptoms of Ovarian Cysts
- Asymptomatic
- Pain
- Menstrual disruption (delayed period, irregular bleeding pattern etc).
-if you have a big cyst, you can get pressure symptoms. (often they have been growing over many many months). the huge stomach swelling in the picture will cause a serious pressure effect.
When should you worry about Asymptomatic Ovarian Cysts
Many of the cysts are natural and benign but in any of the cases below, you should worry.
•>8cm in pre-menopausal group - wait till its over 8cm especially if the woman is pre-menopausal, it can just be a functional cyst. we tend to operate on an asymptomatic cyst that is over 8cm.
•>5cm in a post-menopausal age group
•Complexity of the cyst on USS
-Solid chunk?
- -Septae/ division within the cyst?*
- -Bilateral? although it could still be benign even if bilateral*
- •Free fluid around? many ovarian cancers produce fluid*
Complications of Ovarian Cysts
•Torsion - this is where the ovary twists around its blood supply. the ovary is suspended on one side by a suspensory ligament and on the other side by its blood supply. so its attached to the uterus by the ligament is then hanging with the blood supply coming from the aorta. if you get a cyst on the side of the ovary, its possible for it to twist and cut off the blood supply.
•Rupture- this can happen if there is an activity i..e running, can happen during sex, or spontaneously.
•Haemorrhage - rare
•infection- this is rare but it can happen say if you have an elderly woman with diverticulitis or a young woman with appendicitis and then having an ovarian cyst on top of it.
Case Report 1
•22 y.o. Woman G0P0 (gravidity) and (parity).
- Seen by G.P. With vague RIF pain
- USS 5cm right ovarian cyst
- Later Presented to A & E with acute lower abdominal pain
- Tenderness and guarding lower abdo
- Repeat USS. No cyst some free fluid floating around.
Ovarian Cyst Rupture- looks like the ovarian cyst had ruptured into the abdomen.
- May be traumatic or spontaneous
- symptoms depend on amount and character of contents
- If mild conservative management is appropriate
- If you have unusual contents in the cyst, it can cause a chemical peritonitis and pseudomyxoma peritonei.
Case Report 2
- 29 y.o. Woman presents with acute lower right sided abdominal pain.
- Minimal abdominal signs
- Tender 6cm mass right adnexum
- USS haemorrhage into a cyst
- Management determined by symptoms
- Conservative versus operative.
-She has had a ruptured cyst. she’s clinically stable, everything else about her is fine.
Ovarian Cyst Haemorrhage
- Remember bleeding can be from the cyst rather than into it and can be dramatic.
- Endometriomas. it not uncommon to find them on the ovary in people. with endometriosis. they are very difficult to distinguish from hemorrhagic cyst.
Endometrioma, also called ovarian endometrioma or endometrioid cyst, is a type of cyst formed when endometrial tissue grows in the ovaries. These cysts are benign and estrogen-dependent. Endometrioma is part of a condition known endometriosis.
- In this case, its okay to follow a conservative line. it will get a bit sore at the beginning and then things will sort of normalise.
Case Report 3
- 72 y.o woman G3 P2
- Occasional left-sided twinges
- Presents with acute abdominal pain with nausea and vomiting.
- Tachycardia and temperature 37.8C
- Lower abdo guarding and rigidity
- Leucocytosis -raised white cell count.
- Tender 10cm mass high on left side of pelvis. the mass is high because the ovary has twisted it blood supply and drawn the cyst and the ovary up out of the pelvis along that blood supply. this is a classical torsion.
- USS 10cm ovarian mass. with No doppler flow
The ovary can become necrotic if left untreated for too long.
Patient had Ovarian Cyst Torsion
- Usually ovarian infarction has already occurred at the time of surgery
- Salpingo-oophorectomy usual surgical treatment.
Laparoscopic removal of the ovary.
The Ovary
A Collage of Tissue Types
-There are multiple different tissue types sitting on the ovary and they come from 3 main structures.
Types of Cysts (neoplasms) of the Ovary
1•Epithelial layer
- can be Benign
- can be Borderline (does not mean borderline cancer, it can’t invade or metastasise)
- can be Malignant
2•Germ Cell (made up of primordial follicles that will make the egg and have the potential to make any tissue in the body, they are like a baby just waiting to be fertilised)
- usually Benign
- can be Malignant too
3•Stromal tissue (fat, nerve cells, connective tissue, blood vessels, they are the hormone-producing areas of the ovaries i.e the granulosa cell that produces estrogen etc)
- can be Benign
- can be Malignant
Case Report 4
- 19 year old female presents with two year history of “fullness” in the right side of the pelvis.
- deep dysparunia (pain on intercourse), but increasing urinary frequency
- Periods normal
- otherwise fit and well
mass felt in right adnexum
•USS: shows complex cystic mass ?
this is a Dermoid cyst. A dermoid cyst is arising from the germ cell and is usually being but these are the ones that can have teeth, hair, horrible stuff in them.
- All you need for this patient is a laparoscopic ovarian cystectomy.
- Take the cyst off the ovary but you do it without spilling the content around the ovary
- if you do spill the content, you have to then spend a lot of time washing it all out.
- In the picture, you can see all the horrible things inside the ovary.
Malignant Germ cell tumours
- they happen to Young Women under 30
- Often rapidly growing
- Usually Unilateral
- Express tumour markers
- Usually cured by taking the ovaries out and making sure that it hasn’t spread.
Case 5
- 18 year old female. Nulliparous (had no babies)
- presents with recent onset of amenorrhea (period suddenly stopped)
- noted also hair recession and hirsuitism
- on examination: clitoromegaly (enlarged clitoris) and slightly tender 10cm mass in left side of the pelvis.
- USS shows a complex mass in the pelvis mainly solid and vascular which is classic for a stroma tumour (tumour at the stroma of the ovaries)
- blood test results (check for estrogen, testosterone)
- Laparoscopy or laparotomy removal of the ovary is the treatment
Ovarian tumour with septation
Case 6
- Patient aged 58 y.o. G3P2
- 6/12 of vague abdominal discomfort
- Recent nausea and poor appetite and 1 stone loss of weight.
- Increasing malaise and tiredness
- On examination
- Looking at the patient,/ the rest of her body is not fat but she has a massive belly.
- In the CT, we can see abdominal masses, Ascitis, so its widespread.
•Surgery; Staging / Debulking.
•Chemotherapy; Carboplatin +/- Taxol
•Bevacizumab (Avastin); targets a cancer cell vascular endothelial growth factor (VEGF)
