Ovarian cysts, torsion

Question 1

Describe the effect of menopause [pre/post] on the liklihood of having benign / malignant ovarian cysts [2]

Answer 1

The vast majority of ovarian cysts in premenopausal women are benign.

Cysts in postmenopausal women are more concerning for malignancy and need further investigation.

Question 2

A diagnosis of PCOS requires at least two of: [3]

Answer 2

Anovulation
Hyperandrogenism
Polycystic ovaries on ultrasound

Question 3

Describe the presentation of ovarian cysts [5]

Answer 3

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

Occasionally, ovarian cysts can cause vague symptoms of:
* Pelvic pain
* Bloating
* Fullness in the abdomen
* Pain during sex
* 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 4

Give a basic overview of the follicular and luteal phase of an average cycle with regards to structures created in the ovaries [2]

Answer 4

First two weeks of average 28 day cycle, the ovaries go through the follicular phase:
- couple of follicles become the dominant follicle that releases an ovum in ovulation
- the rest degress and die off
- the follicles secrete oestrogen - which inhibits FSH

At ovulation the oocyte is released into the fallopian tube and luteal phase begins (remaining 2 weeks of 28 day cycle):
- corpus luteum (remnant of ovarian follicle) makes progesterone, which inhibits LH
- if fertilisation occurs the corpus luteum continues to make progesterone until the placenta forms.
- If no fertilisation, then becomes fibrotic and becomes the corpus albicans

Question 5

Describe the difference between follicular and corpus luteums cysts [2]

Answer 5

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.

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

Why might a follicular cyst occur? [1]

Answer 6

Dominant cyst fails to rupture if normal surge of LH that causes ovulation doesnt happen in a given menstrual cycle

Question 7

Describe what theca lutein cysts are [1] and when they occur [2]

Answer 7

Caused by overstimulation of hCG during pregnancy
- stimulates growth in follicular theca cells
- occur in high hCG: multiple pregnancy; trophoblastic disease

Question 8

Describe what is meant by a Dermoid Cysts / Germ Cell Tumours [1]

What pathology are they particularly associated with? [1]

Answer 8

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 9

What type of cyst will bleed within the cyst cavity during menstruation? [1]

What are they aka? [1]

Answer 9

Endometrioma (cyst with endometrial tissue) that grows on the ovary
- aka chocolate cysts

Question 10

Which type of tumours are the most common type in young women? [1]

Answer 10

Mature cystic teratomas

Question 11

What are the two types of serous and mucinous cysts? [2]

Answer 11

Serous or Mucinous cystadenomas

Serous or Mucinous cystadenocarcinomas

Question 12

Which type of cysts are most likely to become haemorrhagic? [2]

Answer 12

Follicular cysts
Corpus lutetal cysts

Question 13

Which type of cysts are most likely to rupture? [2]

Question 14

What are the three key complications of ovarian cysts? [3]

Answer 14

If they become haemorrhagic

If they rupture:
- can cause peritonitis

Ovarian torsion

Question 15

When do ovarian cysts most commonly rupture? [1]

Answer 15

After sex

Question 16

Which investigations would you conduct for ?ovarian cysts [2]

Answer 16

Blood tests:
- If premenopausal w simple cyst < 5cm on US - none
- CA125 helps determine if cyst is related to cancer
- If under 40 and complex cysts - need tumour markers (AFP; LDH; HCG)

Abdominal Ultrasounds:
* simple: unilocular, more likely to be physiological or benign
* complex: multilocular, more likely to be malignant

Question 17

As per RCOG how do you monitor cysts if:

o If pre-menopausal + asymptomatic simple cyst < 5 cm [1]
o If 5-7 cm –> [1]
o If > 7 cm –> [1]
o If multilocular, acoustic shadowing, or solid components (i.e., not simple cyst) –> [1]
o If post-menopausal –> [2]

Answer 17

o If pre-menopausal + asymptomatic simple cyst < 5 cm –> no follow-up

o If 5-7 cm: - repeat USS in 1 year, and if growing –> refer

o If > 7 cm –> refer

o If multilocular, acoustic shadowing, or solid components (i.e., not simple cyst) –> refer

o If post-menopausal –> CA-125, and if normal + asymptomatic simple cyst < 5 cm –> repeat USS in 4-6 months

Question 18

Why do cysts < 5cm not need follow up? [1]

Answer 18

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

Question 19

What would be the referral protocol if:
- postmenopausal, raised CA125

Answer 19

• 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.

Question 20

Describe what is meant by Meig’s syndrome [3]

Answer 20

• Meig’s syndrome involves a triad of:
• Ovarian fibroma (a type of benign ovarian tumour)
• Pleural effusion
• Ascites

Meig’s syndrome typically occurs in older women. Removal of the tumour results in complete resolution of the effusion and ascites.

TOM TIP: It is worth remembering Meig’s syndrome for your MCQ exams. Look out for the woman presenting with a pleural effusion and an ovarian mass.

Question 21

Define ovarian torsion [1]

Answer 21

Ovarian torsion may be defined as the partial or complete torsion of the ovary on it’s 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.

Question 22

What causes ovarian torsion [3]

Answer 22

An ovarian mass larger than 5cm, such as a cyst or a tumour

Twisting of the adnexa and blood supply to the ovary leads to ischaemia

If the torsion persists, necrosis will occur, and the function of that ovary will be lost. Therefore, ovarian torsion is an emergency

Question 23

Describe the presentation of ovarian torsion [3]

Answer 23

The main presenting feature is sudden onset severe unilateral pelvic pain. The pain is constant, gets progressively worse and is associated with nausea and vomiting.
- The pain is NOT always severe, and ovarian torsion can take a milder and more prolonged course

NB: Occasionally, the ovary can twist and untwist intermittently, causing pain that comes and goes.

Question 24

Describe the examination results of ovarian torsion [2]

Answer 24

On examination there will be localised tenderness. There may be a palpable mass in the pelvis, although the absence of a mass does not exclude the diagnosis.

Question 25

Describe why you should still suspect ovarian torsion in younger girls [1]

Answer 25

Ovarian torsion can also happen with normal ovaries in younger girls before menarche (the first period), when girls have longer infundibulopelvic ligaments that can twist more easily.

Question 26

Describe the diagnosis and management of ovarian torsion [3]

Answer 26

Diagnosis:
Pelvic US:
- Transvaginal is 1st choice, but transabdominal can also be used
- “whirlpool sign”: free fluid in pelvis and oedema of the ovary.
- Doppler studies may show a lack of blood flow
- The definitive diagnosis is made with laparoscopic surgery.

Management:
Laparoscopic surgery to either:
* Un-twist the ovary and fix it in place (detorsion)
* Remove the affected ovary (oophorectomy)