Ovarian Cyst

Definition

An ovarian cyst is a sac or pouch filled with fluid or other tissue that forms in or on any
ovary generally arising from epithelial components. Ovarian enlargement that is functional or
dysfunctional, in the form cystic, solid or solid cystic mixtures and can be neoplastic and non-
neoplastic.

Benign ovarian tumors are most frequently diagnosed at the time of routine examination
and are asymptomatic. When symptoms do occur, they generally are either catastrophic (as when
bleeding, rupture, or torsion occur) or indolent and nonspecifi c (such as a vague sense of
pressure or fullness).

Approximately 90% of ovarian tumors encountered in younger women are benign and
metabolically inactive. More than 75% of the benign adnexal masses are functional. Functional
cysts are not true neoplasms; rather, they are anatomic variants resulting from the normal
function of the ovary. Follicular cysts occur when ovulation fails to take place, leaving the
developing follicle to continue beyond its normal time. In a similar manner, the corpus luteum
may persist or, through internal bleeding, enlarge and become symptomatic. Approximately 25%
of ovarian enlargements in reproductive-age women represent true neoplasia, with only
approximately 10% being malignant.

3.2 Risk Factors

- Pre Menopausal age group

- Early menarche
- First trimester of pregnancy
- Personal history of infertility or polycystic ovarian syndrome
- Increased intrinsic or extrinsic gonadotrophins (using fertility treatment, taking hormone
therapy)
- Tamoxifen therapy
- Personal or family history of endometriosis
 - Smoking and alcohol use

3.3 Classifications

a. Functional Cyst

In a normally functioning ovary, simultaneous estrogen production from the dominant

follicle leads to a surge of luteinizing hormone (LH), resulting in ovulation and the release of the
dominant follicle from the ovary and commencing the luteinizing phase of ovulation.

After ovulation, the follicular remnants form a corpus luteum, which produces
progesterone. This, in turn, supports the released ovum and inhibits FSH and LH production. As
luteal degeneration occurs in the absence of pregnancy, the progesterone levels decline, while the
FSH and LH levels begin to rise before the onset of the next menstrual period.

- Follicular cyst . The most common functional cyst, rarely larger than 8 cm. Granulosa cells that
line the follicle may also persist, leading to excess estradiol production, which, in turn, leads to
decreased frequency of menstruation and menorrhagia

- Corpus luteal cyst. Less common than follicular cyst. Corpus luteum cysts may rupture, leading
to a hemoperitoneum and requiring surgical management. Most ruptures occur on cycle days 20
to 26.
- Theca-lutein cyst. Caused by luteinization and hypertrophy of the theca interna cell layer in
response to excessive stimulation from human chorionic gonadotropin (hCG). The least common
of functional ovarian cysts. They are usually bilateral and occur with pregnancy, including molar
pregnancies. Theca lutein cysts may be quite large (up to 30 cm), are multicystic, and regress
spontaneously.

b. Dysfunctional Cyst

- Benign cystic teratomas (dermoid cyst). Mostly occur during the reproductive years, although
dermoid cysts have a wider age distribution than other ovarian germ cell tumors. Histologically,
benign cystic teratomas have an admixture of elements (all 3 embryonic germ layers, ie,
ectoderm, endoderm, and mesoderm)
- Serous cystadenomas. Often multilocular, sometimes with papillary components. The surface
epithelial cells secrete serous fluid, resulting in a watery cyst content.

- Mucinous cystadenomas. Mucinous ovarian tumors may grow to large dimensions. Benign
mucinous tumors typically have a lobulated, smooth surface, are multilocular, and may be
bilateral in up to 10% of cases. Mucoid material is present within the cystic loculations

- Endometriomas. Blood-filled cysts arising from the ectopic endometrium. Endometriomas are
associated with endometriosis, which can cause dysmenorrhea and dyspareunia.

- Polycystic Ovarian Syndrome. The ovary often contains multiple cystic follicles 2-5 mm in
diameter as viewed on sonograms.

3.4 Signs and Symptoms

Most patients with ovarian cysts are asymptomatic, with the cysts being discovered
incidentally during ultrasonography or routine pelvic examination. But some cysts, however may
be associated with a range of symptoms, the following of symptoms are :

 Pain or discomfort in the lower abdomen

 Abdominal fullness and bloating

 Severe pain from torsion (twisting) or rupture - Cyst rupture is characterized by sudden,
sharp, unilateral pelvic pain

 Discomfort with intercourse, particularly deep penetration

 Changes in bowel movements such as constipation

 Pelvic pressure causing urinary frequency

 Menstrual irregularities
  Precocious puberty and early menarche in young children

 Indigestion, heartburn, or early satiety

 Classic triad of endometriosis (painful and heavy periods and dyspareunia)

 Tachycardia and hypotension

 Adnexal or cervical motion tenderness

 May be associated with early satiety, weight loss/cachexia, lymphadenopathy, or shortness

of breath related to ascites or pleural effusion

3.5 Diagnosis of Ovarian Cyst

Patients are commonly discovered as having ovarian cyst incidentally during

ultrasonography or routine pelvic examination, because it is commonly asymptomatic in early
stage. Patients may experience pain or discomfort in the lower abdomen and discomfort with
intercourse. Irregularity of the menstrual cycle and abnormal vaginal bleeding may occur, with
prolonged intermenstrual interval followed by menorrhagia, and sometimes with dysmenorrhea.
Some patients complain of difficult bowel movements, which cause abdominal fullness, bloating,
indigestion, heartburn, or early satiety, and also frequent micturition due to pressure on the
bladder. Ruptured cyst is characterized by sudden, unilateral, sharp pelvic pain. This can be
associated with trauma, exercise, or coitus. In addition, cyst rupture can lead to peritoneal signs,
abdominal distention, and bleeding that is usually self-limited.

On physical examination, a large cyst may be palpable, but gross ascites may interfere
with palpation of an intraabdominal mass. Sometimes, it may be tender to palpation. The cervix
and uterus may be pushed to one side. Examination reveals moderate to severe unilateral or
bilateral lower abdominal tenderness in some women with an ovarian cyst. Some complications
of ovarian cysts may result in adnexal tenderness or cervical motion tenderness. If hemorrhage or
peritonitis ensues, the patient may present with a diffusely tender abdomen with rebound
tenderness and distended abdomen. Hemorrhage due to cyst rupture may lead to tachycardia and
hypotension. Advanced malignant disease may be associated with cachexia and weight loss,
lymphadenopathy, shortness of breath, and signs of pleural effusion.

Patients who come with acute abdominal pain have to be examined carefully before
ovarian cyst is diagnosed. Physicians have to rule out female gynecologic and urologic problems
such as ectopic pregnancy, ovarian torsion, tubo-ovarian abscess, or other conditions such as
appendicitis or diverticulitis.

Supporting exam commonly performed in patients with ovarian cyst is ultrasound, with
transvaginal ultrasonography being preferable due to its increased sensitivity over
transabdominal ultrasound. Combination of color flow Doppler mapping and 3D imaging may
also be used and has good sensitivity. At the present time, the routine use of computed
tomography and MRI for assessment of ovarian masses have a place in the evaluation of more
complex lesions.

An estimation of the risk of malignancy is essential in the assessment of an ovarian mass.

At present the Risk of Malignancy Index (RMI) is the most widely used model. The RMI is a
product of the ultrasound scan score, the menopausal status and the serum CA-125 level (IU/ml)
as follows:

RMI = U x M x CA-125.

The ultrasound result is scored 1 point for multilocular cysts, solid areas, metastases,
ascites and bilateral lesions. U = 0 (for an ultrasound score of 0), U = 1 (for an ultrasound score
of 1), U = 3 (for an ultrasound score of 2–5). The menopausal status is scored as 1 =
premenopausal and 3 = postmenopausal. Postmenopausal can be defined as women who have
had no period for more than one year or women over the age of 50 who have had a hysterectomy.
Serum CA-125 is measured in IU/ml and can vary between zero to hundreds or even thousands
of units. The RMI utility is negatively affected in the premenopausal woman because pathologies
increasing the level of CA-125 in this group.

3.6 Management of Ovarian Cyst

 The aim of management in ovarian cyst is to minimize patient morbidity by conservative
management where possible, use of laparoscopic techniques where appropriate, thus avoiding
laparotomy where possible, or referral to a gynecological oncologist where appropriate.
Asymptomatic simple cysts 30–50 mm in diameter do not require follow-up, cysts 50–70 mm
require follow-up, and cysts more than 70 mm in diameter should be considered for either further
imaging (MRI) or surgical intervention due to difficulties in examining the entire cyst adequately
at time of ultrasound.

Ovarian cysts that persist or increase in size after several cycles are unlikely to be
functional. Surgical management is therefore usually appropriate. The appropriate route for the
surgical management of ovarian masses depends on several factors related to the woman
(including suitability for laparoscopy and her wishes), the mass (size, complexity, likely nature)
and the setting (including surgeon’s skills and equipment). A decision should be made after
careful clinical assessment and counselling considering those factors. The laparoscopic approach
for elective surgical management of ovarian masses presumed to be benign is associated with
lower postoperative morbidity and shorter recovery time and is preferred to laparotomy in
suitable patients. Laparoscopic management is cost-effective because of the associated earlier
discharge and return to work. In the presence of large masses with solid components (for
example large dermoid cysts) laparotomy may be appropriate. The other choice is oophorectomy,
but it has to be discussed with the woman preoperatively.

Before surgery, there are some tests needed to perform, such as CA-125. If a serum CA-
125 assay is raised and less than 200 units/ml, further investigation may be appropriate to
exclude/treat the common differential diagnoses. If serum CA-125 assay more than 200 units/ml,
discussion with a gynecological oncologist is recommended. A serum CA-125 assay does not
need to be undertaken in all premenopausal women when an ultrasonography diagnosis of a
simple ovarian cyst has been made. All women under 40 with a complex ovarian mass should
perform test on α-FP and hCG because of the possibility of germ cell tumors, and also LDH
measuring.