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OVARIAN CYST/ PCOS
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Ovarian Cysts

Introduction

Background

An ovarian cyst is a sac filled with liquid or semi-liquid material arising in an ovary. The number of diagnoses of ovarian cysts has increased with the widespread implementation of regular physical examinations and ultrasound technology. The finding of an ovarian cyst causes considerable anxiety for women because of the fear of malignancy, but the vast majority of ovarian cysts are benign.

Pathophysiology

Each month, normally functioning ovaries develop small cysts called Graafian follicles. At mid cycle, a single dominant follicle up to 2.8 cm in diameter releases a mature oocyte.

The ruptured follicle becomes the corpus luteum, which, at maturity, is a 1.5- to 2-cm structure with a cystic center. In the absence of fertilization of the oocyte, it undergoes progressive fibrosis and shrinkage. If fertilization occurs, the corpus luteum initially enlarges and then gradually decreases in size during pregnancy.

Ovarian cysts arising in the normal process of ovulation are called functional cysts and are always benign. They may be follicular and luteal, sometimes called theca-lutein cysts. These cysts can be stimulated by gonadotropins, including follicle-stimulating hormone (FSH) and human chorionic gonadotropin (hCG).

Multiple functional cysts can occur as a result of excessive gonadotropin stimulation or sensitivity. In gestational trophoblastic neoplasia (hydatidiform mole and choriocarcinoma) and rarely in multiple and diabetic pregnancy, hCG causes a condition called hyperreactio luteinalis. In patients being treated for infertility, ovulation induction with gonadotropins (FSH and luteinizing hormone [LH]), and rarely clomiphene citrate, may lead to ovarian hyperstimulation syndrome, especially if accompanied by hCG administration.

Neoplastic cysts arise by inappropriate overgrowth of cells within the ovary and may be malignant or benign. Malignant neoplasms may arise from all ovarian cell types and tissues. By far, the most frequent are those arising from the surface epithelium (mesothelium), and most of these are partially cystic lesions. The benign counterparts of these cancers are serous and mucinous cystadenomas. Other malignant ovarian tumors may contain cystic areas, and these include granulosa cell tumors from sex cord stromal cells and germ cell tumors from primordial germ cells. Teratomas are a form of germ cell tumor containing elements from all 3 embryonic germ layers, ie, ectoderm, endoderm, and mesoderm.

Endometriomas are cysts filled with blood arising from the ectopic endometrium. In polycystic ovary syndrome, the ovary often contains multiple cystic follicles 2-5 mm in diameter as viewed on sonograms. The cysts themselves are never the main problem, and discussion of this disease is beyond the scope of this article.

Frequency

United States

Ovarian cysts are found on transvaginal sonograms in nearly all premenopausal women and in up to 14.8% of postmenopausal women. Most of these cysts are functional in nature and benign. Mature cystic teratomas or dermoids represent more than 10% of all ovarian neoplasms. The incidence of ovarian carcinoma is approximately 15 cases per 100,000 women per year. Annually in the United States, ovarian carcinomas are diagnosed in approximately 22,000 women, causing 16,000 deaths. Most malignant ovarian tumors are epithelial ovarian cystadenocarcinomas. Tumors of low malignant potential comprise approximately 20% of malignant ovarian tumors, fewer than 5% of malignant germ cell tumors, and approximately 2% of granulosa cell tumors.

Mortality/Morbidity

  • Benign cysts can cause pain and discomfort related to pressure on adjacent structures, torsion, rupture, hemorrhage (both within and outside of the cyst), and abnormal uterine bleeding. They rarely cause death. Mucinous cystadenomas may cause a relentless collection of mucinous fluid within the abdomen, known as pseudomyxoma peritonei, which frequently is fatal.
  • Mortality associated with malignant ovarian carcinoma is related to the stage at the time of diagnosis, and patients with ovarian carcinoma generally present late in the course of disease. The 5-year survival rate overall is 41.6%, varying between 86.9% for International Federation of Gynecology and Obstetrics (FIGO) stage Ia and 11.1% for stage IV. Granulosa cell tumors are associated with an 82% survival rate, whereas squamous cell carcinomas arising in a dermoid cyst have a very poor outcome. Most germ cell tumors are diagnosed at an early stage and have an excellent outcome. Advanced-stage dysgerminomas are associated with a better outcome compared to nondysgerminomatous germ cell tumors. A distinct group of less aggressive tumors of low malignant potential has a more benign course but is still associated with mortality. The overall survival rate is 86.2% at 5 years.
  • Malignant ovarian cystic tumors can cause severe morbidity, including pain, abdominal distension, bowel obstruction, nausea, vomiting, early satiety, wasting, cachexia, indigestion, heartburn, abnormal uterine bleeding, deep venous thrombosis, and dyspnea. Cystic granulosa cell tumors may secrete estrogen, which leads to postmenopausal bleeding and precocious puberty in elderly patients and young patients, respectively.

Race

Malignant epithelial ovarian cystadenocarcinomas are the only ovarian cysts associated with racial differences.

  • Women from northern and western Europe and North America are affected most frequently, whereas women from Asia, Africa, and Latin America are affected least frequently.
  • Within the United States, age-adjusted incidence rates in surveillance areas are highest among American Indian women, followed by white, Vietnamese, Hispanic, and Hawaiian women. Incidence is lowest among Korean and Chinese women.
  • Among women for whom sufficient numbers of cases are available to calculate rates based on age, incidence in those aged 30-54 years is highest in white women, followed by Japanese, Hispanic, and Filipino women. For those aged 55-69 years, the highest rates occur in white women, followed by Hispanic and Japanese women. Among women aged 70 years or older, the highest rate occurs among white women, followed by those of African descent and Hispanic women.

Age

  • Functional ovarian cysts occur at any age (including in utero), but are much more common in reproductive-aged women. They are rare after menopause. Luteal cysts occur after ovulation in reproductive-aged women. Most benign neoplastic cysts occur during the reproductive years, but the age range is wide and they may occur in persons of any age.
  • The incidence of epithelial ovarian cystadenocarcinomas, sex cord stromal tumors, and mesenchymal tumors rises exponentially with age until the sixth decade of life, at which point the incidence plateaus. Tumors of low malignant potential occur at a mean age of 44 years, with a span from adolescence to senescence. The average age is more than a decade less than that for invasive cystadenocarcinoma. Germ cell tumors are most common in adolescence and rarely occur in those older than 30 years.

Clinical

History

  • The majority of ovarian cysts are asymptomatic. Even malignant ovarian cysts commonly do not cause symptoms until they reach an advanced stage.
  • Pain or discomfort may occur in the lower abdomen. Torsion (twisting) or rupture may lead to more severe pain.
  • Patients may experience discomfort with intercourse, particularly deep penetration.
  • Having bowel movements may be difficult, or pressure may develop, leading to a desire to defecate.
  • Micturition may occur frequently and is due to pressure on the bladder.
  • Irregularity of the menstrual cycle and abnormal vaginal bleeding may occur. Young children may present with precocious puberty and early onset of menarche.
  • Patients may experience abdominal fullness and bloating.
  • Patients may experience indigestion, heartburn, or early satiety.
  • Endometriomas are associated with endometriosis, which causes a classic triad of painful and heavy periods and dyspareunia.
  • Polycystic ovaries may be part of the polycystic ovary syndrome, which includes hirsutism, infertility, oligomenorrhea, obesity, and acne.

Physical

  • Advanced malignant disease may be associated with cachexia and weight loss, lymphadenopathy in the neck, shortness of breath, and signs of pleural effusion.
  • A large cyst may be palpable on abdominal examination. Gross ascites may interfere with palpation of an intra-abdominal mass.
  • Although normal ovaries may be palpable during the pelvic examination in thin premenopausal patients, a palpable ovary should be considered abnormal in a postmenopausal woman. If a patient is obese, palpating cysts of any size may prove difficult.
  • Sometimes, discerning the cystic nature of an ovarian cyst may be possible, and it may be tender to palpation. The cervix and uterus may be pushed to one side.
  • Other masses may be palpable, including fibroids and nodules in the uterosacral ligament consistent with malignancy or endometriosis.

Causes

  • Multiple functional cysts can occur as a result of excessive gonadotropin stimulation or sensitivity.
    • In gestational trophoblastic neoplasia (hydatidiform mole and choriocarcinoma) and rarely in multiple or diabetic pregnancy, hCG is the stimulating gonadotropin. The condition is called hyperreactio luteinalis.
    • Patients being treated for infertility by ovulation induction with gonadotropins or other agents, such as clomiphene citrate or letrozole, may develop cysts as part of ovarian hyperstimulation syndrome.
  • Tamoxifen can cause benign functional ovarian cysts that usually resolve following discontinuation of treatment.
  • Risk factors for ovarian cystadenocarcinoma include strong family history, advancing age, white race, infertility, nulliparity, a history of breast cancer, and BRCA gene mutations.

Differential Diagnoses

Abdominal Abscess
Ectopic Pregnancy

Other Problems to Be Considered

Diverticular disease
Hydronephrosis
Hydrosalpinx
Paraovarian cyst
Pedunculated leiomyoma
Pelvic kidney
Pelvic lymphocele
Peritoneal cyst
Tubo-ovarian abscess

Workup

Laboratory Studies

  • No laboratory tests are diagnostic for ovarian cysts.
  • Cancer antigen 125 (CA125) is a protein expressed on the cell membrane of normal ovarian tissue and ovarian carcinomas.
    • A serum level of less than 35 U/mL is considered normal. In some laboratories, the upper limit of normal may be lower than this.
    • While CA125 values are elevated in 85% of patients with epithelial ovarian carcinomas, overall, the value is elevated in only 50% of patients with stage I cancers confined to the ovary. CA125 levels are also elevated in patients with some benign conditions or other malignancies and in 6% of healthy patients.
    • The finding of an elevated CA125 level is most useful when combined with an ultrasonographic investigation while assessing a postmenopausal woman with an ovarian cyst.
  • Other tumor marker values may be elevated in patients with neoplastic ovarian cysts. These markers include serum inhibin in granulosa cell tumors, alpha-fetoprotein in endodermal sinus tumors, lactic dehydrogenase in dysgerminomas, and alpha-fetoprotein and beta-hCG in embryonal carcinomas.

Imaging Studies

  • Ultrasonography
    • This is the primary imaging tool for a patient considered to have an ovarian cyst. Findings can help define morphologic characteristics of ovarian cysts.
    • Simple cysts are unilocular and have a uniformly thin wall surrounding a single cavity that contains no internal echoes. These cysts are unlikely to be cancerous. Most commonly, they are functional follicular or luteal cysts or, less commonly, serous cystadenomas or inclusion cysts.
    • Complex cysts may have more than one compartment (multilocular), thickening of the wall, projections (papulations) sticking into the lumen or on the surface, or abnormalities within the cyst contents. Malignant cysts usually fall within this category, as do many benign neoplastic cysts.
    • Hemorrhagic cysts, endometriomas, and dermoids tend to have characteristic features on sonograms that may help to differentiate them from malignant complex cysts.
    • Sonograms may not be helpful for differentiating hydrosalpinx, paraovarian, and tubal cysts from ovarian cysts.
    • Endovaginal ultrasonography can help in a detailed morphologic examination of pelvic structures. This requires a handheld probe to be inserted into the vagina. It is relatively noninvasive and is well tolerated in reproductive-aged women and post–reproductive-aged women who are still engaging in intercourse. It does not require a full bladder.
    • Transabdominal ultrasonography is better than endovaginal ultrasonography for evaluating large masses and allows assessment of other intra-abdominal structures such as the kidneys, liver, and ascites. It requires a full bladder.
    • 3-dimensional ultrasonography may have advantages in the evaluation of ovarian cysts.1,2
  • Doppler flow studies
    • These studies can help identify blood flow within a cyst wall and adjacent areas, including tumor surface, septa, solid parts within the tumor, and peritumorous ovarian stroma. The principle is that new vessels within tumors have lower resistance to blood flow because they lack developed smooth muscle in the walls. This can be quantitated into a resistive or pulsatility index.
    • Estimation of the resistive index has limited clinical value in premenopausal women because of the great overlap of low-resistance flow characteristics in functional tumors and early cancers.
    • Determination of the presence or absence of any blood flow within certain cysts may be helpful in diagnosis. For instance, hemorrhagic cysts may contain fine internal septations that characteristically do not demonstrate blood flow on Doppler images.
  • MRI
    • MRI with gadolinium allows clearer evaluation of lesions deemed indeterminate after performing ultrasonography.
    • MRI images have better soft tissue contrast compared to CT scan images, particularly for identifying fat and blood products, and can give a better idea of the organ of origin of gynecologic masses.
    • MRI is not necessary in most cases.
  • CT scan
    • CT scanning is inferior to ultrasonography and MRI for helping define ovarian cysts and pelvic masses.
    • CT scan allows examination of the abdominal contents and retroperitoneum in cases of malignant ovarian disease.

Procedures

  • Using needle aspiration to obtain fluid for cytologic examination provides inaccurate cytology results, and needle aspiration is an inappropriate method for cyst drainage in most cases.
  • Performing diagnostic laparoscopy may sometimes be necessary to inspect a suggestive adnexal cystic mass, but an intraovarian malignancy may be missed.

Histologic Findings

The definitive diagnosis of all ovarian cysts is made based on histological analysis. Each type has characteristic findings.


 
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