Ovarian Cysts

INTRODUCTION @

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

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Pathophysiology: Each month, normally functioning ovaries develop small cysts called Graafian follicles. At midcycle 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 1.5-2.0 cm structure with a cystic center. In the absence of fertilization of the oocyte, it undergoes progressive fibrosis and shrinkage. If fertilization takes place, the corpus luteum initially enlarges and then gradually decreases in size during pregnancy.

Ovarian cysts arising in the course of ovarian function 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 gonadotrophins including follicle stimulating hormone (FSH) and human chorionic gonadotrophin (HCG).

Multiple functional cysts can occur as a result of excessive gonadotrophin 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 infertility patients, ovulation induction with agents including gonadotrophin releasing hormone agonists, FSH, HCG, and clomiphene citrate may cause ovarian hyperstimulation syndrome.

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 ectoderm, endoderm, and mesoderm.

Endometriomas are cysts filled with altered blood arising from ectopic endometrium. In the polycystic ovary syndrome, the ovary often contains multiple cystic follicles 2-5 mm in diameter on ultrasound. The cysts themselves are never the main problem and the disease will not be discussed further.

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Frequency:
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Mortality/Morbidity:

Race: Malignant epithelial ovarian cystadenocarcinoma are the only ovarian cysts that have race differences.

Women from northern and western Europe and North America are most frequently affected, whereas those from Asia, Africa, and Latin America are the least affected.

Within the US, age-adjusted incidence rates in surveillance areas are highest among American Indian women, followed by white, Vietnamese, white Hispanic, and Hawaiian women. It is lowest among Korean and Chinese women.

Among women for whom there are sufficient numbers of cases to calculate rates by age, incidence in the age group 30-54 years is highest in whites, followed by Japanese, Hispanics, and Filipinos. For ages 55-69 years, the highest rates occur in whites, then Hispanics, and Japanese. Among women 70 years and older, the highest rate occurs among white women, followed by black and Hispanic women.

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CLINICAL @

History:

Physical:

Causes:

DIFFERENTIALS @

Abdominal Abscess


Other Problems to be Considered:

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

WORKUP @

Lab Studies:
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Histologic Findings: The definitive diagnosis of all ovarian cysts is made histologically. Each type has characteristic findings.

TREATMENT @

Medical Care:

Surgical Care:

Consultations:

Diet: Normal healthy diet

FOLLOW-UP @

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MISCELLANEOUS @

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PICTURES @
Caption: Picture 3. A 24-cm diameter multilocular right ovarian cyst is seen with adjacent fallopian tube and uterus. The infundibulo-pelvic ligament carrying the ovarian artery and vein has been divided.
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Picture Type: Photo
Caption: Picture 5. A dermoid cyst after opening the abdomen. Note the yellowy color of the contents seen through the wall.
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Picture Type: Photo
Caption: Picture 7. Transabdominal ultrasound demonstrating a large, complex cystic mass with septations. Histology reported a mucinous cystadenocarcinoma of low malignant potential. Same cyst as in Picture 3. Courtesy Patrick O'Kane, MD
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Picture Type: Photo
Caption: Picture 8. Same patient as in Picture 7. Color Doppler image shows vascularity within the septations. Red and blue colors show blood flow towards and away from the transducer. The resistive index was low. Histology reported a mucinous cystadenocarcinoma of low malignant potential. Courtesy Patrick O'Kane, MD
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Picture Type: Photo
BIBLIOGRAPHY @