Approach to patient with Ovarian

cysts
Done by: Yahyia Al-Abri
90440
 Outline
• Definition of ovarian cyst
• Case scenario
• How to approach
– History, physical examination , investigation,
management.
• Functional ovarian cyst
• Benign ovarian neoplasm
• Mixed ovarian neoplasm
• Ovarian cancer
 ovarian cyst
• An ovarian cyst is a sac filled with liquid or
semiliquid material that arises in an ovary.
• These cysts can develop in females at any stage of
life, from the neonatal period to postmenopausal
• Most ovarian cysts, occur during infancy and
adolescence, which are hormonally active periods
of development.
• Most are functional in nature and resolve without
treatment.
 Case
• 19 years old Omani lady, Unmarried,
Presented to the A&E with history of
Abdominal left iliac fossa pain started 15
minutes prior coming to the hospital.
 History Examination

Management Investigation
 History
• Most patients with ovarian cysts are
asymptomatic
• Pain or discomfort may occur in the lower
abdomen
sudden, unilateral, sharp pelvic pain Cyst rupture

bilateral, dull pelvic pain. Theca-lutein cysts

painful and heavy periods and dyspareunia Endometriomas

 History
• Associated symptoms
pressure on the Micturition may occur frequently
bladder
polycystic ovarian infertility, oligomenorrhea,
syndrome
– Patients may experience abdominal fullness, bloating and
tenesmus.
• Irregularity of the menstrual cycle.
• Young children may present with precocious puberty
(Granulosa-theca cell tumors) and early onset of
menarche.
 Our case
 She described the pain as colicky, intermittent, located
in left iliac fossa radiates to the suprapubic area.
 Severe pain
 Pain better slightly on lying down
 No h/o of nausea or vomitting
 No h/o fever
 No urinary symptoms
 No PV bleeding.
 Her LMP was at 07/11/2015
 Regular period
 Our case
Past medical history:
• She has similar episodes of pain since March
2015, several visits to the student clinic and
A&E for the same complain
• CT abdomen was done(prominent ovaries
with cysts likely functional) on 26/3/2015
• Follow up US on 20/9/2015: evidence of large
cyst in left adnexa measuring 7.5x6.2 mm in
size
 What is your differential diagnosis ?
• Ovarian cyst accidents
– cyst rupture,
– haemorrhage
– torsion
• Acute PID
 Physical examination
• General examination
• Abdominal examination
• Pelvic examination
 Physical examination
• A large cyst may be palpable on abdominal
examination
• Functional cyts
• mobile, unilateral, and not associated with ascites.
• Tender to palpation
 Physical examination
T Signs Diagnosis
hirsutism, obesity, and acne Polycystic ovarian syndrome

hyperpyrexia complications of ovarian cysts, such

as ovarian torsion
diffusely tender abdomen with rebound hemorrhage or peritonitis
tenderness and guarding
cachexia and weight loss, lymphadenopathy in Advanced malignant disease
the neck, shortness of breath, and signs of
pleural effusion.

Tachycardia and hypotension. Hemorrhage due to cyst rupture

 Our case
O/E:
• vitals: normal
• Abdomen:
– mild tenderness in the lower abdomen
– no guarding ,no rigidity
 Investigation (laboratory)
• No laboratory tests are diagnostic for ovarian
cysts.
• Investigations aid in the differential diagnosis
– Urinary pregnancy test
– CBC ( Anemia + infection)
– Urinalysis (UTI and stones)
– Endocervical swabs
– Cancer antigen 125
 Investigation (radiology )
• Ultrasonography
– primary imaging tool for a patient considered to
have an ovarian cyst
– help to define a cyst’s morphologic characteristics
– Follow up exclude ovarian neoplasm/show
resolution of a cyst
– A normal ovary is 2.5-5 cm long, 1.5-3 cm wide,
and 0.6-1.5 cm thick
 Ultrasonography
• simple ovarian cysts
– uniformly thin, rounded wall and a unilocular
– hypoechoic or anechoic.
– They usually measure 2.5-15 cm in diameter, and
posterior acoustic enhancement

• Complex cysts
– Multilocular ,thickening of the wall, projections
into the lumen or on the surface,
 Radiology
• CT scanning
– more sensitive but less specific than
ultrasonography in detecting ovarian cysts.
– best in imaging hemorrhagic ovarian cysts or
hemoperitoneum due to cyst rupture
– to distinguish other intra-abdominal causes
• CT scanning should be avoided in pregnancy,
– MRI
 Procedure
• Diagnostic laparoscopy
– To inspect a suggestive adnexal cystic mass.
– advantage of decreased morbidity, improved
postoperative recovery.
 Our case
• Labs done in the A&E:
- Hb 11.6 WCC 8.7
- U&E Normal
- Tumor markers normal
• U/S pelvis done:
– The right ovary is normal in size and appearance.
hyperechoic lesion about 5 cm on left ovary that is
new from old scan that can be hemorrhagic
complex cyst & can not rue out/in torsion
Calculation of the Risk Of Malignancy
Index (RMI)

Risk of Malignancy Index = A x B x C. A cut-off value of 200

discriminate a benign from malignant mass with a
Sensitivity of (87%) and a specificity of(97%).
 Functional Cysts - Management
• If the RMI is low and the cyst is considered to be
functional.
– Wait and re-examine the patient after her next menses.

– Low-dose contraceptive agents may be given to suppress

gonadotropin levels and prevent development of another cyst.

• If it is solid, painful, or fixed or has an elevated RMI.

– surgical exploration may be necessary.

– Laparoscopic cystectomy to allow histologic evaluation may be

needed to differentiate between a functional and a neoplastic
ovarian cyst.
 Ovarian Cyst Rupture
• Conservative in stable patient.

• Surgical care
– laparoscopy or laparotomy, depending on clinical
presentation, amount of blood in the abdomen,
patient stability.
 Our case
PLAN:
• consent taken for :
– Emergency laparoscopy ovarain cystectomy ,+/-
salpingectomy +/- salpingo oopherectomy
– risk of converted to laparotomy ,risk of veesels ,bowel
,bladder injuries ,risk of thrombosis , risk of infection all
explined to the pateint ,pateint`s father and mother
• Cross match, NPO
• Shift direct from A&E to the OT
 Our case
Laproscopic findings:
– Left ovarian cystectomy
– Post-op Diagnosis: hemorrhagic cyst with clots, No ovarian
torsion
– Findings: Normal R ovary , pelvis, uterus and upper abdomen
• Day 1 Post op:
She is complaining of mild pain at surgical site.
- Mobilizing.
- Voided well.
- To be discharged with encouraging oral hydration and
analgesia.
- Appointment for tracing histopathology after 6 wks
- Earlier to A&E if any complains as explained.
What are the differential diagnosis of ovarian mass?
Pathogenesis Specific type
Functional Follicular cysts
Lutein cyst
Polycystic ovaries
Inflammatory Salpingo-oophoritis
Pyogenic oophoritis-puerperal,
abortal, or related to an intrauterine
device
Granulomatous oophoritis
Metaplastic Endometriomas
Neoplastic Premenarchal years-10% are
malignant
Menestruating years-15% are
malignant
Postmenopausal years-50% are
malignant
 follicular cysts

-Arise when physiologic release of the mature ovum

fails (follicle fail to rupture).
-Follicular growth continues.
-Excessive stimulation by FSH.
-Lack of the normal preovulatory LH surge.
- 3 cm _Rarely grow larger than 10 cm.
-Most are asymptomatic.
-Larger cysts may cause pelvic discomfort or
heaviness.
-Thin-walled, unilocular
-Usually unilaterally.
 Corpus luteum cyst
(lutein):
• Result when a corpus luteum fails to regress
following the release of an ovum.
• It is the most common pelvic mass
encountered within the 1st trimester.
• most spontaneously involute at the end of
the 2nd trimester.
• -Most are asymptomatic and resolve with
observation and analgesia but If persist =>
surgical.
 Hemorrhagic corpus luteum cysts
• Results from invasion of ovarian vessels into
corpus luteum
• They are more likely to cause symptoms and
more likely to rupture.
• Ruptured hemorrhagic corpus luteum cysts
can result in a Hemoperitoneum requiring
surgery
 Theca-lutein cysts

• hypertrophy of the theca interna cell layer in response to

excessive stimulation from hCG.
• Present with
– hydatidiform mole.
– multiple gestation.
– choriocarcinoma.
– ovulation induction with gonadotropins or clomiphene.
• usually bilateral.
• may become quite large (>30 cm)
• characteristically regress slowly after the gonadotropin level
falls.
 luteoma of pregnancy
• Prolonged hCG stimulation during pregnancy
leading to hyperplasic reaction of ovarian theca
cells.
• Appear as brown to reddish-brown nodules that
may be cystic or solid.
• Multifocal and usually bilateral
• Can cause maternal virilization in 30% of women
and ambiguous genitalia in a female fetus.
• regress spontaneously postpartum.
 Benign neoplastic ovarian tumors

Divided by cell
type of origin

Epithelial Stromal Germ cell

•Mucinous •Fibromas •Benign cystic

•Serous •Granulosa- teratoma
•Brenner theca cell tumors
•Sertoli-Leydig
cell tumors
 1- Epithelial ovarian neoplasms
TYPE DESCRIPTION PRESENTATION US/Cytology
• most common is serous
cystadenoma •Often multilocular
Serous •70 % benign 10% bilateral •Histologicaly contain
•5-10%borderline Psammoma bodies
malignant (calcified concentric
•20% to 25% are malignant concretions)
Huge size,
Often filling entire •Resembles
Mucinous •85% benign pelvis endocervical
•20% of epithelial tumors •may be epithelium
complicated by •Often multilocular
pseudomyxoma •Often associated with
peritonei a mucocele of the
appendix
•usually benign •a small, smooth •Has a large fibrotic
•33% are associated with solid ovarian component that
Brenner mucinous epithelial neoplasm. encases epithelioid
elements. cells that resemble
transitional cells of the
bladder.
 Sex Cord–Stromal Ovarian Neoplasm
TYPE DESCRIPTION • PRESENTATION • US/Cytology

Fibroma • benign • Non-functioning Form encapsulated, solid,

• associated with Meigs smooth-surfaced tumor,
syndrome composed of spindle-
shaped cells.

Granulosa-theca cell •Can be associated with Estrogen-producing -solid-yellow appearance

tumors (benign or endometrial cancer feminizing effects -Histologic hallmark of
malignant) (precocious cancer is small groups of
•Inhibin is tumor marker puberty, menorrhagia, cells known as Call-Exner
postmenopausal bodies
bleeding)

Sertoli-leydig cell Can measure elevated Androgen-producing

tumors (benign or androgens as tumor virilizing effects
malignant) markers (hairsutism, deep voice,
recession of front hair)
 MCQ
• A 4-year-old girl is noted to have breast
enlargement and vaginal bleeding. On physical
examination, she is noted to have a 9-cm pelvic
mass. Which of the following is the most likely
etiology?
• A. Cystic teratoma
B. Dysgerminoma
C. Endodermal sinus tumor
D. Granulosa-theca cell tumors
E. Mucinous tumor
 MCQ
A 47 year old woman is admitted to the gynaecology ward after the
discovery of an ovarian mass on an annual gynaecological checkup. On
general examination she is found to have a distended abdomen, with
possible ascites, and bilateral pleural effusions. Biopsy of the mass
reveals a fibroma.

Given the signs and symptoms, what is the diagnosis?

A. Fitz-Hugh-Curtis syndrome
B. Lung cancer
C. Meig's syndrome
D. Leriche's syndrome
F. Liver failure
 Germ cell tumors
• Occur at any age.
• Make up about 60% of ovarian neoplasms occurring in
infants and children.
• Most common benign cystic teratoma (dermoid cyst).
• 10-15% are bilateral.
• Slow growing tumor.
• Diagnosed b/w 25-50 yrs of age.
• <10 cm in diameter.
 Teratomas
Dermoid cysts (teratomas) are one of the
most common types of cysts , half are
diagnosed in women between 25 and 50 years

Composed primarily of ectodermal tissue

(sweat & sebaceous glands, hair follicles, and
teeth), with some mesodermal and rarely
endodermal elements
A dermoid cyst (mature cystic
teratoma) after opening the abdomen.
 Mixed Ovarian Neoplasms
• Ovarian tumor in which the neoplastic
elements are composed of more than one cell
type
• More solid than epithelia ovarian tumor
• The most common is the cyst-adeno-fibroma.
• It is benign but it may predispose to
malignant dysgerminoma.
Benign Ovarian Tumors- Management
• Benign epithelial ovarian neoplasms are
generally treated by unilateral salpingo-
oophorectomy.
– cystectomy with preservation of the depending on
the neoplasm (cystic teratoma) and age of patient.
– Gonadoblastoma, dysgenetic ovaries = bilateral
salpingo-oorphrectomy

• Appendectomy should also be done in mucinous

cystadenoma. Because it is associated with a
mucocele of the appendix
• Dermoid cyst (teratoma)
• Granulosa cell tumour
• Corpus luteum cyst
• Mucinous cystadenoma
• Follicular cyst
• Serous cystadenoma

• If ruptures may cause pseudomyxoma peritonei

• The most common type of epithelial cell tumour

• May contain skin appendages, hair and teeth

 MCQ
A 20-year-old female presents with a 3 month history of
abdominal pain. Abdominal ultrasound shows a 8cm mass
in the right ovary. Histopathological analysis reveals
Rokitansky's protuberance. What is the most likely
diagnosis?

A. Follicular cyst
B. Teratoma (dermoid cyst)
C. Endometrioma
D. Ovarian adenocarcinoma
E. Ovarian fibroma
 Ovarian cancer
• It is the leading cause of death from gynecologic cancer
because it is difficult to detect before it disseminates.

• Most women with ovarian cancer are in the 5th or 6th

decade of life.

• Population screening is not feasible because

ultrasonography and available tumor markers, lack
specificity and sensitivity for early-stage disease.
 Ovarian Cancer- Clinical features
• In early-stage disease, vague abdominal pain or
bloating
– Other symptoms include dyspareunia, urinary
frequency or constipation and menstrual irregularity
or Postmenopausal bleeding.
• In advanced-stage disease, patients most often
present with abdominal pain or swelling (from
the tumor itself or from associated ascites).
• In bimanual pelvic examination
– a solid, irregular, fixed pelvic mass.
 Ovarian Cancer- Management
• Depending on the stage of the cancer.

• In postmenopausal women they are best

treated by a total abdominal hysterectomy
and bilateral salpingo-oophorectomy.

• In premenopausal women , the contralateral

ovary and the uterus can be preserved in
some types.
 References
• Essentials of obstetrics and gynecology,HACKER
and MOORES.
• Medscape
• Abduljabbar HS, Bukhari Y. Review of 244 cases
of ovarian cysts. Saudi Med J 2015; Vol. 36 (7)
• www.ncbi.nlm.nih.gov/pubmed/21991700
• https://www.womenshealth.gov/publications/o
ur-publications/fact-sheet/ovarian-cysts.html