Ovarian cysts

Ovarian cysts are fluid-filled structures that may be simple or complex. They are commonly found incidentally during physical examination or imaging. Complications such as rupture, hemorrhage, and torsion can be gynecological emergencies requiring prompt diagnosis and treatment to avoid high morbidity and mortality.

Epidemiology:

• Ovarian cysts are common, with many women experiencing at least one in their lifetime.
• Prevalence is higher in reproductive-aged women and those undergoing certain treatments or conditions.
• A random sample showed a 7.8% prevalence of adnexal lesions in women aged 24-40.
• Postmenopausal women have a 2.5% prevalence of simple unilocular adnexal cysts.
• Ovarian cysts are common in infants and fetuses, with a prevalence of over 30%.

Pathophysiology:

• Functional Cysts:
  • Follicular Cysts
    • Occur when the follicle does not rupture and release the egg. The follicle continues to grow and fill with fluid.
  • Corpus Luteal Cysts:
    • Form when the corpus luteum (remnant of the follicle after ovulation) fails to regress and instead fills with fluid or blood.
  • Often resolve spontaneously without treatment.
  • Approximately 70-80% of follicular cysts resolve on their own within 1-3 menstrual cycles.
• Theca Lutein Cysts:
  • Form due to overstimulation by elevated hCG levels (gestational trophoblastic disease, multiple gestation pregnancies, and ovarian hyperstimulation syndrome (OHSS).)
    • generally resolve spontaneously once the source of hCG stimulation is removed or decreases.
• Polycystic Ovary Syndrome (PCOS):
  • Characterized by multiple small follicular cysts due to excess androgens, insulin resistance, and chronic anovulation.
  • Clinical Features: Enlarged ovaries with multiple small cysts, irregular menstrual cycles, hirsutism, acne, obesity.
• Endometriomas (Chocolate Cysts):
  • Pathophysiology: Formed by the ectopic growth of endometrial tissue within the ovaries. These cysts contain thick, dark blood (hence the name “chocolate cysts”).
  • Clinical Features: Chronic pelvic pain, dysmenorrhea, dyspareunia, infertility.
  • Management: Surgical removal, hormonal therapy to suppress endometriosis.
• Dermoid Cysts (Mature Cystic Teratomas):
  • Pathophysiology: Composed of various tissue types (e.g., hair, skin, teeth) derived from germ cells. These cysts can grow large and may contain complex structures.
  • Clinical Features: Often asymptomatic but can cause pain or torsion if they grow large.
  • Management: Surgical removal due to risk of complications and to rule out malignancy.
• Neoplastic Cysts:
  • Benign Neoplastic Cysts:
    • Examples: Serous cystadenoma, mucinous cystadenoma..
  • Malignant Neoplastic Cysts:
    • Examples: Serous carcinoma, mucinous carcinoma, endometrioid carcinoma.y.

Etiology:

• Normal Physiological Processes: Follicular or luteal cysts.
• Risk Factors:
  • Infertility treatments.
  • Tamoxifen use.
  • Pregnancy.
  • Hypothyroidism.
  • Maternal gonadotropins.
  • Cigarette smoking.
  • Tubal ligation.

Symptoms

• pain (torsion or haemorrhage), pressure, menstrual irregularity
• Tend to rupture just before ovulation or after coitus
  • 15-25yo, sudden onset pain in an iliac fossa, may have N/V, pain usually settles in a few hours, no systemic signs

Management

• Simple cysts
  • Small Cysts (<5 cm):
    • Generally low risk of complications.
    • Often asymptomatic and discovered incidentally.
  • Medium Cysts (5-10 cm):
    • Higher risk of complications such as torsion, rupture, or hemorrhage.
    • Regular monitoring with serial ultrasounds is recommended.
  • Large Cysts (>10 cm):
    • Significantly higher risk of complications, including torsion and rupture.
    • Higher likelihood of requiring surgical intervention.
    • Increased suspicion for malignancy, particularly in postmenopausal women.
  • Post menopasual do follow up USS. Can calculate risk of malignancy index
• COCP may prevent formation of cysts
• If mass is suspicious (Complex Cysts: Mixed cystic and solid, irregular, thick-walled, with internal septations)
  • Refer gynae
  • Do Ca-125, LDH, AFP, Bhcg, HE-4

• Postmenopausal Women:
  • Any cysts require careful evaluation due to higher malignancy risk.Elevated CA125 levels and suspicious ultrasound findings warrant referral to a gynecologic oncologist.

Complications

• Cyst rupture – if simple can be managed outpatient
• Ovarian torsion – risk if cyst > 5cm, cannot exclude with USS

• In pregnancy – can usually manage expectantnly. If identified on dating scan – repeat at 12-14 weeks
• No screening for ovarian cancer