Ovarian cyst

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Ovarian cyst
Classification and external resources
Benign Ovarian Cyst.jpg
Ovarian cyst
ICD-10 N83.0-N83.2
ICD-9 620.0-620.2
DiseasesDB 9433
MedlinePlus 001504
eMedicine med/1699 emerg/352
MeSH D010048

An ovarian cyst is any collection of fluid, surrounded by a very thin wall, within an ovary.[1] Any ovarian follicle that is larger than about two centimeters is termed an ovarian cyst. Such cysts range in size from as small as a pea to larger than an orange.

Most ovarian cysts are functional in nature and harmless (benign).[1][2]

Ovarian cysts affect women of all ages. They occur most often, however, during a woman's childbearing years.

Some ovarian cysts cause problems, such as bleeding and pain. Surgery may be required to remove cysts larger than 5 centimeters in diameter.

Classification[edit]

Ovarian cysts may be classified according to whether they are a variant of the normal menstrual cycle, called a functional cyst, or not.[3]

Functional[edit]

Functional cysts form as a normal part of the menstrual cycle. Such cysts may include:

  • Follicular cyst, the most common type of ovarian cyst. In menstruation, a follicle containing the ovum (unfertilized egg) will rupture during ovulation. If this does not occur, a follicular cyst of more than 2.5 cm diameter may result.[3]
  • Corpus luteum cysts appear after ovulation. The corpus luteum is the remnant of the follicle after the ovum has moved to the fallopian tubes. This normally degrades within 5–9 days. A corpus lutem that is more than 3 cm is defined as cystic.[3]
  • Thecal cysts occur within the thecal layer of cells surrounding developing oocytes. Under the influence of excessive hCG, thecal cells may proliferate and become cystic. This is usually on both ovaries.[3]

Non-functional[edit]

A hemorrhagic ovarian cyst, probably originating from a corpus luteum cyst, found in a woman 3 weeks into the postpartum period. The hemorrhage is discerned by a grainy texture of an higher echogenicity than the fluid in the periphery of the cyst that resembles dark crescents.

Non-functional cysts may include:

Signs and symptoms[edit]

Some or all of the following symptoms may be present, though it is possible not to experience any symptoms:[3]

  • Abdominal pain. Dull aching pain within the abdomen or pelvis, especially on intercourse.
  • Uterine bleeding. Pain during or shortly after beginning or end of menstrual period; irregular periods, or abnormal uterine bleeding or spotting.
  • Fullness, heaviness, pressure, swelling, or bloating in the abdomen.
  • When a cyst ruptures from the ovary, there may be sudden and sharp pain in the lower abdomen on one side.
  • Change in frequency or ease of urination (such as inability to fully empty the bladder), or difficulty with bowel movements due to pressure on adjacent pelvic anatomy.
  • Constitutional symptoms such as fatigue, headaches
  • Nausea or vomiting
  • Weight gain

Other symptoms may depend on the cause of the cysts:[3]

Diagnosis[edit]

A 2cm left ovarian cyst as seen on ultrasound
An Axial CT demonstrating a large hemorrhagic ovarian cyst. The cyst is delineated by the yellow bars with blood seen anteriorly.

Ovarian cysts are usually diagnosed by either ultrasound or CT scan. Follow-up imaging for women of reproductive age with small simple or hemorrhagic cyst is generally not required.[4]

There are several systems for scoring of the risk of an ovarian cyst of being an ovarian cancer, including RMI (risk of malignancy index), LR2 and SR (simple rules). Sensitivities and specificities of these systems are given in tables below:[5]

Scoring systems Premenopausal Postmenopausal
Sensitivity Specificity Sensitivity Specificity
RMI I 44% 95% 79% 90%
LR2 85% 91% 94% 70%
SR 93% 83% 93% 76%

Risk of malignancy index[edit]

A widely recognized method of estimating the risk of malignant ovarian cancer based on initial workup is the risk of malignancy index (RMI).[6]

It is recommended that women with an RMI score over 200 should be referred to a center with experience in ovarian cancer surgery.[7]

The RMI is calculated as follows:[7]

RMI = ultrasound score x menopausal score x CA-125 level in U/ml.

There are two methods to determine the ultrasound score and menopausal score, with the resultant RMI being called RMI 1 and RMI 2, respectively, depending on what method is used:[7]

Transvaginal ultrasound showing an ovarian cyst with a solid area in its upper part.
Feature RMI 1 RMI 2

Ultrasound abnormalities:

  • multilocular cyst
  • solid areas
  • bilateral lesions
  • ascites
  • intra-abdominal metastases
  • 0 = no abnormality
  • 1 = one abnormality
  • 3 = two or more abnormalities
  • 0 = none
  • 1 = one abnormality
  • 4 = two or more abnormalities
Menopausal score
  • 1 = premenopausal
  • 3 = postmenopausal
  • 1 = premenopausal
  • 4 = postmenopausal
CA-125 Quantity in U/ml Quantity in U/ml

An RMI 2 of over 200 has been estimated to have a sensitivity of 74 to 80%, a specificity of 89 to 92% and a positive predictive value of around 80% of ovarian cancer.[7] RMI 2 is regarded as more sensitive than RMI 1.[7]

Treatment[edit]

About 95% of ovarian cysts are benign, meaning they are not cancerous.[8]

Treatment for cysts depends on the size of the cyst and symptoms.

Pain caused by ovarian cysts may be treated with:

Also, limiting strenuous activity may reduce the risk of cyst rupture or torsion.

Cysts that persist beyond two or three menstrual cycles, or occur in post-menopausal women, may indicate more serious disease and should be investigated through ultrasonography and laparoscopy, especially in cases where family members have had ovarian cancer. Such cysts may require surgical biopsy. Additionally, a blood test may be taken before surgery to check for elevated CA-125, a tumor marker, which is often found in increased levels in ovarian cancer, although it can also be elevated by other conditions resulting in a large number of false positives.[12]

For more serious cases where cysts are large and persisting, doctors may suggest surgery. This may involve removing the cyst, or one or both ovaries.[13] Features that may indicate the need for surgery include:[14]

  • Persistent complex ovarian cysts
  • Persistent cysts that are causing symptoms
  • Simple ovarian cysts larger than 5-10 centimeters
  • Women who are menopausal or perimenopausal

Ovarian cyst rupture[edit]

A rupture of an ovarian cyst is usually a self-limiting, and only requires expectant management and analgesics. The main symptom is abdominal pain, but can also be asymptomatic. The pain may last from a few days to several weeks.[15]

References[edit]

  1. ^ a b Ashby, Karen L. (2004). "Ovarian Cyst". In Loue, Sana & Sajatovic, Martha. Encyclopedia of Women's Health. Springer. p. 476. ISBN 9780306480737. 
  2. ^ "Ovarian Cysts Causes, Symptoms, Diagnosis, and Treatment". eMedicineHealth.com. 
  3. ^ a b c d e f Helm, William. "Ovarian Cysts". Retrieved 30 August 2013. 
  4. ^ Levine, D; Brown, DL; Andreotti, RF; Benacerraf, B; Benson, CB; Brewster, WR; Coleman, B; DePriest, P; Doubilet, PM; Goldstein, SR; Hamper, UM; Hecht, JL; Horrow, M; Hur, HC; Marnach, M; Patel, MD; Platt, LD; Puscheck, E; Smith-Bindman, R; Society of Radiologists in, Ultrasound (September 2010). "Management of asymptomatic ovarian and other adnexal cysts imaged at US Society of Radiologists in Ultrasound consensus conference statement.". Ultrasound quarterly 26 (3): 121–31. doi:10.1097/RUQ.0b013e3181f09099. PMID 20823748. 
  5. ^ Kaijser, J.; Sayasneh, A.; Van Hoorde, K.; Ghaem-Maghami, S.; Bourne, T.; Timmerman, D.; Van Calster, B. (2013). "Presurgical diagnosis of adnexal tumours using mathematical models and scoring systems: a systematic review and meta-analysis". Human Reproduction Update 20 (3): 449–462. doi:10.1093/humupd/dmt059. ISSN 1355-4786. 
  6. ^ NICE clinical guidelines Issued: April 2011. Guideline CG122. Ovarian cancer: The recognition and initial management of ovarian cancer, Appendix D: Risk of malignancy index (RMI I).
  7. ^ a b c d e EPITHELIAL OVARIAN CANCER SECTION 3: DIAGNOSIS from The Scottish Intercollegiate Guidelines Network. Guideline No 75. October 2003.ISBN 1899893 93 8
  8. ^ http://www.nhs.uk/Conditions/Ovarian-cyst/Pages/Symptoms.aspx
  9. ^ a b "Ovarian Cysts Treatment & Monitoring". Medicine Online. 
  10. ^ http://www.lakeside.ca/Patient_Info/ovarian_cysts.htm
  11. ^ Grimes DA, Jones LB, Lopez LM, Schulz KF. Oral contraceptives for functional ovarian cysts. Cochrane Database of Systematic Reviews 2011, Issue 9. Art. No.: CD006134. DOI: 10.1002/14651858.CD006134.pub4.
  12. ^ MedlinePlus Encyclopedia CA-125
  13. ^ "HealthHints: Gynecologic Health (January/February, 2003)". Texas AgriLife Extension Service: HealthHints. 
  14. ^ Ovarian cysts from MedlinePlus. Update Date: 2/26/2012. Updated by: Linda J. Vorvick and Susan Storck. Also reviewed by David Zieve
  15. ^ Ovarian Cyst Rupture at Medscape. Authors: Nathan Webb and David Chelmow. Updated: Nov 30, 2012

External links[edit]