Ovarian cyst

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Ovarian cyst
Benign Ovarian Cyst.jpg
A simple ovarian cyst of probably follicular origin
Classification and external resources
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 fluid-filled sac within the ovary. Often they cause no symptoms. Occasionally they may produce bloating, lower abdominal pain, or lower back pain. If the cyst either breaks open or twists the ovary severe pain may occur. This may result in vomiting or feeling faint. The majority of cysts are, however, harmless.[1]

Most ovarian cysts are related to ovulation being either follicular cysts or corpus luteum cysts. Other types include cysts due to endometriosis, dermoid cysts, and cystadenomas. Many small cysts occur in both ovaries in polycystic ovarian syndrome. Pelvic inflammatory disease may also result in cysts. Rarely cysts may be a form of ovarian cancer. Diagnosis is undertaken by pelvic examination with an ultrasound or other testing used to gather further details.[1]

Often cysts are simply observed over time. If they cause pain, medications such as paracetamol (acetaminophen) or ibuprofen may be used. Hormonal birth control may be used to prevent further cysts in those who are frequently affected.[1] However, evidence does not support birth control as a treatment of current cysts.[2] If they do not go away after several months, get larger, look unusual, or cause pain they may be removed by surgery.[1]

Most women of reproductive age develop small cysts each month. Large cysts that cause problems occur in about 8% of women before menopause.[1] Ovarian cysts are present in about 16% of women after menopause and if present are more likely to be cancer.[1][3]

Signs and symptoms[edit]

Some or all of the following symptoms may be present, though it is possible not to experience any symptoms:[4]

  • 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:[4]

The effect of cysts not related to PCOS on fertility is unclear.[5]

Complications[edit]

Cyst rupture[edit]

A ruptured ovarian cyst is usually self-limiting, and only requires keeping an eye on the situation and pain medications. The main symptom is abdominal pain, they can also be asymptomatic. The pain may last from a few days to several weeks.[6] Rupture of large ovarian cysts can cause lots of bleeding inside the abdominal cavity and in some cases shock.

Ovarian torsion[edit]

Ovarian cysts increase the risk for ovarian torsion, cysts larger than 4 cm are associated with approximately 17% risk. The torsion can cause obstruction of blood flow and lead to infarction.[7]

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, with additional endocrinological tests.

Follow-up imaging for women of reproductive age with small simple or hemorrhagic cyst is generally not required.[8]

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:[9]

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

Ovarian cysts may be classified according to whether they are a variant of the normal menstrual cycle, called a functional cyst, or not.[4]

Ovarian cysts are considered large when they are over 5 cm and giant when they are over 15 cm. In children ovarian cysts reaching above the level of the umbilicus are considered as giant.

Functional[edit]

Functional cysts form as a normal part of the menstrual cycle. There are several types of cysts:

  • Follicular cyst, the most common type of ovarian cyst. In menstruating women, 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.[4]
  • 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 luteum that is more than 3 cm is defined as cystic.[4]
  • Theca lutein 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.[4]

Non-functional[edit]

Transvaginal ultrasonography of a hemorrhagic ovarian cyst, probably originating from a corpus luteum cyst. The coagulating blood gives the content a spider web-like appearance.
Transvaginal ultrasonography showing a 67 x 40 mm endometrioma, with a somewhat grainy content.

Non-functional cysts may include the following:

Juvenile[edit]

Benign ovarian cysts are common in unsymptomatic premenarchal girls and found in approximately 68% of ovaries of girls 2–12 years old and in 84% of ovaries of girls 0–2 years old. Most of them are smaller than 9 mm while about 10-20% are larger macrocysts. While the smaller cysts mostly disappear within 6 months the larger ones appear to be more persistent.[10][11]

In juvenile hypothyroidism multicystic ovaries are present in about 75% of cases while large ovarian cysts and elevated ovarian tumor marks are one of the symptoms of the Van Wyk and Grumbach syndrome.[12]

The CA-125 marker in children and adolescents can be frequently elevated even in absence of malignancy and conservative management should be considered.

Risk of cancer[edit]

A widely recognised method of estimating the risk of malignant ovarian cancer based on initial workup is the risk of malignancy index (RMI).[13]

It is recommended that women with an RMI score over 200 should be referred to a centre with experience in ovarian cancer surgery.[14]

The RMI is calculated as follows:[14]

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:[14]

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.[14] RMI 2 is regarded as more sensitive than RMI 1.[14]

Treatment[edit]

Cysts associated with hypothyroidism or other endocrine problems are treated by treating the underlying condition.

About 95% of ovarian cysts are benign, not cancerous.[15]

Functional cysts and hemorrhagic ovarian cysts usually resolve spontaneously.[16] However the bigger an ovarian cyst is, the less likely it is to disappear on its own.[17] Treatment may be required if cysts persist over several months, grow or cause increasing pain.[18]

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 tumour 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.[19]

Pain[edit]

Pain associated with ovarian cysts may be treated in several ways:

Surgery[edit]

Some cases require surgery. This may involve removing the cyst, or one or both ovaries.[20] Features that may indicate the need for surgery include:[21]

  • Persistent complex ovarian cysts
  • Persistent cysts that are causing symptoms
  • Complex ovarian cysts larger than 5 cm
  • Simple ovarian cysts larger 10 centimeters or larger than 5 cm in postmenopausal patients
  • Women who are menopausal or perimenopausal

Epidemiology[edit]

Most women of reproductive age develop small cysts each month Large cysts that cause problems occur in about 8% of women before menopause.[1] Ovarian cysts are present in about 16% of women after menopause and if present are more likely to be cancer.[1][22]

References[edit]

  1. ^ a b c d e f g h i j "Ovarian cysts". Office on Women's Health. November 19, 2014. Retrieved 27 June 2015. 
  2. ^ a b Grimes, DA; Jones, LB; Lopez, LM; Schulz, KF (29 April 2014). "Oral contraceptives for functional ovarian cysts.". The Cochrane database of systematic reviews 4: CD006134. PMID 24782304. 
  3. ^ Mimoun, C; Fritel, X; Fauconnier, A; Deffieux, X; Dumont, A; Huchon, C (December 2013). "[Epidemiology of presumed benign ovarian tumors].". Journal de gynecologie, obstetrique et biologie de la reproduction 42 (8): 722–9. PMID 24210235. 
  4. ^ a b c d e f Helm, William. "Ovarian Cysts". Retrieved 30 August 2013. 
  5. ^ Legendre, G; Catala, L; Morinière, C; Lacoeuille, C; Boussion, F; Sentilhes, L; Descamps, P (March 2014). "Relationship between ovarian cysts and infertility: what surgery and when?". Fertility and sterility 101 (3): 608–14. PMID 24559614. 
  6. ^ Ovarian Cyst Rupture at Medscape. Authors: Nathan Webb and David Chelmow. Updated: Nov 30, 2012
  7. ^ "Ovarian Cysts Causes, Symptoms, Diagnosis, and Treatment". eMedicineHealth.com. 
  8. ^ 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 (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. 
  9. ^ 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. PMID 24327552. 
  10. ^ Cohen HL, Eisenberg P, Mandel F, Haller JO (1992). "Ovarian cysts are common in premenarchal girls: A sonographic study of 101 children 2-12 years old". AJR. American journal of roentgenology 159 (1): 89–91. doi:10.2214/ajr.159.1.1609728. PMID 1609728. 
  11. ^ Qublan HS, Abdel-hadi J (2000). "Simple ovarian cysts: Frequency and outcome in girls aged 2-9 years". Clinical and experimental obstetrics & gynecology 27 (1): 51–3. PMID 10758801. 
  12. ^ Durbin KL, Diaz-Montes T, Loveless MB (2011). "Van wyk and grumbach syndrome: An unusual case and review of the literature". Journal of pediatric and adolescent gynecology 24 (4): e93–6. doi:10.1016/j.jpag.2010.08.003. PMID 21600802. 
  13. ^ 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).
  14. ^ 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
  15. ^ http://www.nhs.uk/Conditions/Ovarian-cyst/Pages/Symptoms.aspx
  16. ^ V.T. (14 May 2014). Understanding Ovarian Cyst. V.T. pp. 25–. GGKEY:JTX84XQARW9. 
  17. ^ Edward I. Bluth (2000). Ultrasound: A Practical Approach to Clinical Problems. Thieme. p. 190. ISBN 978-0-86577-861-0. 
  18. ^ Susan A. Orshan (2008). Maternity, Newborn, and Women's Health Nursing: Comprehensive Care Across the Lifespan. Lippincott Williams & Wilkins. p. 161. ISBN 978-0-7817-4254-2. 
  19. ^ MedlinePlus Encyclopedia CA-125
  20. ^ "HealthHints: Gynecologic Health (January/February, 2003)". Texas AgriLife Extension Service: HealthHints. 
  21. ^ Ovarian cysts from MedlinePlus. Update Date: 2/26/2012. Updated by: Linda J. Vorvick and Susan Storck. Also reviewed by David Zieve
  22. ^ Mimoun, C; Fritel, X; Fauconnier, A; Deffieux, X; Dumont, A; Huchon, C (December 2013). "[Epidemiology of presumed benign ovarian tumors].". Journal de gynecologie, obstetrique et biologie de la reproduction 42 (8): 722–9. PMID 24210235. 

External links[edit]