OVARIAN CYSTSFahad zakwan

Introduction• Ovarian enlargements can be cystic or

solid but in most cases ovarian enlargement are cystic.

Non-neoplastic

Neoplastic (Ovarian Tumors)

Non-neoplastic cysts of the ovary

• An ovarian cyst is a sac filled with liquid or semi-liquid material arising in an ovary.

• The number of diagnoses of ovarian cysts has increased with the widespread implementation of regular physical examinations and ultrasound technology.

• The finding of an ovarian cyst causes considerable anxiety for women because of the fear of malignancy, but the vast majority of ovarian cysts are benign.

TYPES OF OVARIAN CYSTS.1. POLYSTIC OVARIAN SYNDROME (PCOS)2. ENDOMETRIOMATOUS CYSTS3. FUNCTIONAL CYSTS (commonest)–Follicular cysts–Theca lutein cysts–Corpus luteum cysts.

FUNCTIONAL CYSTS

Ovarian cysts arising in the normal process of ovulation

• They may be follicular ,theca-lutein or corpus luteum cysts.

• These cysts can be stimulated by gonadotropins, including follicle-stimulating hormone (FSH) and human chorionic gonadotropin (hCG).

• Multiple functional cysts can occur as a result of excessive gonadotropin stimulation or sensitivity

• This stimulation may occurs in cases of

GTDs (hydatiform mole and choriocarcinoma)

multiple pregnancy.

In patients being treated for infertility, ovulation induction with gonadotropins (FSH and luteinizing hormone [LH]), and clomiphene citrate, may lead to ovarian hyperstimulation syndrome, especially if accompanied by hCG administration

ENDOMETRIOMATOUS CYSTS OF THE OVARY

• Cysts filled with blood arising from the ectopic endometrium.

• They usually enlarge pre and during menses and slightly shrink there after.

The ovary is the commonest site of pelvic endometriosis.

POLYCYSTIC OVARIAN SYNDROME (PCOS)

Risk factors of ovarian cysts1. Hypothyroidism

2. Infertility or women who are on treatment for infertility

3. Those taking tamoxifen, a drug to combat breast cancer

4. Irregular periods

5. Early periods (before 11 years)

6. Previous history of ovarian cysts.

7. A drug called clomiphene may lead to formation of corpus luteum cyst.

Rotterdam criteria for diagnosis of PCOS

1. Menstrual irregularities. Most patients with PCOS have menstrual irregularities that begin during adolescence.

–Oligomenorrhea: less than nine menses per year

–Amenorrhea: no menses for 6 months or three or more skipped cycles

Difficulty in conceiving is present in many women with PCOS

2. Hyperandrogenism. Patients may either show signs of clinical hyperandrogenism or have biochemical hyperandrogenism:

–Clinical hyperandrogenism: e.g hirsutism, acne, or male pattern hair loss.

–Biochemical hyperandrogenism: Up to 90% of women with PCOS have elevated serum androgen concentration. However, the androgen levels may be normal.

3. Polycystic ovaries. A diagnosis of polycystic-appearing ovaries can be made using pelvic ultrasound.–PCOS by ultrasound criteria is defined as 12 or more

antral follicles between 2 and 9 mm in size and peripheral in location in at least one ovary

–Transvaginal ultrasound is more sensitive, but may not be appropriate to perform in a young female.

History: Clinical presentation of ovarian cysts

• The majority of ovarian cysts are asymptomatic.

• Pain or discomfort may occur in the lower abdomen.

Torsion (twisting) or rupture may lead to more severe pain.

• Patients may experience discomfort with intercourse, particularly deep penetration.

• Having bowel movements may be difficult, or pressure may develop, leading to a desire to defecate.

• Micturition may occur frequently and is due to pressure on the bladder.

• Patients may experience abdominal fullness and bloating.

• Endometriomas are associated with endometriosis, which causes a classic triad of painful and heavy periods and dyspareunia.

• Patients with polycystic ovary syndrome presents hirsutism, infertility, oligomenorrhea, obesity, and acne.

Note that infertility is not a rule.

Physical findings

• A large cyst may be palpable during the abdominal examination

• Sometimes, discerning the cystic nature of an ovarian cyst may be possible, and it may be tender to palpation.

• If a cyst is huge ,The cervix and uterus may be pushed to one side.

Laboratory Studies: • No laboratory tests are diagnostic for ovarian cysts except for

PCOS for which hormone assays are done:

FSH

LH

Testosterone

Oestradiol

Imaging Studies:

•Ultrasonography

•Doppler flow studies

•MRI

•CT scan

Medical Care:

•Many patients with simple ovarian cysts based on ultrasonography findings do not require treatment.

Surgical Care:

• Persistent simple ovarian cysts larger than 5-10 cm and complex ovarian cysts should be removed surgically.

Laparotomy

Laparascopically

The following diagnostic tests may also be ordered:

• Ultrasound scan - this will be carried out to help the doctor make a diagnosis. A wand-like scanner probe (transducer) is placed on the abdomen, over where the ovaries are.

• Sometimes the probe may be placed inside the vagina. In both cases, the doctor is observing the ovaries on a video screen. This test can help the doctor determine whether there is a cyst, and whether it is solid, filled with fluid (or both).

• Blood test - if there is a tumor present blood levels of CA125 (a protein) will be elevated.

• High CA125 levels could also mean the patient has ovarian cancer. If a woman develops an ovarian cyst that is partially solid she may have ovarian cancer.

• High CA125 levels may also be present in other conditions, including endometriosis, uterine fibroids or pelvic inflammatory disease.

• Laparoscopy - a thin, lighted instrument (laparoscope) is inserted into the patient's abdomen through a small incision (skin cut). If the doctor spots an ovarian cyst he/she may also remove it there and then.

•Pregnancy test - a positive result may suggest the patient has a corpus luteum cyst

Complications of ovarian cysts

• Torsion

• Rupture

• Hemorrhage

• ?Malignant change :remains unproven

Prognosis:

The prognosis for benign cysts is

excellent