Ovarian Cyst

Question 1

Definition

Answer 1

Fluid-filled sac. Functional overian cysts related to the fluctuating hormones of the menstrual cycle,

Question 2

Epidemiology

Answer 2

• Premenopausal women (Benign)
• Cysts in postmenopausal women (more likely malignant)

Question 3

Risk factors

Answer 3

• Age
• Postmenopause
• Increased number of ovulations
• Obesity
• Hormone replacement therapy
• Smoking
• Breastfeeding (protective)
• Family history and BRCA1 and BRCA2 genes

Question 4

Classic appearance of multiple ovarian cysts

Answer 4

“String of pearls” appearance

Question 5

Presentation

Answer 5

Majority asymptomatic
Vague symptoms:
- Pelvic pain
- Bloating
- Fullness in the abdomen
- A palpable pelvic mass (particularly with very large cysts such as mucinous cystadenomas)

Question 6

When may ovarian cysts present with acute pelvic pain

Answer 6

Ovarian torsion
Haemorrhage
Rupture of cyst

Question 7

Functional cysts

Answer 7

Follicular cysts (MC) = represent the developing follicle
- When these fail to rupture and release the egg, the cyst can persist.
- Harmless and tend to disappear after a few menstrual cycles.
- Typically they have thin walls and no internal structures.

Question 8

Corpus luteum cysts

Answer 8

Occurs when the corpus luteum fails to break down and instead with fluid. They may cause pelvic discomfort, pain or delayed menstruation.
Seen often in early pregnancy.

Question 9

Serous cystadenoma

Answer 9

These are benign tumours of the epithelial cells

Question 10

Mucinous cystadenoma

Answer 10

Benign tumour of the epithelial cells. They can become huge, taking up lots of space in the pelvis and abdomen

Question 11

Endometrioma

Answer 11

These are lumps of endometrial tissue within the ovary, occurring in patients with endometriosis. They can cause pain and disrupt ovulation.

Question 12

Dermoid cysts/ Germ cell tumours

Answer 12

• Benign ovarian tumours. - They are teratomas, (come from the germ cells) and may contain various tissue types, such as skin, teeth, hair and bone. They are particularly associated with ovarian torsion.

Question 13

Sex Cord-Stromal Tumours

Answer 13

• Rare tumours, can be benign or malignant.
• They arise from the stroma (connective tissue) or sex cords (embryonic structures associated with the follicles).
• There are several types, including Sertoli–Leydig cell tumours and granulosa cell tumours.

Question 14

Signs

Answer 14

Abdominal bloating
Reduce appetite
Early satiety
Weight loss
Urinary symptoms
Pain
Ascites
Lymphadenopathy

Question 15

More ovulation periods = high risk of ovarian cancer. Which factors reduce the number of ovulations?

Answer 15

• Later onset of periods (menarche)
  -Early menopause
• Any pregnancies
• Use of the combined contraceptive pill

Question 16

Diagnosis

Answer 16

• Premenopausal women with a simple ovarian cyst less than 5cm on USS do not need further investigations.
• CA125
• Women < 40 years + complex ovarian mass require tumour markers for a possible germ cell tumour:
  = Lactate dehydrogenase (LDH)
  = Alpha-fetoprotein (α-FP)
  = Human chorionic gonadotropin (HCG)

Question 17

Causes of raised CA125

Answer 17

• Endometriosis
• Fibroids
• Adenomyosis
• Pelvic infection
• Liver disease
• Pregnancy

Question 18

Risk of Malignancy Index

Answer 18

Estimates the risk of an ovarian mass being malignant, taking account of three things:
- Menopausal status
- Ultrasound findings
- CA125 level

Question 19

Treatment

Answer 19

Managed based on their size:
- <5cm cyst = will always resolve within three cycles
- 5 - 7cm = require routine referral to gynaecology and yearly USS monitoring
- >7cm = Consider MRI scan or surgical evaluation as they can be difficult to characterise with USS
- Persistent or enlarging cysts may require surgical intervention.
= removing the cyst (ovarian cystectomy), = possibly along with the affected ovary (oophorectomy).

Question 20

Complications

Answer 20

• Torsion
• Haemorrhage into the cyst
• Rupture, with bleeding into the peritoneum

Question 21

Meig’s syndrome

Answer 21

Typically occurs in older women.
Triad of:
- Ovarian fibroma (a type of benign ovarian tumour)
- Pleural effusion
- Ascites
Removal of the tumour results in complete resolution of the effusion and ascites.
* IN EXAM LOOK OUT FOR OLDER WOMEN WITH PLEURAL EFFUSION AND OVARIAN MASS *