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    Ovarian Cysts – Diagnosis & Treatment

    Obstetrics and Gynecology

    Last Updated Sep 23, 2021
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    By Gord McInnes, Conor Barrie

    Context

    • Ovarian cysts are found in roughly 35% of premenopausal women and in 17% of postmenopausal women (Pavlik et al 2013).
    • Ovarian cysts can be encountered as incidental findings or as symptomatic entities.
    • Typically, they are benign. However, they have the potential to represent or to lead to serious pathology.

    Pathophysiology

    • There are both benign and malignant ovarian tumors. Ovarian cysts are benign tumors originating from one of three cell lines: epithelial, germ cell or sex cord stromal.
    • Cysts can be classified as functional/physiologic (eg follicular or corpus luteum) or pathologic. They can be further classified as asymptomatic, symptomatic, hemorrhagic or ruptured.
    • Most ovarian cysts are functional as related to normal menstrual cycle:
      • Follicular cyst:
        • begins when the follicle doesn’t rupture and continues to grow
        • often resolve within two or three menstrual cycles
      • Corpus luteum cyst:
        • fluid accumulates inside the ruptured follicle
      • Other benign cysts (not related to menstrual cycle):
        • Dermoid cysts or teratomas
        • Cystadenomas = benign epithelial neoplasms (cytopathological diagnosis)
        • Endometriomas secondary to endometriosis attachment
      • The biggest complication of large cysts is the development of ovarian torsion, a true gynecologic emergency.
      • Ovarian malignancies are outside the scope of this summary but require consultant management.

    Diagnostic Process

    • Ovarian masses can present as asymptomatic incidentalomas or they may present with cyclic or non-cyclic abdominal pain or lower urinary tract symptoms.
    • Bloating, early satiety and constitutional symptoms can be associated with ovarian malignancy.
    • Physical exam findings are limited, but large ovarian masses can be palpable.
    • Ascites and pelvic lymphadenopathy would be more suggestive of malignancy.
    • Ultrasound is the first line in differentiating a benign vs malignant ovarian mass.
    • Most benign masses demonstrate typical ultrasound findings (see table 1).
    • Ruptured or hemorrhagic cysts will present with acute abdominal/pelvic pain with free fluid in the pelvis and collapsed ovarian cysts on ultrasound.

    Recommended Treatment

    Treatment recommendations are all adapted from SOGC guidelines/Wolfman et al 2020.

    A: Asymptomatic Cysts

    • The Society of Obstetricians and Gynecologist of Canada (SOGC) recommends follow-up imaging for asymptomatic ovarian cysts < 10 cm in size based (see figure 1).
    • Asymptomatic cysts >10 cm should be referred to an OBGYN due to the risk of possible ovarian torsion and increased risk of malignancy.

    CLICK TO ENLARGE

    Figure 1: Recommended follow-up for benign, asymptomatic ovarian masses. Image from SOGC guidelines/Wolfman et al 2020.

    B: Symptomatic Cysts

    • Symptomatic, non-ruptured, cysts should be observed for persistence of symptoms as cysts often resolve on their own with expectant management.
    • Avoid definitive intervention for functional cysts (ie physiologic cysts involved with menstrual cycle, such as follicular or corpus luteum cysts).
    • NSAIDs should be first line analgesia and there is no role for hormonal management as this has no advantage compared to expectant management alone.
    • Should consider referral for cystectomy for symptoms that persist.

    C: Ruptured or Hemorrhagic Cysts

    • Usually also managed expectantly with NSAIDs for analgesia.
    • Admission for hemodynamic instability, uncontrolled pain, or diagnostic uncertainty.
    • Obtain baseline labs, including hemoglobin, regardless of disposition.
    • Indications for surgical intervention include: hemodynamic instability, increasing hemoperitoneum or declining hemoglobin, symptoms that persist >48 hours or diagnostic uncertainty, including risk suspicion of ovarian torsion.

    Quality Of Evidence?

    Justification

    Strong: Investigative and treatment recommendations based on recently updated Canadian Clinical Practice Guidelines.

    High

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