Ovarian Cysts

Non-neoplastic (Benign) Cysts

Functional cysts Cysts Any fluid-filled closed cavity or sac that is lined by an epithelium. Cysts can be of normal, abnormal, non-neoplastic, or neoplastic tissues. Fibrocystic Change: Follicular and corpus luteal cysts Cysts Any fluid-filled closed cavity or sac that is lined by an epithelium. Cysts can be of normal, abnormal, non-neoplastic, or neoplastic tissues. Fibrocystic Change

• Follicular cyst:
  • Most common ovarian mass Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast in women of reproductive age
  • Unruptured graafian follicle Graafian follicle Ovaries: Anatomy that continues to grow
  • Characteristics:
    • Simple collections of fluid without septations or internal debris 
    • May be a single cyst or multiple cysts Cysts Any fluid-filled closed cavity or sac that is lined by an epithelium. Cysts can be of normal, abnormal, non-neoplastic, or neoplastic tissues. Fibrocystic Change
    • Variable Variable Variables represent information about something that can change. The design of the measurement scales, or of the methods for obtaining information, will determine the data gathered and the characteristics of that data. As a result, a variable can be qualitative or quantitative, and may be further classified into subgroups. Types of Variables size (normal follicles < 3 cm; pathologic follicular cysts Cysts Any fluid-filled closed cavity or sac that is lined by an epithelium. Cysts can be of normal, abnormal, non-neoplastic, or neoplastic tissues. Fibrocystic Change are typically < 10 cm)
    • Lined with granulosa and theca cells Theca cells The flattened stroma cells forming a sheath or theca outside the basal lamina lining the mature ovarian follicle. Thecal interstitial or stromal cells are steroidogenic, and produce primarily androgens which serve as precursors of estrogens in the granulosa cells. Puberty
• Corpus luteal cyst:
  • Following ovulation Ovulation The discharge of an ovum from a rupturing follicle in the ovary. Menstrual Cycle, follicles become corpus luteal cysts Cysts Any fluid-filled closed cavity or sac that is lined by an epithelium. Cysts can be of normal, abnormal, non-neoplastic, or neoplastic tissues. Fibrocystic Change 
  • Normal: Physiologic structures in the 2nd half of the menstrual cycle Cycle The type of signal that ends the inspiratory phase delivered by the ventilator Invasive Mechanical Ventilation and 1st trimester of pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care
  • Abnormal: When they persist (without a pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care) or enlarge beyond about 3 cm
  • Secrete progesterone Progesterone The major progestational steroid that is secreted primarily by the corpus luteum and the placenta. Progesterone acts on the uterus, the mammary glands and the brain. It is required in embryo implantation; pregnancy maintenance, and the development of mammary tissue for milk production. Progesterone, converted from pregnenolone, also serves as an intermediate in the biosynthesis of gonadal steroid hormones and adrenal corticosteroids. Gonadal Hormones required to maintain the endometrium Endometrium The mucous membrane lining of the uterine cavity that is hormonally responsive during the menstrual cycle and pregnancy. The endometrium undergoes cyclic changes that characterize menstruation. After successful fertilization, it serves to sustain the developing embryo. Embryoblast and Trophoblast Development in pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care
  • Characteristics:
    • Unilateral
    • Typically, 2‒3 cm size (but can be up to 8 cm)
    • Uniloculated cysts Cysts Any fluid-filled closed cavity or sac that is lined by an epithelium. Cysts can be of normal, abnormal, non-neoplastic, or neoplastic tissues. Fibrocystic Change, which can contain some internal debris.
• Clinical presentation:
  • Usually asymptomatic if < 6 cm
  • Symptoms may include:
    • Pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways
    • Peritoneal irritation
    • Delayed menses Menses The periodic shedding of the endometrium and associated menstrual bleeding in the menstrual cycle of humans and primates. Menstruation is due to the decline in circulating progesterone, and occurs at the late luteal phase when luteolysis of the corpus luteum takes place. Menstrual Cycle 
    • Abnormal uterine bleeding Abnormal Uterine Bleeding Abnormal uterine bleeding is the medical term for abnormalities in the frequency, volume, duration, and regularity of the menstrual cycle. Abnormal uterine bleeding is classified using the acronym PALM-COEIN, with PALM representing the structural causes and COEIN indicating the non-structural causes. Abnormal Uterine Bleeding

Hemorrhagic cysts Cysts Any fluid-filled closed cavity or sac that is lined by an epithelium. Cysts can be of normal, abnormal, non-neoplastic, or neoplastic tissues. Fibrocystic Change and endometriomas

• Hemorrhagic cysts Cysts Any fluid-filled closed cavity or sac that is lined by an epithelium. Cysts can be of normal, abnormal, non-neoplastic, or neoplastic tissues. Fibrocystic Change
  • Follicular or corpus luteal cysts Cysts Any fluid-filled closed cavity or sac that is lined by an epithelium. Cysts can be of normal, abnormal, non-neoplastic, or neoplastic tissues. Fibrocystic Change that rupture and bleed into themselves
  • Present with a relatively sudden onset of acute pain Acute pain Intensely discomforting, distressful, or agonizing sensation associated with trauma or disease, with well-defined location, character, and timing. Pain Management (often, but not always, unilateral)
  • Typically self-limited, but on occasion they may present with potentially significant intraperitoneal Intraperitoneal Peritoneum: Anatomy hemorrhage, seen clinically as:
    • Severe pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways
    • Signs of an acute abdomen Acute Abdomen Acute abdomen, which is in many cases a surgical emergency, is the sudden onset of abdominal pain that may be caused by inflammation, infection, perforation, ischemia, or obstruction. The location of the pain, its characteristics, and associated symptoms (e.g., jaundice) are important tools that help narrow the differential diagnosis. Acute Abdomen
    • Hemodynamic instability
• Endometriomas 
  • Also called chocolate cysts Chocolate Cysts Endometriosis
  • Arise from ectopic growth of endometrial tissue Endometrial tissue The mucous membrane lining of the uterine cavity that is hormonally responsive during the menstrual cycle and pregnancy. The endometrium undergoes cyclic changes that characterize menstruation. After successful fertilization, it serves to sustain the developing embryo. Endometriosis on the ovary 
  • A form of endometriosis Endometriosis Endometriosis is a common disease in which patients have endometrial tissue implanted outside of the uterus. Endometrial implants can occur anywhere in the pelvis, including the ovaries, the broad and uterosacral ligaments, the pelvic peritoneum, and the urinary and gastrointestinal tracts. Endometriosis
  • Endometriomas are much more likely to be symptomatic, regardless of size, typically presenting with:
    • Dysmenorrhea
    • Dyspareunia Dyspareunia Recurrent genital pain occurring during, before, or after sexual intercourse in either the male or the female. Primary Ovarian Insufficiency
    • Infertility Infertility Infertility is the inability to conceive in the context of regular intercourse. The most common causes of infertility in women are related to ovulatory dysfunction or tubal obstruction, whereas, in men, abnormal sperm is a common cause. Infertility

Neoplastic Cysts

Classification

• Neoplastic masses are classified according to their cell of origin, with 3 main types: 
  • Epithelial cell tumors
  • Germ cell tumors Germ cell tumors A true neoplasm composed of a number of different types of tissue, none of which is native to the area in which it occurs. It is composed of tissues that are derived from three germinal layers, the endoderm, mesoderm, and ectoderm. They are classified histologically as mature (benign) or immature (malignant). Ovarian Cancer
  • Sex-cord stromal tumors. 
• In all 3 types:
  • Multiple histologic subtypes (see table) 
  • Can be benign Benign Fibroadenoma or malignant 
  • Epithelial tumors can also be classified as “borderline” or being of “low malignant potential” (managed differently from disease that is clearly benign Benign Fibroadenoma or clearly malignant)
• Histology, rather than radiographic appearance, determines if a tumor Tumor Inflammation is benign Benign Fibroadenoma, borderline, or malignant.

Clinical presentation

Neoplastic ovarian masses are frequently asymptomatic. If they are symptomatic, they typically present with vague, nonspecific symptoms which can include:

• Lower abdominal and/or pelvic pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways:
  • Typically vague, noncyclic pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways of insidious onset
  • Acute-onset pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways associated with ovarian torsion Ovarian torsion Ovarian torsion is a clinical emergency in which the ovaries (with or without the fallopian tubes) twist along their axis, leading to partial or complete obstruction of their blood supply. Ovarian torsion is also called adnexal or tubo-ovarian torsion, especially if a fallopian tube is also involved. Ovarian Torsion, or bleeding
• Abdominal distention Abdominal distention Megacolon
• Abdominal fullness, bloating Bloating Constipation
• Indigestion
• Heartburn Heartburn Substernal pain or burning sensation, usually associated with regurgitation of gastric juice into the esophagus. Gastroesophageal Reflux Disease (GERD)
• Early satiety Early Satiety Bariatric Surgery
• Painful intercourse
• Irregular periods
• Abnormal uterine bleeding Abnormal Uterine Bleeding Abnormal uterine bleeding is the medical term for abnormalities in the frequency, volume, duration, and regularity of the menstrual cycle. Abnormal uterine bleeding is classified using the acronym PALM-COEIN, with PALM representing the structural causes and COEIN indicating the non-structural causes. Abnormal Uterine Bleeding
• Urinary frequency
• Constipation Constipation Constipation is common and may be due to a variety of causes. Constipation is generally defined as bowel movement frequency < 3 times per week. Patients who are constipated often strain to pass hard stools. The condition is classified as primary (also known as idiopathic or functional constipation) or secondary, and as acute or chronic. Constipation
• Leg Leg The lower leg, or just “leg” in anatomical terms, is the part of the lower limb between the knee and the ankle joint. The bony structure is composed of the tibia and fibula bones, and the muscles of the leg are grouped into the anterior, lateral, and posterior compartments by extensions of fascia. Leg: Anatomy swelling Swelling Inflammation
• Weight loss Weight loss Decrease in existing body weight. Bariatric Surgery
• Sex-cord stromal tumors in particular may secrete hormones Hormones Hormones are messenger molecules that are synthesized in one part of the body and move through the bloodstream to exert specific regulatory effects on another part of the body. Hormones play critical roles in coordinating cellular activities throughout the body in response to the constant changes in both the internal and external environments. Hormones: Overview and Types:
  • Granulosa cell Granulosa cell Supporting cells for the developing female gamete in the ovary. They are derived from the coelomic epithelial cells of the gonadal ridge. Granulosa cells form a single layer around the oocyte in the primordial ovarian follicle and advance to form a multilayered cumulus oophorus surrounding the ovum in the graafian follicle. The major functions of granulosa cells include the production of steroids and LH receptors. Puberty tumors: estrogen Estrogen Compounds that interact with estrogen receptors in target tissues to bring about the effects similar to those of estradiol. Estrogens stimulate the female reproductive organs, and the development of secondary female sex characteristics. Estrogenic chemicals include natural, synthetic, steroidal, or non-steroidal compounds. Ovaries: Anatomy → may present with:
    • Suppression Suppression Defense Mechanisms of menses Menses The periodic shedding of the endometrium and associated menstrual bleeding in the menstrual cycle of humans and primates. Menstruation is due to the decline in circulating progesterone, and occurs at the late luteal phase when luteolysis of the corpus luteum takes place. Menstrual Cycle/abnormal bleeding
    • Breast enlargement
  • Theca cell tumors: testosterone Testosterone A potent androgenic steroid and major product secreted by the leydig cells of the testis. Its production is stimulated by luteinizing hormone from the pituitary gland. In turn, testosterone exerts feedback control of the pituitary LH and FSH secretion. Depending on the tissues, testosterone can be further converted to dihydrotestosterone or estradiol. Androgens and Antiandrogens → may present with:
    • Hirsutism Hirsutism A condition observed in women and children when there is excess coarse body hair of an adult male distribution pattern, such as facial and chest areas. It is the result of elevated androgens from the ovaries, the adrenal glands, or exogenous sources. The concept does not include hypertrichosis, which is an androgen-independent excessive hair growth. Polycystic Ovarian Syndrome
    • Hair loss
    • Suppression Suppression Defense Mechanisms of menses Menses The periodic shedding of the endometrium and associated menstrual bleeding in the menstrual cycle of humans and primates. Menstruation is due to the decline in circulating progesterone, and occurs at the late luteal phase when luteolysis of the corpus luteum takes place. Menstrual Cycle

Diagnosis

The key to diagnosing ovarian cysts Cysts Any fluid-filled closed cavity or sac that is lined by an epithelium. Cysts can be of normal, abnormal, non-neoplastic, or neoplastic tissues. Fibrocystic Change is to accurately identify benign Benign Fibroadenoma cysts Cysts Any fluid-filled closed cavity or sac that is lined by an epithelium. Cysts can be of normal, abnormal, non-neoplastic, or neoplastic tissues. Fibrocystic Change that will resolve spontaneously (e.g., follicular, corpus luteal, and hemorrhagic cysts Cysts Any fluid-filled closed cavity or sac that is lined by an epithelium. Cysts can be of normal, abnormal, non-neoplastic, or neoplastic tissues. Fibrocystic Change), differentiating them from cysts Cysts Any fluid-filled closed cavity or sac that is lined by an epithelium. Cysts can be of normal, abnormal, non-neoplastic, or neoplastic tissues. Fibrocystic Change that are benign Benign Fibroadenoma but will not resolve spontaneously (e.g., endometriomas, benign Benign Fibroadenoma neoplastic cysts Cysts Any fluid-filled closed cavity or sac that is lined by an epithelium. Cysts can be of normal, abnormal, non-neoplastic, or neoplastic tissues. Fibrocystic Change) and cysts Cysts Any fluid-filled closed cavity or sac that is lined by an epithelium. Cysts can be of normal, abnormal, non-neoplastic, or neoplastic tissues. Fibrocystic Change that are malignant.

History and exam

• Consistent clinical symptoms 
• Palpable adnexal mass Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast on pelvic examination
• BRCA carriers Carriers The Cell: Cell Membrane are at increased risk for malignancy Malignancy Hemothorax.

Imaging

Ultrasonography (1st-choice imaging method):

• Benign Benign Fibroadenoma cysts Cysts Any fluid-filled closed cavity or sac that is lined by an epithelium. Cysts can be of normal, abnormal, non-neoplastic, or neoplastic tissues. Fibrocystic Change:
  • Unilocular
  • Thin-walled
  • Absence of solid components and vascularity within the lesion
  • Follicular cysts Cysts Any fluid-filled closed cavity or sac that is lined by an epithelium. Cysts can be of normal, abnormal, non-neoplastic, or neoplastic tissues. Fibrocystic Change: simple, anechoic Anechoic A structure that produces no echo at all (looks completely black) Ultrasound (Sonography) structures
  • Corpus luteal cysts Cysts Any fluid-filled closed cavity or sac that is lined by an epithelium. Cysts can be of normal, abnormal, non-neoplastic, or neoplastic tissues. Fibrocystic Change: may have a complex appearance with internal echoes and slightly thicker walls
  • Hemorrhagic cysts Cysts Any fluid-filled closed cavity or sac that is lined by an epithelium. Cysts can be of normal, abnormal, non-neoplastic, or neoplastic tissues. Fibrocystic Change and endometriomas:
    • Can have a very similar sonographic appearance
    • Hemorrhagic cyst Hemorrhagic Cyst Gynecological Imaging: Cystic Cystic Fibrocystic Change mass Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast with internal echoes; blood clots appear as a solid internal mass Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast; this mass Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast develops a “cobweb” appearance as the clot is resorbed.
    • Endometriomas: Cystic Cystic Fibrocystic Change mass Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast containing homogeneous Homogeneous Imaging of the Spleen internal echoes; often described as having a “ground glass” appearance 
    • Differentiated from one another with follow-up ultrasonography in 8‒12 weeks; a hemorrhagic cyst Hemorrhagic Cyst Gynecological Imaging will resolve (or be resolving), whereas an endometrioma Endometrioma Endometriosis will persist without significant changes.
• Malignant tumors:
  • Worrisome size: > 10 cm
  • Multilocular (thicker and/or vascularized walls are more worrisome)
  • Presence of papillary projections
  • Solid areas within the tumor Tumor Inflammation
  • Lesions are more likely to be bilateral.
  • Increased vascularity within and surrounding the lesion
  • Presence of ascites Ascites Ascites is the pathologic accumulation of fluid within the peritoneal cavity that occurs due to an osmotic and/or hydrostatic pressure imbalance secondary to portal hypertension (cirrhosis, heart failure) or non-portal hypertension (hypoalbuminemia, malignancy, infection). Ascites
  • Abdominal involvement

MRI: 2nd-line imaging used for surgical planning and/or when diagnosis is unclear after ultrasonography

• Benign Benign Fibroadenoma lesions:
  • Ovarian cysts Cysts Any fluid-filled closed cavity or sac that is lined by an epithelium. Cysts can be of normal, abnormal, non-neoplastic, or neoplastic tissues. Fibrocystic Change show low signal intensity on T1-weighted images T1-Weighted Images Imaging of the Head and Brain and high signal intensity on T2-weighted images T2-Weighted Images Imaging of the Head and Brain because of the fluid content of the cyst. 
  • MRI usually reveals a thin and featureless wall that enhances the uptake of gadolinium Gadolinium An element of the rare earth family of metals. It has the atomic symbol gd, atomic number 64, and atomic weight 157. 25. Its oxide is used in the control rods of some nuclear reactors. Magnetic Resonance Imaging (MRI). 
  • T2 shortening is not seen in corpus luteal cysts Cysts Any fluid-filled closed cavity or sac that is lined by an epithelium. Cysts can be of normal, abnormal, non-neoplastic, or neoplastic tissues. Fibrocystic Change, in contrast to endometrial chocolate cysts Chocolate Cysts Endometriosis.
• Malignant lesions (similar features are seen on ultrasonography):
  • Heterogeneous
  • Faster contrast enhancement
  • Calcification
  • Multilocular cyst

Laboratory and pathology

Definitive diagnosis of an ovarian cyst/ mass Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast is made on histologic examination (see Ovarian cancer Ovarian cancer Ovarian cancer is a malignant tumor arising from the ovarian tissue and is classified according to the type of tissue from which it originates. The 3 major types of ovarian cancer are epithelial ovarian carcinomas (EOCs), ovarian germ cell tumors (OGCTs), and sex cord-stromal tumors (SCSTs). Ovarian Cancer concept for additional details). Several serum tests are available to help assess the risk of malignancy Malignancy Hemothorax prior to surgery.

• Pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care test in individuals of reproductive age:
  • Rules out ectopic pregnancy Ectopic pregnancy Ectopic pregnancy refers to the implantation of a fertilized egg (embryo) outside the uterine cavity. The main cause is disruption of the normal anatomy of the fallopian tube. Ectopic Pregnancy
  • A normal intrauterine pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care affects management.
• Cancer antigen 125 Cancer antigen 125 A carbohydrate antigen that occurs in tumors of the ovary as well as in breast, kidney, and gastrointestinal tract tumors and normal tissue. While it is tumor-associated, it is not tumor-specific and may have a protective function against particles and infectious agents at mucosal surfaces. Serum Tumor Markers ( CA-125 CA-125 A carbohydrate antigen that occurs in tumors of the ovary as well as in breast, kidney, and gastrointestinal tract tumors and normal tissue. While it is tumor-associated, it is not tumor-specific and may have a protective function against particles and infectious agents at mucosal surfaces. Serum Tumor Markers) blood test:
  • Indications:
    • Postmenopausal women with an adnexal mass Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast
    • Premenopausal women with ultrasound findings suspicious for malignancy Malignancy Hemothorax
  • Complex cysts Cysts Any fluid-filled closed cavity or sac that is lined by an epithelium. Cysts can be of normal, abnormal, non-neoplastic, or neoplastic tissues. Fibrocystic Change and high CA-125 CA-125 A carbohydrate antigen that occurs in tumors of the ovary as well as in breast, kidney, and gastrointestinal tract tumors and normal tissue. While it is tumor-associated, it is not tumor-specific and may have a protective function against particles and infectious agents at mucosal surfaces. Serum Tumor Markers associated with increased risk of malignancy Malignancy Hemothorax 
  • Note: CA-125 CA-125 A carbohydrate antigen that occurs in tumors of the ovary as well as in breast, kidney, and gastrointestinal tract tumors and normal tissue. While it is tumor-associated, it is not tumor-specific and may have a protective function against particles and infectious agents at mucosal surfaces. Serum Tumor Markers may be elevated in many conditions, including:
    • Endometriosis Endometriosis Endometriosis is a common disease in which patients have endometrial tissue implanted outside of the uterus. Endometrial implants can occur anywhere in the pelvis, including the ovaries, the broad and uterosacral ligaments, the pelvic peritoneum, and the urinary and gastrointestinal tracts. Endometriosis
    • Leiomyomas
    • Pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care
    • Pelvic inflammatory disease Pelvic inflammatory disease Pelvic inflammatory disease (PID) is defined as a polymicrobial infection of the upper female reproductive system. The disease can affect the uterus, fallopian tubes, ovaries, and adjacent structures. Pelvic inflammatory disease is closely linked with sexually transmitted diseases, most commonly caused by Chlamydia trachomatis, Neisseria gonorrhoeae, and Gardnerella vaginalis. Pelvic Inflammatory Disease ( PID PID Pelvic inflammatory disease (PID) is defined as a polymicrobial infection of the upper female reproductive system. The disease can affect the uterus, fallopian tubes, ovaries, and adjacent structures. Pelvic inflammatory disease is closely linked with sexually transmitted diseases, most commonly caused by Chlamydia trachomatis, Neisseria gonorrhoeae, and gardnerella vaginalis. Pelvic Inflammatory Disease)
    • Nongynecologic cancers
• In women < 40 years of age with a complex ovarian mass Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast, additional biomarkers are recommended to screen for germ cell tumors Germ cell tumors A true neoplasm composed of a number of different types of tissue, none of which is native to the area in which it occurs. It is composed of tissues that are derived from three germinal layers, the endoderm, mesoderm, and ectoderm. They are classified histologically as mature (benign) or immature (malignant). Ovarian Cancer, including:
  • Lactate dehydrogenase Lactate Dehydrogenase Osteosarcoma ( LDH LDH Osteosarcoma)
  • α-fetoprotein ( AFP AFP The first alpha-globulins to appear in mammalian sera during fetal development and the dominant serum proteins in early embryonic life. Hepatocellular Carcinoma (HCC) and Liver Metastases)
  • HCG

Risk of Malignancy Malignancy Hemothorax Index (RMI)

• Clinical tool used to determine risk of cancer for ovarian tumors and to guide management
• Considers 3 features:  
  • Menopausal status
  • Ultrasound score: points given for specific findings of concern 
  • Presence of CA-125 CA-125 A carbohydrate antigen that occurs in tumors of the ovary as well as in breast, kidney, and gastrointestinal tract tumors and normal tissue. While it is tumor-associated, it is not tumor-specific and may have a protective function against particles and infectious agents at mucosal surfaces. Serum Tumor Markers in serum
• Higher RMI correlates with increased risk of malignancy Malignancy Hemothorax.

Management

• Cysts Cysts Any fluid-filled closed cavity or sac that is lined by an epithelium. Cysts can be of normal, abnormal, non-neoplastic, or neoplastic tissues. Fibrocystic Change/masses with an elevated RMI should be referred to a gynecologic oncologist.
• Indications for surgical removal:
  • Size > 10 cm
  • Suspected ovarian torsion Ovarian torsion Ovarian torsion is a clinical emergency in which the ovaries (with or without the fallopian tubes) twist along their axis, leading to partial or complete obstruction of their blood supply. Ovarian torsion is also called adnexal or tubo-ovarian torsion, especially if a fallopian tube is also involved. Ovarian Torsion
  • Persistent adnexal mass Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast
  • Suspected malignancy Malignancy Hemothorax
  • Symptomatic (e.g., pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways)
  • Concern for active internal hemorrhage (e.g., hemodynamic instability) → emergency
• In general, if surgery is indicated:
  • Cysts Cysts Any fluid-filled closed cavity or sac that is lined by an epithelium. Cysts can be of normal, abnormal, non-neoplastic, or neoplastic tissues. Fibrocystic Change should be removed via cystectomy or oophorectomy. 
  • Cysts Cysts Any fluid-filled closed cavity or sac that is lined by an epithelium. Cysts can be of normal, abnormal, non-neoplastic, or neoplastic tissues. Fibrocystic Change should not be aspirated owing to a very high risk of recurrence. 
• Follicular, corpus luteal, and hemorrhagic cysts Cysts Any fluid-filled closed cavity or sac that is lined by an epithelium. Cysts can be of normal, abnormal, non-neoplastic, or neoplastic tissues. Fibrocystic Change: 
  • Typically, no treatment is required unless complications occur.
  • Usually resolve spontaneously within 1–2 menstrual cycles 
  • Resolution occurs after cyst fluid resorption or spontaneous rupture.
  • Cysts Cysts Any fluid-filled closed cavity or sac that is lined by an epithelium. Cysts can be of normal, abnormal, non-neoplastic, or neoplastic tissues. Fibrocystic Change that do not resolve require further investigation.
  • Use of oral contraceptives has not proved to be helpful to resolve the current cyst; however, they may be helpful in preventing cyst recurrence.
  • Transvaginal ultrasonography may be required to monitor cyst changes
• Endometriomas: 
  • Do not resolve spontaneously
  • Require surgical excision
  • Hormonal contraceptives Hormonal contraceptives Hormonal contraceptives (HCs) contain synthetic analogs of the reproductive hormones estrogen and progesterone, which may be used either in combination or in progestin-only formulations for contraception. Hormonal Contraceptives are helpful to suppress endometriosis Endometriosis Endometriosis is a common disease in which patients have endometrial tissue implanted outside of the uterus. Endometrial implants can occur anywhere in the pelvis, including the ovaries, the broad and uterosacral ligaments, the pelvic peritoneum, and the urinary and gastrointestinal tracts. Endometriosis.
• Neoplastic cysts Cysts Any fluid-filled closed cavity or sac that is lined by an epithelium. Cysts can be of normal, abnormal, non-neoplastic, or neoplastic tissues. Fibrocystic Change/masses:
  • Surgical removal
  • Chemotherapy Chemotherapy Osteosarcoma for malignancies

Complications

Complications from ovarian cysts Cysts Any fluid-filled closed cavity or sac that is lined by an epithelium. Cysts can be of normal, abnormal, non-neoplastic, or neoplastic tissues. Fibrocystic Change include:

• Cystic Cystic Fibrocystic Change rupture:
  • Typically presents with acute onset of moderate to severe pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways, often unilateral
  • Typically resolves spontaneously over several weeks → treat with analgesics
  • If actively hemorrhaging (less common) → requires emergency surgery
• Ovarian torsion Ovarian torsion Ovarian torsion is a clinical emergency in which the ovaries (with or without the fallopian tubes) twist along their axis, leading to partial or complete obstruction of their blood supply. Ovarian torsion is also called adnexal or tubo-ovarian torsion, especially if a fallopian tube is also involved. Ovarian Torsion:
  • Twisting of the ovary and fallopian tube Fallopian Tube A pair of highly specialized canals extending from the uterus to its corresponding ovary. They provide the means for ovum transport from the ovaries and they are the site of the ovum’s final maturation and fertilization. The fallopian tube consists of an interstitium, an isthmus, an ampulla, an infundibulum, and fimbriae. Its wall consists of three layers: serous, muscular, and an internal mucosal layer lined with both ciliated and secretory cells. Uterus, Cervix, and Fallopian Tubes: Anatomy, obstructing blood supply
  • Presents with acute onset and severe unilateral pain Unilateral Pain Cluster Headaches
  • Occurs more often in larger, heterogeneous (i.e., lopsided) cysts Cysts Any fluid-filled closed cavity or sac that is lined by an epithelium. Cysts can be of normal, abnormal, non-neoplastic, or neoplastic tissues. Fibrocystic Change (e.g., dermoids)
  • Surgical emergency Surgical Emergency Acute Abdomen
• Fertility challenges
• Infection (e.g., iatrogenic Iatrogenic Any adverse condition in a patient occurring as the result of treatment by a physician, surgeon, or other health professional, especially infections acquired by a patient during the course of treatment. Anterior Cord Syndrome introduction of bacteria Bacteria Bacteria are prokaryotic single-celled microorganisms that are metabolically active and divide by binary fission. Some of these organisms play a significant role in the pathogenesis of diseases. Bacteriology following aspirational biopsy Biopsy Removal and pathologic examination of specimens from the living body. Ewing Sarcoma)
• Bowel or ureteral obstruction Ureteral obstruction Blockage in any part of the ureter causing obstruction of urine flow from the kidney to the urinary bladder. The obstruction may be congenital, acquired, unilateral, bilateral, complete, partial, acute, or chronic. Depending on the degree and duration of the obstruction, clinical features vary greatly such as hydronephrosis and obstructive nephropathy. Vesicoureteral Reflux (due either to mass Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast effect of a fixed ovarian cyst or to local invasion of malignant lesions)
• Malignant lesions also predispose to deep venous thrombosis Venous thrombosis The formation or presence of a blood clot (thrombus) within a vein. Budd-Chiari Syndrome ( DVT DVT Deep vein thrombosis (DVT) usually occurs in the deep veins of the lower extremities. The affected veins include the femoral, popliteal, iliofemoral, and pelvic veins. Proximal DVT is more likely to cause a pulmonary embolism (PE) and is generally considered more serious. Deep Vein Thrombosis)/ pulmonary embolism Pulmonary Embolism Pulmonary embolism (PE) is a potentially fatal condition that occurs as a result of intraluminal obstruction of the main pulmonary artery or its branches. The causative factors include thrombi, air, amniotic fluid, and fat. In PE, gas exchange is impaired due to the decreased return of deoxygenated blood to the lungs. Pulmonary Embolism (PE)

Differential Diagnosis

In addition to ovarian cysts Cysts Any fluid-filled closed cavity or sac that is lined by an epithelium. Cysts can be of normal, abnormal, non-neoplastic, or neoplastic tissues. Fibrocystic Change, the differential diagnosis of a pelvic mass Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast includes:

• Ectopic pregnancy Ectopic pregnancy Ectopic pregnancy refers to the implantation of a fertilized egg (embryo) outside the uterine cavity. The main cause is disruption of the normal anatomy of the fallopian tube. Ectopic Pregnancy: A pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care that implants outside the uterus Uterus The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The uterus has a thick wall made of smooth muscle (the myometrium) and an inner mucosal layer (the endometrium). The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Uterus, Cervix, and Fallopian Tubes: Anatomy, most commonly in the fallopian tubes Fallopian tubes The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The fallopian tubes receive an ovum after ovulation and help move it and/or a fertilized embryo toward the uterus via ciliated cells lining the tubes and peristaltic movements of its smooth muscle. Uterus, Cervix, and Fallopian Tubes: Anatomy. Ectopic pregnancies can grow large enough to rupture, which can lead to life-threatening hemorrhage. For this reason, all women of reproductive age who present with a pelvic mass Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast and/or unilateral pelvic pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways should have a urine pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care test to rule out ectopic pregnancy Ectopic pregnancy Ectopic pregnancy refers to the implantation of a fertilized egg (embryo) outside the uterine cavity. The main cause is disruption of the normal anatomy of the fallopian tube. Ectopic Pregnancy. Management is typically either medical (with methotrexate Methotrexate An antineoplastic antimetabolite with immunosuppressant properties. It is an inhibitor of tetrahydrofolate dehydrogenase and prevents the formation of tetrahydrofolate, necessary for synthesis of thymidylate, an essential component of DNA. Antimetabolite Chemotherapy) or surgical, depending on the situation.
• Uterine leiomyomas ( fibroids Fibroids A benign tumor derived from smooth muscle tissue, also known as a fibroid tumor. They rarely occur outside of the uterus and the gastrointestinal tract but can occur in the skin and subcutaneous tissue, probably arising from the smooth muscle of small blood vessels in these tissues. Infertility): Benign Benign Fibroadenoma tumors arising from the smooth muscle layer of the uterus Uterus The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The uterus has a thick wall made of smooth muscle (the myometrium) and an inner mucosal layer (the endometrium). The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Uterus, Cervix, and Fallopian Tubes: Anatomy. Fibroids Fibroids A benign tumor derived from smooth muscle tissue, also known as a fibroid tumor. They rarely occur outside of the uterus and the gastrointestinal tract but can occur in the skin and subcutaneous tissue, probably arising from the smooth muscle of small blood vessels in these tissues. Infertility can also be pedunculated (i.e., on a stalk), which may be confused for a solid adnexal mass Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast. Fibroids Fibroids A benign tumor derived from smooth muscle tissue, also known as a fibroid tumor. They rarely occur outside of the uterus and the gastrointestinal tract but can occur in the skin and subcutaneous tissue, probably arising from the smooth muscle of small blood vessels in these tissues. Infertility typically present with heavy menstrual bleeding Heavy menstrual bleeding Excessive menstrual blood loss (objectively defined as > 80 mL blood loss/cycle). Can be based on heavy flow, as determined by the patient Abnormal Uterine Bleeding and/or pelvic pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways/bulk symptoms and are usually diagnosed with ultrasonography. Management is typically surgical.  
• Polycystic ovarian syndrome Polycystic ovarian syndrome Polycystic ovarian syndrome (PCOS) is the most common endocrine disorder of reproductive-age women, affecting nearly 5%-10% of women in the age group. It is characterized by hyperandrogenism, chronic anovulation leading to oligomenorrhea (or amenorrhea), and metabolic dysfunction. Polycystic Ovarian Syndrome: Heterogeneous multisystem endocrinopathy Endocrinopathy IPEX Syndrome that is characterized by hyperandrogenism Hyperandrogenism A condition caused by the excessive secretion of androgens from the adrenal cortex; the ovaries; or the testes. The clinical significance in males is negligible. In women, the common manifestations are hirsutism and virilism as seen in patients with polycystic ovary syndrome and adrenocortical hyperfunction. Potassium-sparing Diuretics, ovarian dysfunction, and multiple cysts Cysts Any fluid-filled closed cavity or sac that is lined by an epithelium. Cysts can be of normal, abnormal, non-neoplastic, or neoplastic tissues. Fibrocystic Change in the ovaries Ovaries Ovaries are the paired gonads of the female reproductive system that contain haploid gametes known as oocytes. The ovaries are located intraperitoneally in the pelvis, just posterior to the broad ligament, and are connected to the pelvic sidewall and to the uterus by ligaments. These organs function to secrete hormones (estrogen and progesterone) and to produce the female germ cells (oocytes). Ovaries: Anatomy, which can cause the ovaries Ovaries Ovaries are the paired gonads of the female reproductive system that contain haploid gametes known as oocytes. The ovaries are located intraperitoneally in the pelvis, just posterior to the broad ligament, and are connected to the pelvic sidewall and to the uterus by ligaments. These organs function to secrete hormones (estrogen and progesterone) and to produce the female germ cells (oocytes). Ovaries: Anatomy to become enlarged. The condition is also associated with metabolic syndrome Metabolic syndrome Metabolic syndrome is a cluster of conditions that significantly increases the risk for several secondary diseases, notably cardiovascular disease, type 2 diabetes, and nonalcoholic fatty liver. In general, it is agreed that hypertension, insulin resistance/hyperglycemia, and hyperlipidemia, along with central obesity, are components of the metabolic syndrome. Metabolic Syndrome, hyperinsulinemia Hyperinsulinemia Diabetes Mellitus, and insulin resistance Insulin resistance Diminished effectiveness of insulin in lowering blood sugar levels: requiring the use of 200 units or more of insulin per day to prevent hyperglycemia or ketosis. Diabetes Mellitus. Diagnosis is one of exclusion, so other causes of abnormal uterine bleeding Abnormal Uterine Bleeding Abnormal uterine bleeding is the medical term for abnormalities in the frequency, volume, duration, and regularity of the menstrual cycle. Abnormal uterine bleeding is classified using the acronym PALM-COEIN, with PALM representing the structural causes and COEIN indicating the non-structural causes. Abnormal Uterine Bleeding and hirsutism Hirsutism A condition observed in women and children when there is excess coarse body hair of an adult male distribution pattern, such as facial and chest areas. It is the result of elevated androgens from the ovaries, the adrenal glands, or exogenous sources. The concept does not include hypertrichosis, which is an androgen-independent excessive hair growth. Polycystic Ovarian Syndrome should be ruled out. Management includes attempting to restore normal ovulation Ovulation The discharge of an ovum from a rupturing follicle in the ovary. Menstrual Cycle through weight loss Weight loss Decrease in existing body weight. Bariatric Surgery, oral contraceptive Oral contraceptive Compounds, usually hormonal, taken orally in order to block ovulation and prevent the occurrence of pregnancy. The hormones are generally estrogen or progesterone or both. Benign Liver Tumors pills, and assistance with fertility.
• Tubo-ovarian abscess Abscess Accumulation of purulent material in tissues, organs, or circumscribed spaces, usually associated with signs of infection. Chronic Granulomatous Disease (TOA): An infected collection in the adnexa, typically arising in the setting of pelvic inflammatory disease Pelvic inflammatory disease Pelvic inflammatory disease (PID) is defined as a polymicrobial infection of the upper female reproductive system. The disease can affect the uterus, fallopian tubes, ovaries, and adjacent structures. Pelvic inflammatory disease is closely linked with sexually transmitted diseases, most commonly caused by Chlamydia trachomatis, Neisseria gonorrhoeae, and Gardnerella vaginalis. Pelvic Inflammatory Disease ( PID PID Pelvic inflammatory disease (PID) is defined as a polymicrobial infection of the upper female reproductive system. The disease can affect the uterus, fallopian tubes, ovaries, and adjacent structures. Pelvic inflammatory disease is closely linked with sexually transmitted diseases, most commonly caused by Chlamydia trachomatis, Neisseria gonorrhoeae, and gardnerella vaginalis. Pelvic Inflammatory Disease). Diagnosis can usually be made with ultrasonography, so all patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with PID PID Pelvic inflammatory disease (PID) is defined as a polymicrobial infection of the upper female reproductive system. The disease can affect the uterus, fallopian tubes, ovaries, and adjacent structures. Pelvic inflammatory disease is closely linked with sexually transmitted diseases, most commonly caused by Chlamydia trachomatis, Neisseria gonorrhoeae, and gardnerella vaginalis. Pelvic Inflammatory Disease and worrisome findings (such as those who are acutely ill, have a tender adnexal mass Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast, or have a poor response to initial therapy), should undergo imaging to look for a TOA. Management is with antibiotics and, potentially, surgical drainage.
• Müllerian anomalies: Congenital Congenital Chorioretinitis anomalies of the internal female genital organs can result in the presence of a pelvic mass Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast. Presentation and management depend on the anomaly, which can typically be identified with an exam and pelvic imaging.
• GI masses: Since the GI system also occupies space in the pelvis Pelvis The pelvis consists of the bony pelvic girdle, the muscular and ligamentous pelvic floor, and the pelvic cavity, which contains viscera, vessels, and multiple nerves and muscles. The pelvic girdle, composed of 2 “hip” bones and the sacrum, is a ring-like bony structure of the axial skeleton that links the vertebral column with the lower extremities. Pelvis: Anatomy, GI masses should be considered in the differential diagnosis of any pelvic mass Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast. This includes GI tumors (e.g., colorectal cancers), as well as diverticular and appendiceal abscesses. Symptoms depend on the etiology and may include nausea Nausea An unpleasant sensation in the stomach usually accompanied by the urge to vomit. Common causes are early pregnancy, sea and motion sickness, emotional stress, intense pain, food poisoning, and various enteroviruses. Antiemetics, vomiting Vomiting The forcible expulsion of the contents of the stomach through the mouth. Hypokalemia, and/or abnormal stooling. A CT scan is typically the best test to identify GI pathology.
• Ureteral or bladder Bladder A musculomembranous sac along the urinary tract. Urine flows from the kidneys into the bladder via the ureters, and is held there until urination. Pyelonephritis and Perinephric Abscess diverticulum Diverticulum A pouch or sac opening from the colon. Diverticular Disease: As with GI masses, masses in the urinary tract Urinary tract The urinary tract is located in the abdomen and pelvis and consists of the kidneys, ureters, urinary bladder, and urethra. The structures permit the excretion of urine from the body. Urine flows from the kidneys through the ureters to the urinary bladder and out through the urethra. Urinary Tract: Anatomy should also be in the differential diagnosis of a pelvic mass Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast. Imaging can typically clarify the diagnosis.
• Pelvic kidney: During embryologic develoment, the kidneys Kidneys The kidneys are a pair of bean-shaped organs located retroperitoneally against the posterior wall of the abdomen on either side of the spine. As part of the urinary tract, the kidneys are responsible for blood filtration and excretion of water-soluble waste in the urine. Kidneys: Anatomy initially develop in the pelvic region. Abnormal development may result in failure of the kidneys Kidneys The kidneys are a pair of bean-shaped organs located retroperitoneally against the posterior wall of the abdomen on either side of the spine. As part of the urinary tract, the kidneys are responsible for blood filtration and excretion of water-soluble waste in the urine. Kidneys: Anatomy to “ascend” into their typical position, resulting in a normal functioning kidney located within the pelvis Pelvis The pelvis consists of the bony pelvic girdle, the muscular and ligamentous pelvic floor, and the pelvic cavity, which contains viscera, vessels, and multiple nerves and muscles. The pelvic girdle, composed of 2 “hip” bones and the sacrum, is a ring-like bony structure of the axial skeleton that links the vertebral column with the lower extremities. Pelvis: Anatomy.