Ovarian Cysts, Functional Paula J.

Adams Hillard MD Basics Description Functional or physiologic cysts are non neoplastic ovarian masses that result !rom an e"aggeration o! the physiologic cyclic ovarian !unction in premenopausal #omen. $he vast ma%ority o! !unctional cysts resolve #ithin &'() #ee*s or ('+ cycles. Functional cysts include,
o

Follicular,

Follicular cysts result #hen ovulation does not occur and !ollicular cyst !luid accumulates. -. appearance is that o! thin #alled, smooth, unilocular mass. Because a normal !ollicle may /e as large as +0'1) mm, a cystic area should not /e de!ined as a 2cyst3 unless larger than these dimensions. Functional cysts are typically descri/ed as /eing 40'() cm in si5e.

Corpus luteum 6C78,

$ypically present in luteal phase o! cycle A ruptured C7 cyst can cause signi!icant intraperitoneal /leeding. C7 cysts can cause acute pain #ithout rupture, presuma/ly due to /leeding into the enclosed cyst cavity 6a hemorrhagic C7 cyst8. -. characteristics,

Mi"ed echogenicity 6solid and cystic8 $ypically #ith septa May /e 2reticular3 or 2spongeli*e3 pattern

May /e con!used #ith ectopic pregnancy

Pregnancy luteoma,

9are Hyperandrogenemia #ith maternal virili5ation Fetal masculini5ation o! !emale !etus 60):8 $ypically asymptomatic and discovered incidentally at time o! Cesarean delivery or postpartum tu/al sterili5ation

May /e unilateral or /ilateral May /e up to +) cm in diameter .olid, /ut can have cystic areas May /e di!!icult to di!!erentiate !rom hyperreactio luteinalis /ecause o! presence o! multiple /enign theca lutein cysts.

Age 9elated Factors $he ma%ority occur in #omen o! reproductive age. Pediatric Considerations Benign, !unctional ovarian cysts can occur in prepu/ertal girls and even !etuses and, i! unilocular and small, can /e o/served to demonstrate resolution or lac* or gro#th. ;eriatric Considerations Although the presence o! a mass in a postmenopausal #oman #as once considered evidence o! neoplasm, increasing use o! -. !re<uently demonstrates transient or nonenlarging cysts, o An autopsy study demonstrated 0=: #ith /enign adne"al cysts and concluded that small 640) mm8 cysts are so common that their presence may /e regarded as normal. >pidemiology Ovarian cysts #ere demonstrated in ?.@: o! a random sample o! asymptomatic #omen, o @1: resolved, indicating !unctional cysts

Pregnancy luteomas,
o

4+)) cases descri/ed

9is* Factors Progestin only contraceptives .terili5ation associated #ith increased ris*

.mo*ers #ith relative ris* o! +.) in ( study 9is* o! malignancy increased,

o o o o

An prepu/ertal or postmenopausal #omen A! the mass is comple" or solid Ascites is present Past history o! /reast, colon, gastric cancer

Associated Conditions Ovulatory dys!unction Pregnancy luteomas reported #ith hydronephrosis, -$A !rom ureteral o/struction, maternal and !etal virili5ation, ascites Diagnosis

.igns and .ymptoms History Functional cysts may /e asymptomatic and an incidental !inding. Functional cysts can cause acute pain due to,
o o o

$orsion, A cystic ovary is more li*ely to torse than a normal ovary. 9upture #ith intraperitoneal /leeding that can /e li!e threatening Bleeding into the enclosed space o! the cyst

Functional cysts can cause,

o o

.ymptoms o! pressure .u/acute pain over several #ee*s,

O!ten descri/ed as dull, achy Pain #ith intercourse Pain #ith a /o#el movement Bloating

A/normal /leeding,

.horter or longer menstrual cycle Arregular /leeding

$iming in relationship to menses should /e correlated #ith -. characteristics

o o

-nilocular thin #alled cyst in !ollicular phase Comple" or mi"ed echogenicity in luteal phase

Physical >"am ;eneral e"am, o Hirsutism or virili5ation

A/dominal e"am, $enderness or re/ound Pelvic e"am,

o

An adne"al mass may /e palpa/le,

A/ility to palpate mass depends on cyst si5e, patientBs /ody #eight or ha/itus

$ests 7a/s

hC; essential

CA (+0 in premenopause not help!ul in distinguishing /enign !rom malignant masses, as many conditions, including endometriosis and !unctional cysts can cause an elevation Pregnancy luteomas can /e associated #ith,
o

Hyperandrogenism,

$estosterone

o o

CA (+0 may /e elevated AFP

Amaging -. imaging is the modality most commonly used #hen an adne"al mass is suspected. C$ #ill demonstrate mass, /ut is -. /etter !or distinguishing cystic vs. solid characteristic.

M9A not !re<uently indicated.

Di!!erential Diagnosis Benign ovarian neoplasm, o .erous and mucinous cystadenoma

o

Dermoid cyst 6mature cystic teratoma8

Malignant neoplasm,
o o o o

>pithelial ovarian cancer ;erm cell tumor Fallopian tu/e carcinoma Metastatic disease o! /reast or ;A tract

Pedunculated uterine leiomyoma >ndometrioma PCO. An!lammatory lesions, acute or chronic,

o o

PAD #ith $OA or tu/o ovarian comple" Hydrosalpin"

Paratu/al cyst >ctopic pregnancy Appendicitis

Hyperandrogenism in pregnancy,
o

Pregnancy luteomas, solid, /ilateral,

Hyperreactio luteinalis, usually /ilateral, associated #ith high hC;, including molar pregnancy, multiple pregnancies, erythro/lastosis !etalis, and gestational dia/etes

o o o o

Hyperthecosis PCO. 7eydig cell tumor Other malignant ovarian tumors

P.(11 $reatment ;eneral Measures $he primary management issue is distinguishing #hich ovarian masses are li*ely malignant and re<uire surgical e"cision. A! li*ely /enign 6young patient, /enign characteristics on -., no evidence o! ascites, metastasis, or intra a/dominal spread8, then !unctional cysts must /e distinguished !rom /enign neoplasms.

$he characteristics o! the mass on -. and the clinical presentation determine management,
o

A! -. suggests !ollicular cyst 6unilocular, thin #alled, no septations, 4() cm8 or C7 cyst, o/serve mass !or ('+ cycles and repeat -..

Functional cysts #ill /e smaller or resolved. Other masses re<uire surgery.

A! patient presents #ith acute pain, consider,

$iming in cycle and -. characteristics Possi/ility o! torsion 6see Adne"al $orsion8. Possi/le rupture #ith hemodynamic insta/ility

Management o! ovarian cysts presenting #ith acute pain, late in cycle, and suspected to /e C7,
o

Avoid surgery and manage e"pectantly,

Ade<uate analgesia, including narcotics 9eassess #ithin a #ee*C pain should /e mar*edly improved and onset o! menses is li*ely.

A! pain is persistently severe or #orsens, reconsider torsion. 9epeat -. in D& #ee*s 6not sooner8. >nlarging or persistent cysts may /e neoplastic.

Ovary sparing procedures are generally indicated i! surgery re<uired and i! possi/leC avoid oophorectomy i! li*ely /enign,
o

Ovarian cystectomy i! dermoid

$he management o! ovarian masses in pregnancy can /e di!!icult or challenging in di!!erentiating /et#een possi/le malignancy re<uiring surgery and /enign masses that can /e managed e"pectantly.

Medication 6Drugs8 OCPs do not hasten the resolution o! !unctional ovarian cysts. E.AADs and narcotics i! acute pain .urgery .urgery should /e avoided i! possi/leC >"pectant management is indicated as !unctional cysts resolve spontaneously. Eeedle aspiration, via laparoscopy or using interventional radiologic techni<ues !re<uently results in recurrence, and is seldom re<uired.

7aparoscopy indicated i! possi/le torsion,

o

Detorsion alone, #ith !ollo# up to assess resolution o! mass 6li*ely i! !unctional8

.urgery indicated !or enlarging or persistent mass a!ter ('+ cycles,

o o o

7aparoscopic vs. laparotomy A! appears /enign, cystectomy i! possi/le Approach as i! possi/le malignancy, Pelvic #ashings, e"ploration, peritoneal /iopsies

Follo#up Disposition Assues !or 9e!erral 9e!erral to gyn oncologist may /e indicated i! malignancy considered li*ely on the /asis o! -. characteristics. Prognosis Follicular and C7 cysts #ill resolve #ithout surgical intervention over a period o! ('+ cycles or &'() #ee*s, o Failure o! resolution suggests neoplastic, rather than !unctional cyst, and should prompt consideration o! surgery.

Pregnancy luteomas resolve spontaneously a!ter delivery.

9ecurrence ris*s !or symptomatic !unctional ovarian cysts are un*no#n, although this is a clinically important <uestion,
o

Consider OCPs to prevent su/se<uent !unctional cysts.

Patient Monitoring 9egular e"ams -. not routinely re<uired Bi/liography Borg!eldt C, et al. $ransvaginal sonographic ovarian !indings in a random sample o! #omen +0'=) years old. -ltrasound O/stet ;ynecol. (FFFC(1608,1=0'10). ;rimes DA, et al. Oral contraceptives !or !unctional ovarian cysts. Cochrane Data/ase .yst 9ev. +))&C6=8,CD))&(1=. Hallatt J;, et al. 9uptured corpus luteum #ith hemoperitoneum, A study o! (?1 surgical cases. Am J O/stet ;ynecol. (F@=C(=F6(8,00'0F. Helmrath MA, et al. Ovarian cysts in the pediatric population. .emin Pediatr .urg. (FF@C?6(8,(F'+@. Manganiello PD, et al. Girili5ation during pregnancy #ith spontaneous resolution postpartum, A case report and revie# o! the >nglish literature. O/stetric ;ynecol .urvey. (FF0C0)608,=)='=(). Muram D, et al. Functional ovarian cysts in patients cured o! ovarian neoplasms. O/stet ;ynecol. (FF)C?06=8,&@)'&@1. Galentin 7, et al. Fre<uency and type o! adne"al lesions in autopsy material !rom postmenopausal #omen, -ltrasound study #ith histological correlation. -ltrasound O/stet ;ynecol. +))1C++618,+@='+@F. Miscellaneous .ynonym6s8 H Benign cysts H .imple cysts H Physiologic cysts Clinical Pearls H Functional cysts resolve #ith time aloneC COCs do not lead to a more rapid regression. H Avoid surgery !or !unctional cysts i! possi/le /ecause se<uelae, including adhesions, hampering !ertility. H Do not assume that patient #ill al#ays have the contralateral ovary. H Avoid oophorectomy i! possi/le. A//reviations H AFPIJ Fetoprotein H C7ICorpus luteum H COCICom/ination oral contraceptive H hC;IHuman chorionic gonadotropin H OCPIOral contraceptive pill H PCO.IPolycystic ovarian syndrome H PADIPelvic in!lammatory disease H $OAI$u/o ovarian a/scess H -$AI-rinary tract in!ection Codes ACDF CM

H &+).) Follicular 6atretic8 cyst H &+).( Corpus luteal cyst H &+).+ Other and unspeci!ied ovarian cyst Patient $eaching H Patient an"iety is almost al#ays high, #ith specter o! cancer or in!ertility. H 9eassure concerning lo# li*elihood o! malignancy #ith typical presentation and -. characteristics H ACO; patient education pamphlet, Ovarian Cysts Prevention H OCPs, /y preventing ovulation, mar*edly decrease the ris*s o! C7 cysts. H Current lo# dose COCs decrease the ris* o! !ollicular cysts, /ut may not prevent their !ormation as e!!ectively as did previous higher dose pills. H COCs can /e help!ul in girls and #omen #ith a previous malignant ovarian neoplasm /y preventing the occurrence o! !unctional cysts that lead to concern a/out recurrent malignancy.