Ovaries

The most common types of lesions encountered in the ovary include functional or benign
cysts and tumors. Intrinsic inflammations of the ovary (oophoritis) are uncommon, usually
accompanying tubal inflammation. Rarely, a primary inflammatory disorder involving
ovarian follicles (autoimmune oophoritis) occurs and is associated with infertility.

Non-Neoplastic and Functional Cysts

FOLLICULAR AND LUTEAL CYSTS

Cystic follicles in the ovary are so common as to be virtually physiologic. They originate in
unruptured graafian follicles or in follicles that have ruptured and immediately sealed.

Morphology.

These cysts are usually multiple. They range in size up to 2 cm in diameter, are filled with
a clear serous fluid, and are lined by a gray, glistening membrane. On occasion, larger
cysts exceeding 2 cm (follicular cysts) may be diagnosed by palpation or ultrasonography
and cause pelvic pain. Granulosa lining cells can be identified histologically if the
intraluminal pressure has not been too great. The outer theca cells may be conspicuous
with increased cytoplasm and a pale appearance (luteinized). As discussed
subsequently, when this alteration is pronounced (hyperthecosis), it may ultimately result
in increased estrogen production and endometrial abnormalities.

Granulosa luteal cysts (corpora lutea) are normally present in the ovary. These cysts are
lined by a rim of bright yellow luteal tissue containing luteinized granulosa cells. They
occasionally rupture and cause a peritoneal reaction. When advanced, the combination of
old hemorrhage and fibrosis may make their distinction from endometriotic cysts difficult.

POLYCYSTIC OVARIES AND STROMAL HYPERTHECOSIS

Polycystic ovarian disease (PCOD, formerly termed Stein-Leventhal syndrome) affects

3% to 6% of reproductive-age women. The central pathologic abnormality is numerous
cystic follicles or follicle cysts, often associated with oligomenorrhea. Patients with PCOD
have persistent anovulation, obesity (40%), hirsutism (50%), and, rarely, virilism.[95][96]

The initiating event in polycystic ovarian disease is not clear. Increased secretion of
luteinizing hormone may stimulate the theca-lutein cells of the follicles, with excessive
production of androgen (androstenedione), which is converted to estrone. For years,
these endocrine abnormalities were attributed to primary ovarian dysfunction because
large wedge resections of the ovaries sometimes restored fertility. It is now believed that
a variety of enzymes involved in androgen biosynthesis are poorly regulated in polycystic
ovarian disease. Recent studies link polycystic ovarian disease, like type II diabetes, to
insulin resistance. Administration of insulin mediators has been associated with
resumption of ovulation.[97]

Stromal hyperthecosis, also called cortical stromal hyperplasia, is a disorder of ovarian

stroma most commonly seen in postmenopausal women, but it may blend with polycystic
ovarian disease in younger women. The disorder is characterized by uniform enlargement
of the ovary (up to 7 cm) with a white to tan appearance on sectioning. The involvement
is usually bilateral and microscopically consists of hypercellular stroma with luteinization
of the stromal cells, which are visible as discrete nests with vacuolated cytoplasm. The
clinical presentation and effects on the endometrium are similar to those of polycystic
ovarian disease, although virilization may be striking.[95]

A physiologic condition mimicking the above syndromes is theca lutein hyperplasia of

pregnancy. In response to pregnancy hormones (gonadotropins), proliferation of theca
cells with expansion of the perifollicular zone occurs. As the follicles regress, the
concentric theca-lutein hyperplasia may appear nodular. This change is not to be
confused with true luteomas of pregnancy (see below).

Morphology.

The ovaries are usually twice normal size, gray-white with a smooth outer cortex, and are
studded with subcortical cysts 0.5 to 1.5 cm in diameter. On histologic examination, there
is a thickened superficial cortex beneath which are innumerable follicle cysts with
hyperplasia of the theca interna (follicular hyperthecosis) ( Fig. 22-36A–D ). Corpora lutea
are frequently but not invariably absent.

Figure 22-36
Polycystic ovarian
disease and cortical
stromal hyperplasia.
A, The ovarian
cortex reveals
numerous clear
cysts. B, Sectioning
of the cortex reveals
several subcortical
cystic follicles. C,
Cystic follicles seen
in a low-power
microphotograph. D,
Cortical stromal
hyperplasia
manifests as diffuse
stromal proliferation
with symmetrical
enlargement of the
ovary.
Benign ovarian conditions
Figure 1 shows the stages of ovarian
development from the primordial ridge.
Cells in the ovary may develop from all
three types, hence the diversity of
problems that may be found within the
ovary. The mesodermal ridge is covered
in epithelium for development of
gonads and imagination of the
coelomic epithelium forms the
Miillerian duct Primordial germ cells
migrate from the yolk sac
Physiological cysts
The physiological cysts are a persistence
of structures found during normal
ovarian function. They are largely
asymptomatic and frequently undergo
spontaneous resolution. They may
present with pain and need
investigation. Rupture or torsion may
both present with an acute abdomen
needing surgical intervention (see
below). Haemorrhage into the cyst,
although painful, may be managed
conservatively and laparoscopy is only
performed if the symptoms fail to settle.
Table 1 Pathological ovarian cysts
Derivation Pathology
Coelomic epithelium
Germ cells
Sex cord cells
Serous cystadenoma
Mucinous cystadenoma
Brenner cell tumour
Endometrioid cystadenoma
Cystic teratoma (dermoid cyst)
Solid teratoma
Granulosa/theca cell tumours
Fibroma
Sertoli-Leydig cell
(arrhenoblastoma] tumour
Follicular. These cysts are small (but
may reach 10 cm diameter), unilocular,
common, lined by oestrogen-producing
granulosa cells and contain clear fluid
rich in hormones. They are particularly
likely in patients undergoing ovulation
stimulation.
Luteal. These may present with
intraperitoneal haemorrhage. Luteal
cysts are formed when the corpus
luteum does not regress.
Pathological cysts
The pathological cysts and their
derivation are shown in Table 1.
Serous cystadenoma. The most
common presenting cyst (Fig. 2) is
unilocular with papilliferous growths on
the inner surface (may also be on the
outer surface making distinction from a
malignant tumour very difficult). The
fluid content is thin and serous,
epithelial lining is cuboidal or columnar
Fig. 1 Development of the ovary. Fig. 2 Serous cystadenoma.
Fig. 3 Mucinous cystadenoma.
epithelium and they occasionally
contain calcified granules known as
psammoma bodies.
Mucinous cystadenoma. These are
unilateral, multilocular, full of thick
mucin, lined by columnar mucinsecreting
epithelium and may reach
great size (recorded up to 100 kg)
(Fig. 3). Rarely they rupture, releasing
mucin-producing cells which may
implant and continue to secrete mucin
which compromises bowel function and
gives rise to significant mortality
(pseudomyxoma peritonei).
Brenner cell tumour. A rare presentation
with islands of transitional epithelium in
dense fibrotic stroma. They are usually
small and may secrete oestrogen, so
they can present with abnormal vaginal
bleeding.
Endometrioid cystadenoma. This is
seldom distinguishable from a cystic
patch of endometriosis.
Dermoid cyst (cystic teratoma). This is
the commonest cyst presenting in young
women (Fig. 4). Their derivation from
the pluripotential germ cells means that
all tissue types may be found with hair,
sebaceous cells, fat cells and teeth being
most common. One cell-line may
predominate (e.g. struma ovarii with
hormonally-active thyroid tissue). They
are mostly asymptomatic but may tort
or rupture.
Solid teratoma. Another rare
presentation which will be benign if it
contains mature tissues. Immature
tissues are malignant
Granulosa cell tumour. The commonest
hormone-secreting tumour - 25% of
which are malignant
Benign ovarian conditions 141
Fig. 4 Opened dermoid cyst. Showing hair,
fat tissue and peripheral infarction due to ovarian
torsion.
Symptoms found with ovarian cysts
include:
« pain - due to torsion or
haemorrhage
« asymptomatic - especially
physiological cysts
« abdominal swelling - large cyst or
associated ascites (fibroma)
« pressure symptoms - affecting
bladder and bowel function
• menstrual upset due to hormone
secretion.
Investigations
Bimanual examination (Fig. 5). This may
allow distinction between an enlarged
fibroid uterus and an ovarian cyst but
ultrasound may also be necessary.
Ultrasound scan. The cyst fluid will
show as dark on the picture (see
follicular cyst) with a white-flecked
appearance if blood is present Dermoid
cysts appear more complex. It is
important to look for features which
may suggest malignancy (Fig. 6)
(protrusions inside the cyst,
multilocular, neovascularization, ascitic
fluid in pouch of Douglas).
(a) (b)
Fig. 6 Ultrasound examination of ovarian cyst, (a) Smooth outline in a non-malignant cyst.
(b) Projections into a malignant cyst.
Hormone assays. If the main symptoms
suggest hormone-producing cysts (such
as menstrual upset, hirsutism or
virilization) check oestrogen and
androgen levels.
CA125. This tumour marker will be
modestly raised in the face of
endometriosis but a high value is
suggestive of malignancy. Unfortunately
a low value does not completely exclude
malignancy.
Diagnostic laparoscopy. This allows
visualization of the cyst, peritoneal
washings for cytology if concerned
about possible malignancy and
treatment by laparoscopic removal if
appropriate (see below).
Treatment
Asymptomatic cysts less than 5 cm in
diameter in a young woman require
no action as these will usually undergo
spontaneous resolution.
Asymptomatic cysts greater than 5 cm
in diameter in a young woman should
be rescanned in 6 weeks. The cyst will
be either smaller (or the same size) and
need no action, or enlarged in size,
possibly with blood in the fluid, and
would be best removed to avoid the
risk of torsion and loss of the ovary.
A cyst that is symptomatic or rapidly
enlarging requires removal. The
traditional approach is by laparotomy.
An ovarian cystectomy conserving all
normal ovarian tissue and restoring
the ovarian surface to normal with
minimal chance for adhesion
formation is the aim. This ensures that
future fertility is not compromised. A
fine, inert suture is used on the ovary
to excite less tissue reaction and
peritoneal lavage used to remove all
blood, which would promote
development of adhesions. The need to
limit adhesion formation has
encouraged the development of
laparoscopic techniques to allow
removal of the cyst with minimal
tissue handling. The contents of a
dermoid cyst, if spilled into the
peritoneal cavity, may cause a chemical
peritonitis so this may be best
managed through a mini-laparotomy
incision.
Laparoscopic management of simple
cysts can be performed by drainage of
the cyst contents then peeling off the
cyst capsule, which is sent for
histological examination. In the case
where the cyst may be malignant it is
sometimes appropriate to offer
laparoscopic oophorectomy. This will
be considerably less invasive for the
patient than the previous practice of
total abdominal hysterectomy with
bilateral salpingo-oophorectomy and
omentectomy in any woman over
45 years old found to have an ovarian
cyst The ovary is captured in a bag
and removed intact from the abdomen
so there is no risk of peritoneal
seeding if any tumour exists. The
patient may not require to proceed
with more major surgery if histology
confirms benign disease.
An ovarian cyst is a sac filled with liquid or semiliquid material that arises in an
ovary. Although the discovery of an ovarian cyst causes considerable anxiety in
women owing to fears of malignancy, the vast majority of these lesions are
benign.

Essential update: Many ovarian cysts resolve without surgery

Pavlik et al determined that many ovarian cysts resolve without surgery and that
as a result, monitoring women with serial ultrasonography is a better way to
screen for ovarian abnormalities than is relying on a single ultrasonographic
finding.[1]

In the study, nearly 40,000 women underwent baseline and interval examinations
with transvaginal ultrasonography, with abnormal findings—most or all of which
were various types of cysts—observed on the initial ultrasonograms of nearly
3200 subjects. In about 2000 of these women, however, findings on subsequent
ultrasonograms resolved to normal, no matter whether the abnormality initially
appeared to be complex, solid, or bilateral.

Signs and symptoms

Most patients with ovarian cysts are asymptomatic, with the cysts being
discovered incidentally during ultrasonography or routine pelvic examination.
Some cysts, however, may be associated with a range of symptoms, sometimes
severe, including the following[2] :

 Pain or discomfort in the lower abdomen

 Severe pain from torsion (twisting) or rupture - Cyst rupture is
characterized by sudden, sharp, unilateral pelvic pain; this can be
associated with trauma, exercise, or coitus;[2, 3] cyst rupture can lead to
 peritoneal signs, abdominal distention, and bleeding (which is usually self-
limited)
 Discomfort with intercourse, particularly deep penetration
 Difficulty having bowel movements
 Desire to defecate - This can occur if pressure develops
 Micturition - This can occur frequently, due to pressure on the bladder
 Irregularity of the menstrual cycle and abnormal vaginal bleeding - The
intermenstrual interval may be prolonged, followed by menorrhagia[4]
 Precocious puberty and early onset of menarche in young children
 Abdominal fullness and bloating
 Indigestion, heartburn, or early satiety
 Endometriomas - These are associated with endometriosis, which causes a
classic triad of painful and heavy periods and dyspareunia
 Polycystic ovarian syndrome - This includes hirsutism, infertility,
oligomenorrhea, obesity, and acne
 Tenesmus
 Dull, bilateral pelvic pain - This may result from theca-lutein cysts[5]
 Tachycardia and hypotension - These may result from hemorrhage caused
by cyst rupture
 Hyperpyrexia - This may result from some complications of ovarian cysts,
such as ovarian torsion[2]
 Adnexal or cervical motion tenderness
 Diffusely tender abdomen with rebound tenderness and guarding - This
may occur if hemorrhage or peritonitis ensues; a distended abdomen may
be found on abdominal examination
 Cachexia and weight loss, lymphadenopathy in the neck, shortness of
breath, and signs of pleural effusion - These may be associated with
advanced malignant disease

Palpation

 A large cyst may be palpable on abdominal examination, but gross ascites

may interfere with palpation of an intra-abdominal mass
 The cyst may be tender to palpation
 Other masses may be palpable, including fibroids and nodules in the
uterosacral ligament consistent with malignancy or endometriosis

See Clinical Presentation for more detail.

Diagnosis

An ultrasonographic examination of the pelvis should always be obtained if, on

clinical examination, a patient is thought to have a pelvic mass.

The definitive diagnosis of all ovarian cysts is made based on histologic analysis.
Each cyst type has characteristic findings.
Laboratory tests, although not diagnostic for ovarian cysts, can aid in the
differential diagnosis of cysts and in the diagnosis of cyst-related complications.
Studies include the following:

 Urinary pregnancy test

 Complete blood count (CBC)
 Urinalysis
 Endocervical swabs
 Rh status
 Cancer antigen 125 (CA125) - The finding of an elevated CA125 level is
most useful when combined with an ultrasonographic investigation while
assessing a postmenopausal woman with an ovarian cyst[6, 2]

See Workup for more detail.

Management

Many patients with simple ovarian cysts found through ultrasonographic

examination do not require treatment. In a postmenopausal patient, a persistent
simple cyst smaller than 5 cm in dimension in the presence of a normal CA125
value may be monitored with serial ultrasonographic examinations.[4, 7]

Pharmacologic therapy

Oral contraceptive pills (OCPs) protect against the development of functional

ovarian cysts. Existing functional cysts, however, do not regress more quickly
when treated with combined oral contraceptives than they do with expectant
management.[8]

Laparotomy and laparoscopy

Persistent simple ovarian cysts larger than 5-10 cm (especially if symptomatic)

and complex ovarian cysts should be considered for surgical removal. The
surgical approaches include an open incisional technique (laparotomy) and a
minimally invasive technique (laparoscopy) with very small incisions. Removing
the cyst intact for pathologic analysis may mean removing the entire ovary.

Bilateral oophorectomy

Bilateral oophorectomy and, often, hysterectomy are performed in many

postmenopausal women with ovarian cysts, because of the increased incidence of
neoplasms in this population.

See Treatment and Medication for more detail.

Image library
 A multilocular right ovarian cyst that is 24 cm in
diameter. It is seen with the adjacent fallopian tube and uterus. The infundibulo-
pelvic ligament carrying the ovarian artery and vein has been divided. Histology
reported a mucinous cystadenocarcinoma of low malignant potential. Image
courtesy of C. William Helm, MBBChir.

Background
An ovarian cyst is a sac filled with liquid or semiliquid material that arises in an
ovary. The number of diagnoses of ovarian cysts has increased with the
widespread implementation of regular physical examinations and ultrasonographic
technology. The discovery of an ovarian cyst causes considerable anxiety in
women owing to fears of malignancy, but the vast majority of ovarian cysts are
benign. (See Prognosis, Presentation, and Workup.)

These cysts can develop in females at any stage of life, from the neonatal period
to postmenopause. Most ovarian cysts, however, occur during infancy and
adolescence, which are hormonally active periods of development. Most are
functional in nature and resolve with minimal treatment. (See Epidemiology,
Prognosis, Treatment, and Medication.)

However, ovarian cysts can herald an underlying malignant process or, possibly,
distract the clinician from a more dangerous condition, such as ectopic pregnancy,
ovarian torsion, or appendicitis. (On the other hand, there may be an inverse
relationship between ovarian cysts and breast cancer.[9, 10] ) (See Presentation and
Workup.)

When ovarian cysts are large, persistent, or painful, surgery may be required,
sometimes resulting in removal of the ovary. A large ovarian cyst is shown in the
images below. (See Treatment.)
 A multilocular right ovarian cyst that is 24 cm in
diameter. It is seen with the adjacent fallopian tube and uterus. The infundibulo-
pelvic ligament carrying the ovarian artery and vein has been divided. Histology
reported a mucinous cystadenocarcinoma of low malignant potential. Image

courtesy of C. William Helm, MBBChir.

Transabdominal sonogram of a multilocular right ovarian cyst that is 24 cm in
diameter, with the adjacent fallopian tube and uterus. The infundibulo-pelvic
ligament carrying the ovarian artery and vein has been divided. This sonogram
demonstrates a large, complex cystic mass with vascularity within the septations.
Red and blue colors show blood flow towards and away from the transducer. The
resistive index was low. Histology reported a mucinous cystadenocarcinoma of
low malignant potential. Courtesy Patrick O'Kane, MD.

A multilocular right ovarian cyst that is 24 cm in

diameter has been removed and cut open. It has a smooth surface and a
multicystic internal structure. Image courtesy of C. William Helm, MBBChir.

Emergency diagnosis

Abdominal pain in the female can be one of the most difficult cases to diagnose
correctly in the emergency department (ED). The spectrum of gynecologic disease
is broad, spanning all age ranges and representing various degrees of severity,
from benign cysts that eventually resolve on their own to ruptured ectopic
pregnancy that causes life-threatening hemorrhage. (See Prognosis.)
When presented with this scenario, the goal of the emergency physician is to rule
out acute causes of abdominal pain associated with high morbidity and mortality,
such as appendicitis or ectopic pregnancy, to assess for the possibility of
neoplasm or malignancy, and either to refer the patient to the appropriate
consultant or to discharge them with a clear plan for follow-up with an
obstetrician/gynecologist. (See Presentation, DDx, and Workup.)

Patient education

Provide patients with adequate discharge and follow-up instructions and

information, including documentation of the potential risks of infertility,
disability, and malignancy caused by delays or noncompliance.

For patient education information, see the Women's Health Center and the Cancer
Center, as well as Ovarian Cysts, Female Sexual Problems, and Ovarian Cancer.

Pathophysiology
Ovarian hyperstimulation syndrome

Patients with polycystic ovarian syndrome and anovulatory patients are at an

increased risk of developing hyperstimulated ovary, as these conditions cause
increased estradiol levels at baseline.

Ovarian hyperstimulation syndrome is seen with hyperstimulated ovaries and

fluid shifts. It is graded on a spectrum from mild to severe based on weight gain
and size of ovarian enlargement with accompanying nausea and vomiting. These
patients are treated with bed rest, serial ultrasonography, and repeat electrolyte
and hematocrit studies. Complications include rupture, ascites, pleural and
pericardial effusions with subsequent hypovolemia, hemoconcentration, and
electrolyte abnormalities.

Hyperreactio luteinalis

Hyperreactio luteinalis is an abnormal, hypersensitive response of the ovaries to

circulating levels of hCG in the absence of ovulation induction therapy, with
either normal or elevated hCG levels. Hyperreactio luteinalis is typically
asymptomatic or minimally symptomatic, but as many as 25% of cases can result
in maternal virilization. The incidence can be increased in polycystic ovarian
syndrome and other states that cause hyperandrogenism. Hyperreactio luteinalis is
usually seen in the third-trimester in patients with bilateral, enlarged, multicystic
ovaries.

Etiology
Functional cysts

The median menstrual cycle lasts 28 days, beginning with the first day of
menstrual bleeding and ending just before the subsequent menstrual period. The
variable first half of this cycle is termed the follicular phase and is characterized
by increasing follicle-stimulating hormone (FSH) production, leading to the
selection of a dominant follicle that is primed for release from the ovary.[11]

In a normally functioning ovary, simultaneous estrogen production from the

dominant follicle leads to a surge of luteinizing hormone (LH), resulting in
ovulation and the release of the dominant follicle from the ovary and commencing
the luteinizing phase of ovulation.

After ovulation, the follicular remnants form a corpus luteum, which produces
progesterone. This, in turn, supports the released ovum and inhibits FSH and LH
production. As luteal degeneration occurs in the absence of pregnancy, the
progesterone levels decline, while the FSH and LH levels begin to rise before the
onset of the next menstrual period.

Follicular cysts

Different kinds of functional ovarian cysts can form during this cycle. In the
follicular phase, follicular cysts may result from a lack of physiologic release of
the ovum due to excessive FSH stimulation or lack of the normal LH surge at
midcycle just before ovulation. Hormonal stimulation causes these cysts to
continue to grow. Follicular cysts are typically larger than 2.5 cm in diameter and
manifest as pelvic discomfort and heaviness. Granulosa cells that line the follicle
may also persist, leading to excess estradiol production, which, in turn, leads to
decreased frequency of menstruation and menorrhagia.[12]

Corpus luteal cysts

In the absence of pregnancy, the lifespan of the corpus luteum is 14 days. If the
ovum is fertilized, the corpus luteum continues to secrete progesterone for 5-9
weeks, until its eventual dissolution in 14 weeks’ time, when the cyst undergoes
central hemorrhage. Failure of dissolution to occur may result in a corpus luteal
cyst, which is arbitrarily defined as a corpus luteum that grows to 3 cm in
diameter. The cyst can cause dull, unilateral pelvic pain and may be complicated
by rupture, which causes acute pain and possibly massive blood loss.

Theca-lutein cysts

Theca-lutein cysts are caused by luteinization and hypertrophy of the theca interna
cell layer in response to excessive stimulation from human chorionic
gonadotropin (hCG) These cysts are predisposed to torsion, hemorrhage, and
rupture.
Theca-lutein cysts can occur in the setting of gestational trophoblastic disease
(hydatiform mole and choriocarcinoma), multiple gestation, or exogenous ovarian
hyperstimulation.

These cysts are associated with maternal androgen excess in up to 30% of cases
but usually resolve spontaneously as the hCG level falls. Theca-lutein cysts are
usually bilateral and result in massive ovarian enlargement, a characteristic of the
condition termed hyperreactio luteinalis. (See the image below.)[5]

Theca-lutein cysts replacing an ovary in a patient

with a molar pregnancy. Despite their size these cysts are benign and usually
resolve after treatment of the underlying disease. Image courtesy of C. William
Helm, MBBChir.

Luteoma of pregnancy

A luteoma of pregnancy results when ovarian parenchyma is replaced by

proliferation of luteinized stromal cells that may become hormonally active with
production of androgens. Maternal virilization can occur in up to 30% of cases,
with a 50% risk of virilization of the female fetus; male fetuses are unaffected.
Luteoma of pregnancy appears as complex, heterogenous, hypoechoic mass on
ultrasonography. After completion of pregnancy, the mass typically resolves and
testosterone levels typically normalize.[13]

Neoplastic cysts

Neoplastic cysts arise via the inappropriate overgrowth of cells within the ovary
and may be malignant or benign. Malignant neoplasms may arise from all ovarian
cell types and tissues. The most frequent by far, however, are those arising from
the surface epithelium (mesothelium); most of these are partially cystic lesions.
The benign counterparts of these cancers are serous and mucinous cystadenomas.
Other malignant ovarian tumors may also contain cystic areas, including
granulosa cell tumors from sex cord stromal cells and germ cell tumors from
primordial germ cells. Cystic spaces within a tumor are seen in the image below.
 Cross-section of a clear cell carcinoma of the
ovary. Note the cystic spaces intermingled with solid areas. Image courtesy of C.
William Helm, MBBChir.

Teratomas

Teratomas are a form of germ cell tumor[14] containing elements from all 3
embryonic germ layers, ie, ectoderm, endoderm, and mesoderm. A mature cystic
teratoma is shown in the image below.

A dermoid cyst (mature cystic teratoma) after

opening the abdomen. Note the yellowish color of the contents seen through the
wall. Image courtesy of C. William Helm, MBBChir.

Endometriomas

Endometriomas are blood-filled cysts arising from the ectopic endometrium.

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

Polycystic ovarian syndrome

In polycystic ovarian syndrome, the ovary often contains multiple cystic follicles
2-5 mm in diameter as viewed on sonograms. The cysts themselves are never the
main problem, and discussion of this disease is beyond the scope of this article.

Risk factors

Risk factors for ovarian cyst formation include the following:

  Infertility treatment - Patients being treated for infertility by ovulation
induction with gonadotropins or other agents, such as clomiphene citrate
or letrozole, may develop cysts as part of ovarian hyperstimulation
syndrome
 Tamoxifen - Tamoxifen can cause benign functional ovarian cysts that
usually resolve following discontinuation of treatment
 Pregnancy - In pregnant women, ovarian cysts may form in the second
trimester, when hCG levels peak[5]
 Hypothyroidism - Because of similarities between the alpha subunit of
thyroid-stimulating hormone (TSH) and hCG, hypothyroidism may
stimulate ovarian and cyst growth[6]
 Maternal gonadotropins - The transplacental effects of maternal
gonadotropins may lead to the development of neonatal and fetal ovarian
cysts[15]
 Cigarette smoking - The risk of functional ovarian cysts is increased with
cigarette smoking; risk from smoking is possibly increased further with a
decreased body mass index (BMI)[16, 17]
 Tubal ligation - Functional cysts have been associated with tubal ligation
sterilizations[18]

Risk factors for ovarian cystadenocarcinoma include the following:

 Strong family history

 Advancing age
 White race
 Infertility
 Nulliparity
 History of breast cancer
 BRCA gene mutations

Epidemiology
Occurrence in the United States

Ovarian cysts are found on transvaginal sonograms in nearly all premenopausal

women and in up to 18% of postmenopausal women (women develop one or more
Graafian follicles each menstrual cycle, which appear as cysts on imaging).[19, 2, 6]
Most of these cysts are functional in nature and benign. Mature cystic teratomas,
or dermoids, represent more than 10% of all ovarian neoplasms. Ovarian cysts are
the most common fetal and infant tumor, with a prevalence exceeding 30%.[20]

The incidence of ovarian carcinoma is approximately 15 cases per 100,000

women per year. In the United States, ovarian carcinomas are diagnosed in more
than 21,000 women annually, causing an estimated 14,600 deaths.[21] Most
malignant ovarian tumors are epithelial ovarian cystadenocarcinomas.
Tumors of low malignant potential make up approximately 20% of malignant
ovarian tumors, whereas less than 5% are malignant germ cell tumors, and
approximately 2% are granulosa cell tumors.[22]

Race-related demographics

Malignant epithelial ovarian cystadenocarcinomas are the only ovarian cysts

associated with a race predilection. Women from northern and western Europe
and North America are affected most frequently, whereas women from Asia,
Africa, and Latin America are affected least frequently.

Within the United States, age-adjusted incidence rates in surveillance areas are
highest among American Indian women, followed by white, Vietnamese,
Hispanic, and Hawaiian women. Incidence is lowest among Korean and Chinese
women.[23]

Among women for whom sufficient numbers of cases are available to calculate
rates based on age, incidence in those aged 30-54 years is highest in white
women, followed by Japanese, Hispanic, and Filipino women. For women aged
55-69 years, the highest rates occur in white women, followed by Hispanic and
Japanese women. Among women aged 70 years or older, the highest rate occurs
among white women, followed by those of African descent and Hispanic women.

Age-related demographics

Functional ovarian cysts can occur at any age (including in utero) but are much
more common in women of reproductive age. They are rare after menopause.
Luteal cysts occur after ovulation in reproductive-age women. Most benign
neoplastic cysts occur during the reproductive years, but the age range is wide and
they may occur in persons of any age.

The incidence of epithelial ovarian cystadenocarcinomas, sex cord stromal

tumors, and mesenchymal tumors rises exponentially with age until the sixth
decade of life, at which point the incidence plateaus.

Tumors of low malignant potential occur at a mean age of 44 years, with a span
from adolescence to senescence. The average age is more than a decade less than
that for invasive cystadenocarcinoma. Germ cell tumors are most common in
adolescence and rarely occur in women older than 30 years.

In a child found to have a symptomatic abdominopelvic mass, the ovary is the

most common site of origin. Although such masses are infrequent occurrences, the
percentage due to malignant tumors is thought to be higher than for older age
groups. The most common are germ cell tumors, followed by epithelial and
granulosa cell tumors. Such tumors may be partially cystic.
Prognosis
The prognosis for benign cysts is excellent. All such cysts may occur in residual
ovarian tissue or in the contralateral ovary. Overall, 70%-80% of follicular cysts
resolve spontaneously.

Malignancy is a common concern among patients with ovarian cysts. Pregnant

patients with simple cysts smaller than 6cm in diameter have a malignancy risk of
less than 1%. Most of these cysts resolve by 16-20 weeks' gestation, with 96% of
these masses resolving spontaneously.[24] In postmenopausal patients with
unilocular cysts, malignancy develops in 0.3% of cases.

In complex, multiloculated cysts, the risk of malignancy climbs to 36%. If cancer

is diagnosed, regional or distant spread may be present in up to 70% of cases, and
only 25% of new cases will be limited to stage I disease.[19]

Mortality associated with malignant ovarian carcinoma is related to the stage at

the time of diagnosis, and patients with this carcinoma tend to present late in the
course of the disease. The 5-year survival rate overall is 41.6%, varying between
86.9% for International Federation of Gynecology and Obstetrics (FIGO) stage Ia
and 11.1% for stage IV.

A distinct group of less aggressive tumors of low malignant potential runs a more
benign course but still is associated with definite mortality. The overall survival
rate is 86.2% at 5 years.[13]

The potential of benign ovarian cystadenomas to become malignant has been

postulated but, to date, remains unproven. Malignant change can occur in a small
percentage of dermoid cysts and endometriomas.

Granulosa cell tumors are associated with an 82% survival rate, whereas
squamous cell carcinomas arising in a dermoid cyst are associated with a very
poor outcome.

The potential of benign ovarian cystadenomas to become malignant has been

postulated but, to date, remains unproven. Malignant change can occur in a small
percentage of dermoid cysts and endometriomas.

Complications
Ovarian cysts have a broad range of potential outcomes. In most cases, the cyst is
benign and asymptomatic, requires no further management, and will resolve on its
own. In other cases, ovarian cyst–related accidents, such as rupture and
hemorrhage or torsion, occur.
Torsion

Ovarian cysts larger than 4 cm in diameter have been shown to have a torsion rate
of approximately 15%. Ovarian torsion involves the rotation of the ovarian
vascular pedicle, causing obstruction to venous and, eventually, arterial flow that
can lead to infarction. (See the image below.)

An ovarian cyst that underwent torsion (twisting

of the vascular pedicle). The patient presented with a short history of severe lower
abdominal pain. The twisted pedicle can be seen attached to the cyst, which has
turned dusky due to ischemia. No viable epithelial lining was available for
histologic diagnosis. Image courtesy of C. William Helm, MBBChir.

Most torsion cases occur in premenopausal females of childbearing age, but up to

17% of cases affect prepubertal and postmenopausal women. It is also strongly
associated with ovarian stimulation and polycystic ovarian syndrome. Ovarian
torsion is more common on the right side owing to the sigmoid colon restricting
the mobility of the left ovary.

Malignancy may be seen in up to 2% of cases of ovarian torsion. The most

common ovarian mass associated with torsion is a dermoid cyst.

CT scanning and ultrasonography can assist with diagnosis. The absence of blood
flow within an ovary can support the diagnosis of torsion. Treatment options
include laparoscopic “detorsion” and adnexal preservation in premenopausal
women and salpingo-oophorectomy in postmenopausal women. Ovarian function
may be preserved with laparoscopic detorsion in 90% of cases.

Rupture

The outcome of ovarian cyst rupture is evaluated based on associated symptoms

and will dictate whether the patient is discharged or admitted for laparoscopy.

Ovarian cyst rupture commonly occurs with corpus luteal cysts. They involve the
right ovary in two thirds of cases and usually occur on days 20-26 of the woman’s
menstrual cycle. Mittelschmerz is a form of physiologic cyst rupture. In pregnant
women, hemorrhagic corpus luteal cysts are usually seen in the first trimester,
with most resolving by 12 weeks' gestation. Hemorrhage and shock may occur
and may present late in the symptomatology.
In ovarian cyst rupture, ultrasonography may demonstrate free fluid in the pouch
of Douglas in 40% of cases. Cyst rupture and hemorrhage may be treated
conservatively with observation if the patient is stable, with follow-up scanning in
6 weeks to confirm hemorrhage resolution. Laparoscopy is indicated in
hemodynamic compromise, possibility of torsion, no relief of symptoms within 48
hours, or increasing hemoperitoneum or falling hemoglobin concentration.

Morbidity
Benign cysts can cause pain and discomfort related to pressure on adjacent
structures, torsion, rupture, and hemorrhage (within and outside of the cyst).
Morbidity also includes menorrhagia, an increased intermenstrual interval,
dysmenorrhea, pelvic discomfort, and abdominal distention. Benign cysts rarely
cause death.

Mucinous cystadenomas may cause a relentless collection of mucinous fluid

within the abdomen, known as pseudomyxoma peritonei, which may be fatal
without extensive treatment.

Approximately 3% of theca lutein cysts are complicated by torsion or

hemorrhage, and approximately 30% of these cysts can cause maternal androgen
excess.[5] Follicular cysts can cause excess estradiol production, leading to
metrorrhagia and menorrhagia.

Ovarian cysts, and more specifically corpus luteal cysts, can rupture, causing
hemoperitoneum, hypotension, and peritonitis. This can be exacerbated in women
with bleeding dyscrasias, such as those with von Willebrand disease and those
receiving anticoagulation therapy.

Ovarian torsion can complicate ovarian cysts and can result in ovarian infarction,
necrosis, infertility, premature ovarian menopause, and preterm labor.[13]

Malignant ovarian cystic tumors can cause severe morbidity, including the
following:

 Pain
 Abdominal distension
 Bowel obstruction
 Nausea
 Vomiting
 Early satiety
 Wasting
 Cachexia
 Indigestion
 Heartburn
 Abnormal uterine bleeding
  Deep venous thrombosis
 Dyspnea

Cystic granulosa cell tumors may secrete estrogen, leading to postmenopausal

bleeding and precocious puberty in elderly patients and young patients,
respectively.

In addition to the normal complications of cysts, the presence of cysts in

pregnancy may cause obstructed labor.

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Ovarian cysts
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An ovarian cyst is a sac filled with fluid that forms on or inside of an ovary.

This article is about cysts that form during your monthly menstrual cycle, called functional
cysts. Functional cysts are not the same as cysts caused by cancer or other diseases.

For more information about other causes of cysts on or near the ovaries, see also:

 Dermoid cyst
 Ectopic pregnancy
 Endometriosis
 Ovarian cancer
 Polycystic ovary syndrome

Causes
Each month during your menstrual cycle, a follicle grows on your ovary. A follicle is
where an egg is developing. Most months, an egg is released from this follicle. This is
called ovulation. If the follicle fails to break open and release an egg, the fluid stays in the
follicle and forms a cyst. This is called a follicular cyst.

Another type of cyst occurs after an egg has been released from a follicle. This is called a
corpus luteum cyst. Such cysts often contain a small amount of blood.
Ovarian cysts are more common from puberty to menopause. This period of time is
known as the childbearing years. Ovarian cysts are less common after menopause.

Taking fertility drugs can cause a condition in which multiple large cysts are formed on
the ovaries. This is called ovarian hyperstimulation syndrome. The cysts usually go away
after a woman's period, or after a pregnancy.

Functional ovarian cysts are not the same as ovarian tumors (including ovarian cancer) or
cysts due to hormone-related conditions such as polycystic ovary syndrome.

Symptoms
Ovarian cysts often cause no symptoms. When symptoms occur, they are typically pain
or a late period.

An ovarian cyst is more likely to cause pain if it:

 Becomes large
 Bleeds
 Breaks open
 Interferes with the blood supply to the ovary
 Is bumped during sexual intercourse
 Is twisted or causes twisting (torsion) of the Fallopian tube

Symptoms of ovarian cysts can include:

 Bloating or swelling in the abdomen

 Pain during bowel movements
 Pain in the pelvis shortly before or after beginning a menstrual period
 Pain with intercourse or pelvic pain during movement
 Pelvic pain -- constant, dull aching
 Sudden and severe pelvic pain, often with nausea and vomiting, may be a
sign of torsion or twisting of the ovary on its blood supply, or rupture of a
cyst with internal bleeding

Changes in menstrual periods are not common with follicular cysts, and are more
common with corpus luteum cysts. Spotting or bleeding may occur with some cysts.

Exams and Tests

Your doctor or nurse may discover a cyst during a pelvic exam, or when you have an
ultrasound test for another reason.

Ultrasound may be done to diagnose a cyst. Your doctor or nurse may want to check you
again in 6 weeks to make sure it is gone.

Other imaging tests that may be done when needed include:

  CT scan
 Doppler flow studies
 MRI

The following blood tests may be done:

 Ca-125 test, to look for possible cancer if you have an abnormal

ultrasound or are in menopause
 Hormone levels (such as LH, FSH, estradiol, and testosterone)
 Pregnancy test (Serum HCG)

Treatment
Functional ovarian cysts often don't need treatment. They usually go away on their own
within 8 - 12 weeks.

If you have frequent cysts, your doctor or nurse may prescribe birth control pills (oral
contraceptives). These medicines may reduce the risk of new ovarian cysts. Birth control
pills do not decrease the size of current cysts.

Surgery to remove the cyst or ovary may be needed to make sure it isn't ovarian cancer.
Surgery is more likely to be needed for:

 Complex ovarian cysts that don't go away

 Cysts that are causing symptoms and do not go away
 Simple ovarian cysts that are larger than 5 - 10 centimeters
 Women who are menopausal or near menopause

Types of surgery for ovarian cysts include:

 Exploratory laparotomy
 Pelvic laparoscopy to remove the cyst or the ovary

Other treatments may be recommend if you have polycystic ovary syndrome or another
disorder that can cause cysts.

Outlook (Prognosis)
Cysts in women who are still having periods are more likely to go away. There is a higher
risk of cancer in women who are postmenopausal.

Possible Complications
Complications have to do with the condition causing the cysts. Complications can occur
with cysts that:

 Bleed
  Break open
 Show signs of changes that could be cancer
 Twist

When to Contact a Medical Professional

Call for an appointment with your health care provider if:

 You have symptoms of an ovarian cyst

 You have severe pain
 You have bleeding that is not normal for you

Also call for an appointment if the following symptoms have been present on most days
for at least 2 weeks:

 Getting full quickly when eating

 Losing your appetite
 Losing weight without trying

Prevention
If you are not trying to get pregnant and you often get functional cysts, you can prevent
them by taking hormone medications (such as birth control pills), which prevent follicles
from growing.

Alternative Names
Physiologic ovarian cysts; Functional ovarian cysts; Corpus luteum cysts; Follicular cysts

References
Katz VL. Benign gynecologic lesions: Vulva, vagina, cervix, uterus, oviduct, ovary. In:
Katz VL, Lentz GM, Lobo RA, Gershenson DM, eds. Comprehensive Gynecology. 5th ed.
Philadelphia, Pa: Mosby Elsevier; 2007:chap 18.

Bulun SE. The physiology and pathology of the femalereproductive axis. In: Melmed S,
Polonsky KS, Larsen PR, Kronenberg HM, eds. Williams Textbook of Endocrinology. 12th
ed. Philadelphia, Pa: Saunders Elsevier; 2011:chap 17.

http://www.nlm.nih.gov/medlineplus/ency/article/001504.htm