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Benign ovarian conditions

Nur Hanani binti Mohd Khan

Learning outcomes
1. Epidemiology
2. Types
3. Characteristics
4. Pathology of Disease
5. Associated problems
6. Differential diagnosis
7. Investigations
8. Management
9. Concept of “do nothing” – selected intervention if needed
10. Risks of malignancy.
• Benign ovarian tumours occur in 30% of females with regular menses
(eg, luteal cysts as incidental findings on pelvic scans) and 50% of
females with irregular menses.
• Predominantly they occur in premenopausal women; they may also
occur perinatally.
• Benign ovarian tumours are uncommon in premenarchal and
postmenopausal women.
• Germ cell tumor most commonly seen in woman <30 years old and
contributed 15-20% of all ovarian tumor
• The likelihood of malignancy in women of childbearing age is low and a
large proportion of cysts are of functional origin, tending to resolve over
- Follicular cysts
- Corpus Luteal cyst
- Theca luteal cyst

- Inflammatory
- Common epithelial tumours
- Sex cord tumours
- Germ cells tumours
- Lipid cell tumours
Characteristics of physiological cyst

• Form in the ovary during normal ovarian

• Rarely complicated in appearance
• Related to hormonal changes
• Do not exceed more than 5cm in diameter
• Mostly unilocular
• Present of accumulation of fluid inside the
functional unit of ovary
Follicular cyst
• Lined by granulosa cells
• Commonest in reproductive age group
• Results from the non-ruptured dominant follicle
• Usually asymptomatic / vague pain
• Detection – accidentally by USG/ Bimanual
• Usually multiple and small - 6-8cm, can reach
up to 10cm
• Resolves 2-3months, combined oral
contraceptive help for resolution
• Uncomplicated: follow up 3-6 months
• If increased in size / ruptured causing
abdominal pain, laparotomy is indicated
• Less common
• Due to overactivity of corpus luteum
• Become cystic due to excessive bleeding inside the CL
• Fail to regress after 14 days
• Progesterone and estrogen continue to be secreted
• Associated with pregnancy and persists for 12 weeks
• Complaint of:
• prolonged menses and heavy bleeding
• Cysts can enlarge continue producing progesterone – causing delay
menstrual period
• Resolves spontaneously
• If rupture – intra-abdominal bleeding and acute abdomen
• Delay menses + acute abdomen (due to peritoneal irritation) –
mimic Ectopic pregnancy
• Laparacopic / laparotomy = to stop bleeding and enucleate syst
• The sonographic appearances
depending on the stage of evolution
and age of the associated intracystic
• General characteristics include:
• diffusely thick wall
• peripheral vascularity
• <3 cm
• possible crenulated contour
• If the cyst has been present for some Corpus luteal cyst
time with complicating haemorrhage, a
fine internal lace-like echo-pattern may
be seen.
Theca luteal cyst
• They are thought to originate due to
excessive amounts of circulating
gonadotrophins such as beta-hCG.
• Hyperplasia of the theca interna cells
• Usually involves bilaterally
• Common associated with gestational
trophoblastic disease, choriocarcinoma
• The cysts are usually large (2-3 cm) and
the ovaries often have a typical
multilocular cystic
• The cysts are classically thin walled and
have clear contents.
• Regress after gonadotrophin levels fall
Germ cell tumors
- Commonest ovarian tumor seen <30 years old
- Origin from germ cells
• Rare
• Contain mature tissues
• But with minimal cystic spaces
• 97% of teratomas
• Chance of malignancy 1-2%
• Torsion is common
• Grossly- Moderate size, smooth and uniloculated
• Cut section – Contain sebum, hair, bone, teeth, cartilage
• Avoid spilling of contents – Chemical peritonitis
Epithelial tumors
• Most common
• Occur in 30-50 years old
• Bilateral in 50%
• Arises from surface epithelium of ovary
• Gross appearance – unilocular, smooth surface, fluid filled
• Cut section- papillary projection into the cavity, pale
yellow serous fluid
• Unilateral, large and multiloculated
• Occur in 30-60
• Gross – Very large size, lobulated and translucent,
smooth surface
• Cut section – Thick mucinous material
• Perforation – pseudomyxoma peritonitis
Epithelial tumors
• Solid epithelial tumor
• Seen in woman around menopause
• Unilateral, small to moderate size
• Gross: firm, yellowish-white cut surface
• <2cm
• Consists nets of transitional epithelium
in a dense fibrous stroma
• Estrogen secreting tumor – abnormal
vaginal bleeding
Sex cord stromal tumors
- 6% of ovarian tumor
- Originate from sex
• Composed of cells resembling granulosa cells of Graafian follicle
• Secretes oestrogen
• Cystic glandular hyperplasia of endometrium
• Causing precocious puberty if occur before puberty & postmenopausal bleeding
• Most are malignant


• Solid, unilateral, mc after menopause
• Secrete estrogen – precocious puberty, endometrial hyperplasia, endometrial carcinoma,
post-menopausal bleeding
Sex cord stromal tumors
• Low grade malignancy
• Produce androgen  virilisation is possible
• Small and bilateral

• Secretes androgen
• Cause defiminization & masculinization


• Composed of large clear cells of adrenal
cortex tumor
Ovarian fibroma
• Most common benign connective tissue
tumor of the ovary
• Occurs frequently around 50 years old
• Firm, mobile, smooth cyst with glistening
capsule and consist of network of spindle
shaped cells
• May associated with ascites and pleural
effusion = Meigs’ syndrome
• Fibromas are slow-growing and are usually
less than 3 inches (about 7 centimeters) in
• Usually occur unilaterally Ovarian Fibroma: Transverse ultrasound
• Uss ddx: pedunculated uterine fibroid, ovarian image through the pelvis at a level inferior
torsion, Brenner Tumor, fibroma or to the uterus shows a large 7.3 cm by 4.5 cm
fibrotheoma, homogeneously hypoechoic solid mass
• Urine pregnancy test – TRO pregnancy
• Transabdominal and tranvaginal ultrasound
• Look for: mass origin, consistency: cystic / solid, benign / malignant
• characteristics of ovarian malignancy are:
 mixed echogenicity
 Solid component, often nodular or papillary.
 Septations, if present, that are thick (>2 to 3 mm).
 Presence of ascites / Peritoneal masses / Enlarged lymph nodes.
• If findings on ultrasound scan cannot clearly characterize the nature and origin of the
adnexal mass
• Suspected malignancy
• Baseline blood investigations
• Renal function test
• Liver function test
• If major surgery is indicated in emergency situation: coagulation profile, GXM
Tumor markers
Risk of malignancy index (RMI)
• Using an RMI cut-off of 200, a
sensitivity of 70% & specificity of 90%
• Women at high risk of malignancy
(usually RMI > 200 or clinical
suspicion) need to be discussed with a
gynaecological oncologist and at the
gynaecological oncology
multidisciplinary team meeting.
• The RMI is a clinical prediction rule
based on ultrasound, CA-125, and
menopausal status defined as follows:
No further action required

• Premenopausal simple ovarian cysts less than 5cm.

• Postmenopausal simple ovarian cysts less than 1cm.
Conservative management

• Ultrasound features are suggestive of a functional ovarian cyst.

• Premenopausal simple cysts ≤7 cm with no other features of malignancy
• Postmenopausal simple cysts ≤5 cm with no other features of malignancy and
normal CA 125.
• Asymptomatic.
• Risks of surgery outweigh the benefits of cyst removal.
• Patient preference (after counselling regarding risks).

“Combined oral contraceptive pills appear to be of no benefit for the treatment

of functional ovarian cysts, although stopping progesterone methods may be
Grimes, D.A., et al., Oral contraceptives for functional ovarian cysts. Cochrane Database Syst Rev, 2009(2): p. CD006134 .
Follow up
• Premenopausal simple cysts
• <5cm : No further investigation as there is no significant risk of malignancy
• 5-7cm : 90% of functional cysts will have resolved within 2 months. Therefore,
repeat ultrasound scan at 6 months, with CA 125 only if cyst still present
• If the cyst has resolved then no further follow up is required.
• If the cyst remains unchanged, an annual scan or surgery could be
• Those cysts that increase in size or complexity should be considered for
• Postmenopausal
• Ultrasound and CA 125 should be performed every six months until the cyst has
• If there is no change in the size of the cyst after one year of follow up, then the
patient can be discharged
• Consideration of surgery should be made if the cyst does not meet the criteria for
conservative management and present of complications (torsion, rupture, haemorrhage,
• The laparoscopic approach to surgery in presumed benign ovarian masses is preferred to
laparotomy due to lower morbidity and shorter recovery time
• The risks, benefits and potential complications of surgery should be individualised.
• Large ovarian cysts may still require laparotomy.
• Spillage of cyst contents should be avoided where possible, this may involve the use of
retrieval bags. Where spillage does occur, extensive peritoneal lavage with warmed fluid
should be performed.
• In women wishing to retain their fertility
• Ovarian cystectomy and preservation of ovarian tissue is preferred
• The risk of oophorectomy, for example to control bleeding, should be mentioned during consent.
• postmenopausal women / women had completed family
• The management should involve bilateral salpingoophorectomy rather than cystectomy.
• Women should be counselled preoperatively that if features of malignancy are suspected
during laparoscopy, then the procedure may have to be abandoned with recourse to a
laparotomy under the oncology team at a later date.
• Williams gynaecology second edition
• Essentials of gynaecology second edition, JAYPEE
• Gynaecology by ten teacher
• Guideline on the Management of Ovarian Masses. Tim Duncan, Sarah
Scott-Barrett. Norfolk and Norwich University Hospital. NHS