it will cover benign ovarian masses, diagnosis, management and complications in detail.

1. Dr. Ayesha Sherzada
FCPS trainee at THE INDUS HOSPITAL.
Karachi, Pakistan.

2.  Describe the types of ovarian cysts
 Clinical presentation
 Diagnosis
 Management

3.  Ovaries are normally not palpable in pre-menarche,
and after the menopause
 In the reproductive age group ovaries are palpable in
the lean pts.
 Ovarian size of different age groups
Premenopause 3.5 x 2 x 1.5 cm
Early menopause 1 – 2 yrs
2 x 1.5x0.5cm
Late menopause 2-5yrs
1.5x0.75x0.5cm

4.  Variation in diameter can result from:
 Endogenous hormonal production(varies with age and
menstrual cycle).
 Exogenous substances, including OCs, GnRH agonists
or ovulation-inducing medications, may affect size.

5.  Up to 10% of women will have some form of surgery
during their lifetime for the presence of an ovarian
mass.
 In premenopausal women almost all ovarian masses
and cysts are benign.
 The overall incidence of a symptomatic ovarian cyst in
a premenopausal female being malignant is
approximately 1:1000 increasing to 3:1000 at the age of
50.
green-top guidline #62, RCOG 2011

6.  Pain (acute / chronic).
 Mass
 An incidental finding
 Ascites
 Primary or secondary amenorrhea
 Menstrual irregularities
 Virilization
 Precocious puberty.

7.  Types of benign ovarian tumors varies with age.
 Functional—common in young girls, adolescents and
women in their reproductive years.
 Germ cell tumors—young women
 Benign epithelial tumors—older and post-menopausal
women.

8.  Abdominal and bimanual pelvic examination
may elicit a pelvic/ abdominal mass that may
be tender and will be separate from the uterus.
 In the acute presentation with pain the
diagnosis of accident to the ovarian cyst should
be considered (torsion, rupture, hemorrhage).

9.  Ultrasound scan.
 Pregnancy test, CRP, TLC.
 Tumour markers.
 CT and MRI can.

10. Tumour markers Ovarian tumour type Uses
Ca 125 Epithelial ovarian
cancers(serous),
borderline ovarian
tumours
Pre-operative, F/U
Ca 19-9 Epithelial ovarian
cancers(mucinous), BOT
Pre-operative, F/U
inhibin Granulosa cell tumours Follow up
B-HCG Dysgerminoma,
choriocarcinoma
Pre-operative, F/U
AFP Endodermal yolk sac,
immature teratoma
Pre-operative, F/U
LDH Dysgerminoma Pre-operative, F/U

11.  It is an effective way of triaging patients into low,
moderate, high risk for malignancy, according to
which the referral to a higher Centre and management
protocol will differ.
green-top guidline #62, RCOG 2011

15. Category Examples
Functional • Follicular cyst
• Corpus luteal cyst
• Theca luteal cyst
Inflammatory • Tubo-ovarian abscess
• endometrioma
Germ cell Benign teratoma
Epithelial • Serous cystadenoma
• Mucinous cystadenoma
• Brenner tumor
Sex cord stromal • Fibroma
• thecoma

16. - These are cysts related to ovarian function i.e. the
process of ovulation
- They are the most common detected cysts in the
reproductive age group
- Can be reach up to 10 cm in diameter
- Resolve spontaneously

17.  Cystic follicle is defined as follicular cyst of diameter
>3cm.
 Most common functional cysts.
 Rarely larger than 8cm.
 Lined by granulosa cells.
 Found incidentally on pelvic examination.
 Usually resolve within 4-8weeks with expectatant
management.
 May rupture or torse occasionally causing pain and
peritoneal symptoms.

19.  Less common than follicular cyst.
 May rupture leading to hemoperitoneum and
requiring surgical management (more in pt. taking
anti-coagulants or with bleeding disorder).
 Unruptured cysts may cause pain because of bleeding
into enclosed ovarian cyst cavity.

21.  Least common.
 Usually bilateral.
 Result from overstimulation of ovary by B-HCG.
 Do not commonly occur in normal pregnancy.
 Often associated with hydatidiform moles,
choriocarcinoma, multiple gestations, use of
clomiphene and GnRH analogues.
 May be quite large (up to 30cm), multicystic and
regress spontaneously.

25.  Most common site of involvement is the ovary.
 Endometriomas are pseudocysts formed by
invagination of the ovarian cortex, sealed off by
adhesions.
 They may completely replace normal ovarian tissue.
Cyst walls are usually thick and fibrotic.
 They may be unilocular or multilocular with thin or
thick septations.
 Management: medical and/or surgical.

28.  Serous cystadenoma (epithelial tumour)
 Mucinous cystadenoma (epithelial tumour)
 Dermoid cyst (germ cell tumour)
 Fibroma (sex cord stromal)
 Thecoma (sex cord stromal)
 Brenner’s tumor (epithelial tumour)

29.  Accounts for 20-30% of benign tumours in women
under 40.
 Bilateral- 10%.
 Risk of malignancy: 5-10% borderline malignant
20-25% malignant.
 GROSS: multilocular with papillary components.
 MICRO: low columnar epithelium with cilia.
 Characteristic psammoma bodies(end products of
degeneration of papillary implants) are found.
 Associated fibrosis may lead to “cystadenofibroma”.

31.  Have tendency to become huge masses.
 Round to ovoid masses with smooth capsules that are
usually translucent or bluish to whitish gray.
 Interior divide by discrete septa into loculi containing
clear, viscid fluid.
 Epithelium- tall, pale staining, secretory with basal
nuclei and goblet cells.
 5-10% are malignant.

33.  Most common ovarian tumor in youngs women (20-40yrs).
 The most common form of benign germ cell tumour is the
mature dermoid cyst(cystic teratoma).
 Often bilateral (10%).
 GROSS: hair, bone, cartilage, and a large amount of greasy
sebaceous material.
 MICRO: all the three germ layers (ectoderm, mesoderm,
endoderm).
 Malignant change occurs rare in <2% in women over 40yrs.
 Risk of torsion is 15%.
 An ovarian cystectomy is almost always possible, even if it
appears that only a small amount of ovarian tissue remains.

35.  Most common benign, solid, neoplasm of the ovary.
 Compose approx. 5% of benign ovarian neoplasm and
20% of all solid tumors of the ovary.
 Frequently seen in middle-aged women.
 Characterized by their firmness and resemblance to
myomas.

36.  Misdiagnosed as exophytic fibroids or primary ovarian
malignancy.
 Not hormonally active.
 Meig’s syndrome (ovarian fibromas, ascites and
hydrothorax) is uncommon and usually resolves after
surgical excision.

38.  Estrogen-secreting tumours.
 Often presents after menopause.
 Almost always confined to one ovary.
 Hormonally active and hence associated with
estrogenic or occasionally androgenic effects.
 Rarely malignant.

39.  Uncommon tumor grossly identical to fibroma.
 Small tumours.
 Found incidentally within ovary.
 On microscopy- markedly hyperplastic fibromatous
matrix interspersed with nests of epitheloid cells
showing coffee bean pattern.
 Considered uniformly benign. But scattered reports of
malignant Brenner’s available.
 Endocrinologically inert, but could be ass. with
virilization and endometrial hyperplasia.

41.  Torsion.
 Intracystic hemorrhage.
 Infection.
 Rupture.
 Pseudomyxoma peritonei.
 Malignancy.

43. green-top guidline #62, RCOG 2011

45.  Any solid ovarian lesion.
 Any ovarian lesion with papillary vegetation on the
cyst wall.
 Any adnexal mass >10cm in diameter.
 Palpable adnexal mass in a premenarchal or
postmenopausal women.
 Torsion or rupture suspected.
green-top guidline #62, RCOG 2011

46.  Diagnostic cytology has poor sensitivity to detect
malignancy, ranging from 25% to 82%.
 Not therapeutic, even when a benign mass is aspirated.
 Approx. 25% of cyst will recur within 1 year.
 Aspiration of a malignant mass induce spillage and
seeding of cancer cells into the peritoneal cavity.
green-top guidline #62, RCOG 2011

47.  Laparoscopy vs. laparotomy- decision based on
suspicion of malignancy and technical expertise.
 No RCTs comparing recurrence rate following
laparoscopy or laparotomy.
 The objective is to try cystectomy if possible.
 Laparoscopic surgery for benign ovarian tumor is
associated with less pain, shorter hospital stay, and
fewer adverse events than with laparotomy.
Cochrane database of systematic
reviews 2009

48.  Careful examination of the external surface of the
tumor and sampling of the peritoneal cavity.
 Avoidance of any tumoural rupture.
 Protection of the ovarian tumor with an endoscopic
bag before removal.