This document discusses ovarian cysts including their types, clinical presentation, diagnosis, and management. It covers the normal sizes of ovaries at different ages, types of benign cysts such as functional, inflammatory, and epithelial cysts. Diagnosis involves physical exam, ultrasound, and tumor markers. Small unilateral cysts without solid areas can often be observed. Suspicious cysts require surgery. Laparoscopy is preferred when possible for removal of benign cysts.

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.