Overview, types and management of various ovarian masses and cysts

1. OVARIAN CYSTS & MASSES
PRESENTER: DR BWALYA MUBANGA
SUPERVISOR: DR MUBIANA

2. CLASSIFICATION
A. Non-neoplastic conditions
i) Functional cysts: Follicular cysts, Corpus luteum cysts
These cysts are confined to the reproductive years and those not using
hormonal contraception
ii) Pathological cysts: Demoid, cystadenoma and endometriomas
B. Neoplastic conditions

3. OVARIAN CYSTS
- It is normal for women to develop a small blister-like growth filled
with fluid or semisolid tissue either inside the ovary or on its
surface.
- Ovarian cysts are pockets or sacs filled with fluid in an ovary or on
its surface
- The term “cyst” is descriptive, it is not a diagnosis because are many
causes for cysts on the ovary.
- Ovarian cysts are usually small-sized structures that rarely present
any symptoms and usually resolve on their own.

4. TYPES OF OVARIAN CYSTS
1. FUNCTIONAL CYSTS
- Most common type
- develop routinely as part of monthly growth and ovulation during menstrual
cycle and disappear in a matter of 2–8 weeks without any treatment.
a. Follicular cyst
- usually start from a follicle, a cyst-like structure that produces egg cells.
- Normally, a mature follicle, or sac, breaks open to release an egg. After the
egg is released, the follicle dissolves and becomes a corpus luteum, which
produces oestrogen and progesterone.
- An ovarian cyst forms when the follicle, or corpus luteum, has a defect that
causes it to accumulate liquid and thus form a cyst.

5. b. Corpus luteum cyst
• Corpus luteum: tissue that remains after ovulation. It produces the
hormone progesterone.
• Fluid can accumulate in the corpus luteum leading to the cyst. In
some women, bleeding into the ovary after ovulation results in a
hemorrhagic cyst.
• Sometimes, the follicle may fail to ovulate. The egg remains in the
ovary, and the corpus luteum produces progesterone. This type of
cyst is called a luteinized unruptured follicle. These types of cysts
are also categorized as functional cysts.
• Both these cysts result from a functional process rather than a
disease process and are benign.

6. 2. PATHOLOGICAL CYST
- menstrual cycle has no involvement
- results from excessive growth of ovarian cells and can occur both
inside or outside the ovaries.
a. Dermoid cysts
- also known as cystic teratomas, are the most common in women in
the reproductive age (below 30 years).
- made up of those ovarian cells that are used to form the ova
- may also contain traces of hair, dermal tissue, fat, teeth, or bone
within it.
Despite the threatening appearance, these cysts are usually benign but
can become quite large and typically require surgical removal.

7. b. Cystadenoma
- differ from dermoid cysts both in terms of their composition and
location.
- largely benign tumors that develop from the abnormal growth of those
ovarian cells that cover the surface epithelium of the ovaries.
- relatively bigger than regular teratomas and can grow large enough to
obstruct blood flow to the ovaries.
- On average, cystadenoma tends to be at least 10 cm wide but can
expand to a much greater size. These cysts tend to have a smooth
outer and inner surface and are usually filled with a translucent and
runny substance.
- Women above the age of 40 are more prone to developing
cystadenomas.
- These cysts require surgical removal.

8. c. Endometriomas
- Caused by endometriosis, a medical condition where uterine
endometrial tissue, tissue similar to the lining of the uterus, grows
outside of the uterus.
- Referred to as “chocolate cysts” due to the colour of blood found
within the cysts.
Note: most pathological cysts are noncancerous, but the risk of
malignancy is possible and therefore cannot be completely ruled out.
Pathological cysts can affect women of all ages, both reproductive and
post-menopausal women.

9. RISK FACTORS
- Hormonal imbalance, or other hormonal issues
- Pregnancy (a cyst that persists on the ovary even after ovulation)
- Endometriosis
- Polycystic ovary syndrome (PCOS)
- Severe pelvic infection
- Smoking
- Hypothyroidism
- Previous ovarian cyst
Note that having any of these risk factors does not mean that you will
develop one

10. CAUSES
1. Hormonal issues
- hormonal dysfunction or imbalance in the female body.
- Women who face fertility problems and taking hormone-based
medicines to stimulate ovulation are particularly prone to this type
of cyst formation.
2. Pregnancy
It is normal for a woman to develop an ovarian cyst soon after
conceiving, which serves the purpose of supporting the embryo until
the placenta forms. It is also common for childbearing women to
retain the ovarian cyst formed during their last phase of ovulation
throughout the course of their pregnancy.

11. 3. Endometriosis
- Ovaries are often affected by this kind of endometrial tissue growth, which
results in the formation of cyst-like mass that is prone to bleeding.
- This brown-colored cyst is known as endometrioma, or chocolate cyst in
more general terms.
4. Pelvic infections
- Pelvic infection can spread to the ovaries, resulting in the formation of cysts
called ovarian abscesses, which are purulent, or pus-filled, cysts.
5. Polycystic ovary syndrome (PCOS)
- Common hormonal disorder afflicting up to 20% of women all over the
world.
- Characterized by the development of multiple tiny cysts in and on the
ovaries. It is a common cause of female infertility.

12. SIGNS & SYMPTOMS

13. DIAGNOSIS
• History and Clinical examination
• Ultrasound : to determine the exact location and size of the cyst and to see
if it is a solid mass or a fluid-containing cyst.
• CT scan: not good at evaluating cyst, however, good in presence of ascites
• MRI: to analyze ovarian growth in greater detail.
• Pregnancy test: to check if the cyst is the outcome of early-stage gestation

14. • Hormonal profile: to identify possible hormonal factors that may
contribute to the occurrence of ovarian cysts.
• Blood tests: to evaluate the level of CA 125, a substance which, if
found in higher levels, can signal the risk of cancer, especially in
post-menopausal women. The CA-125 test can also be increased in
benign conditions associated with ovarian cysts (endometriosis and
pelvic infections)
• Biopsy: a sample of the ovarian tissue is tested for the presence of
cancer cells.

15. COMPLICATIONS OF OVARIAN CYSTS
1. Malignancy
- Functional ovarian cysts and benign ovarian tumors do not become
cancerous.
- However, differentiating a cancerous cyst from a functional cyst or
benign tumor is difficult in some cases.
Physical examination, blood tests, ultrasounds, X-rays, and MRIs are all
descriptive, not diagnostic. These tests help estimate the risk of an
ovarian cyst being cancer. However, if concerned about cancer, surgical
biopsy is the only definitive test to either prove or disprove cancer.
Postmenopausal women are more likely to have ovarian cancer as a
cause of an ovarian cyst.

16. 2. Ruptured cyst
- Although development of ovarian cysts should rarely be a cause of concern,
sometimes they can grow to a large size and even rupture, leading to pain,
internal bleeding, and other discomforts.
3. Ovarian torsion (adnexal torsion)
- Rare but very dangerous, cause the ovary to twist around its blood supply
resulting in pelvic pain, acute hemorrhage, nausea and vomiting, dizziness,
lower back pain, and groin pain.
- Once diagnosed, often by pelvic ultrasound, surgery may allow preservation
of the tube and/or ovary.
4. Infertility
If the cyst is endometrioma or chocolate cyst, fertility is significantly
compromised by the presence of chocolate cysts

17. TREATMENT OF OVARIAN CYSTS
Watchful waiting
- recommended in most cases and then re-examining to check as most
of the cysts go away on their own.
- preferred when one is not showing any symptoms and the diagnostic
exam showed a small and simple fluid-filled cyst.
- However, follow-up pelvic ultrasound is necessary for making sure
that the cyst is not changing in size.
Medication
- Some hormonal contraceptives such as COCs might be prescribed to
prevent recurrence. However, these pills won’t do anything for
shrinking existing cysts.

18. Surgery
- Usually Laparotomy
- If the cyst is large, is growing, causing pain, continues for more than
3 menstrual cycles, and doesn’t look like a functional cyst, surgical
removal might be recommended.
- Ovarian cystectomy where the cyst is removed without the removal
of the ovary. In some cases, the affected ovary might be removed
and leave the other just as it is. This procedure is called
oophorectomy.
If a cyst is cancerous, radiation or chemotherapy and total
hysterectomy are other options

19. SURGICAL MANAGEMENT
• Laparoscopy – up to 12cm
• Laparotomy
• Cystectomy – if confident not malignant
• Hysterectomy – if malignant
• Unilateral oophorectomy
• Bilateral oophorectomy

20. Ovarian
cyst
Simple
<5cm
No FU
5-7cm
Rescan 3/12
>7cm
Refer
Complex
<3cm
No FU
3-5cm
Re scan
3/12
>5cm
Refer
Premenopausal

21. Ovarian cyst
Simple
<3cm
Re scan
3/12
>5cm
Refer
Complex
<3cm
Re scan
3/12
>3cm
Refer
With ascites
Urgent
Referal
Post Menopausal

22. OVARIAN TUMORS
Risk factors
1. Nulliparity: Higher frequency of carcinoma in unmarried women and
in married women with low parity.
2. Family history: 5-10% of ovarian cancers are familial. Two genes
may be altered in susceptible families (i.e., ovarian cancer genes).
Mutations in both BRCA1 and BRCA2 increase susceptibility to
ovarian cancer.
The estimated risk of ovarian cancer in women bearing BRCA1 or
BRCA2 is 16% by the age of 70 years.
Prolonged use of oral contraceptives reduce the risk of developing
ovarian cancer
3. Early Menarche and late menopause
4. Personal history: colon, endometrial, breast cancer

23. OVARIAN NEOPLASMS
• Types
• Epithelial
• Stromal
• Germ cell
• Metastatic
• Behaviour
• Benign / borderline malignancy / malignant

24. ULTRASOUND CRITERIA: MOST LIKELY BENIGN
• Unilocular
• Thin walled
• Smooth walls
• Echo free contents
• Unilateral
• Usually <8cm in diameter

25. ULTRASOUND CRITERIA FOR POTENTIALLY
MALIGNANT
• Solid / semicystic
• Multilocular
• Thick walled
• Papillary growths on walls of cysts and tumour
• Bilateral
• Ascites

26. MANAGEMENT
• Principle: surgery followed by chemotherapy
• Operations
• Staging laparotomy: for confined disease: TAH BSO
omentectomy, nodes and ascites
• Cytoreduction: for intraperitoneal spread: aim to do same and
not leave tumour larger than 1cm behind
• Interval cytoreduction: apparently inoperable: biopsy and
chemotherapy, then surgery

27. References
1. RCOG
2. Pubmed
3. Medscape
4. Medline