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STUDY OF MANAGEMENT OF OVARIAN CYSTS
Dr. Maysaa Fawzi Ali*, Dr. Zainab Falih Ali and Dr. Shatha Khayoon Jasim
1,2,3
M.B.CH.B, D.G.O, IRAQ.
Ovarian cyst accidents include cyst rupture, haemorrhage and torsion.
Torsion commonly occurs to the whole adnexa and is not necessarily
associated with an ovarian cyst. Suspected adnexal torsion should
always be managed with early laparoscopy and detorsion of the twisted
tube or ovary. Ovarian cyst rupture and haemorrhage usually occur in
association with physiological (functional) cysts and are generally self-
limiting. Laparoscopy may be necessary in cases where the diagnosis
is in doubt or for haemodynamic compromise.
Clinical features of ovarian cyst accidents are nonspecific. Ultrasound is the first-line
investigation and is diagnostic in the case of haemorrhage. Typical ultrasound findings have
been described for ovarian torsion, including an enlarged oedematous ovary with peripheral
displacement of follicles. Doppler blood flow findings are variable and not diagnostic.
Recurrent cyst rupture or haemorrhage should be prevented by suppression of ovulation,
usually with the combined oral contraceptive. Fixation of the ovary by a variety of techniques
should be considered to prevent recurrent torsion.
Ovarian cyst ‘accident’ is the term used to refer to any of the three classical complications of
ovarian cysts that present to the emergency gynaecology department. These are ovarian cyst
haemorrhage, rupture and torsion. Historically surgery has been employed either by
laparotomy, or more recently laparoscopy, to facilitate diagnosis and operative management
of the cyst. With the advent of high resolution transvaginal ultrasound (TVS), and advances
in other imaging modalities, an accurate diagnosis can often be made without surgical
intervention and conservative management strategies may be employed in many clinical
situations.
WORLD JOURNAL OF PHARMACY AND PHARMACEUTICAL SCIENCES
SJIF Impact Factor 7.632
Volume 10, Issue 10, 2244-2267 Research Article ISSN 2278 – 4357
*Corresponding Author
Dr. Maysaa Fawzi Ali
M.B.CH.B, D.G.O, IRAQ.
Article Received on
21 August 2021,
Revised on 10 Sept. 2021,
Accepted on 30 Sept. 2021
DOI: 10.20959/wjpps202110-19888
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A good history is often very important in establishing a diagnosis in women presenting with
pelvic pain. TVS is an accurate and reliable tool for detecting and characterising ovarian
tumours, in most cases allowing diagnosis not only of the presence of an ovarian cyst but
generally of the type and nature of the lesion, such that appropriate subsequent management
can be directed. A detailed discussion of this can be found elsewhere in this volume.
The availability of transvaginal ultrasound at the point of initial contact for women with
pelvic pain has been demonstrated to be effective at making a diagnosis. In a study of 1000
women attending an acute gynaecology unit where ultrasound was performed at the initial
assessment, 90 of 399 women were clinically suspected to have a significant ovarian cyst
(greater than 5 cm in diameter), and thiswas confirmed in 31% of the cases by using
ultrasound.1 Importantly, the ultrasound assessment was associated with a significant
reduction in the number of women deemed to need admission (from 37% to 19%) and a
decrease in the need for follow-up examinations as well (from 26% to 18%).
AIM
Ovarian masses are very common in pre- and postmenopausal women and are typically an
incidental finding.
Initial assessment
A thorough history should be taken, with specific attention to:
• Risk factors
–– family history of breast, colon, uterine or ovarian cancer, hereditary ovarian cancer
syndrome (BRCA gene mutation/Lynch syndrome)
• Protective factors
–– parity and breastfeeding (50% reduced risk)
–– combined oral contraceptive pill
• Menopause status
• Symptoms, including those of endometriosis or malignancy (persistent abdominal
distension, change in appetite, pelvic pain, urinary urgency).
A careful examination, including an abdominal and vaginal examination, should be
undertaken and the presence of lymphadenopathy assessed.
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Investigations
Box 1
Investigations for suspected ovarian cyst accidents.
A A urinary pregnancy test must always be performed in women of reproductive age with
abdominal pain.
A Full blood count, urea and electrolytes and possibly liver function and coagulation screen
(depending on the clinical situation) should be taken.
A The white count may be raised in torsion but also with appendicitis, infection and a pelvic
abscess.
A Ca125 should not usually be taken as it is particularly non-specific in the acute setting and
in a woman of reproductive age, being raised with any cause of peritonitis, including
haemorrhage, cyst rupture and infection as well as menstruation, fibroids and endometriosis.
A Urinary infection or calculus should be ruled out by confirming the absence of blood,
nitrites and leucocytes on urine dipstick.
A Triple swabs for infection should be taken if PID is a possible differential diagnosis from
the history and examination.
A Transvaginal ultrasound (TVS) examination (transabdominal in children) should be
arranged preferably at the time of presentation in a dedicated acute gynaecology unit, or as
soon as possible.
A If the adnexae appear normal on TVS then consideration should be given to
transabdominal ultrasound scan to examine the appendix, or CT scan in cases of an acute
abdomen
IMAGING
Ultrasonography
Transvaginal and transabdominal ultrasound views should be obtained.[1,3]
This allows better
differentiation and characterisation of the mass. The only definitive diagnosis of an ovarian
mass is through histology; however, there are typical characteristics of certain structures seen
on an ultrasound. Although ultrasonography is the best mode of imaging we have for
assessment of ovarian pathology, its sensitivity and specificity for the diagnosis of ovarian
cancer is only 86–91% and 68–81% respectively.[3]
The International Ovarian Tumor Analysis (IOTA) Group has developed a list of
characteristics for benign and malignant masses.[1,4,5]
These rules are used in premenopausal
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women; however, similar characteristics are also used in the risk of malignancy index (RMI),
which is discussed later. The IOTA Group rules are defined as benign or B-rules and
malignant or M-rules (Table 1). Any patient with an M-rule should be referred to a
gynaecologist.[4,5]
The presence of ascites has a positive predictive value of 95% for ovarian
cancer.
Sonographic characteristics that have been typically associated with ovarian
malignancy are:
Solid component, often nodular or papillary.
Septations, if present, that are thick (>2 to 3 mm).
Presence of ascites.
Peritoneal masses.
Enlarged lymph nodes.
NB Unilocular cysts with a single (<3mm) thin septum can be considered as simple
Computed tomography and magnetic resonance imaging
Ovarian masses may be seen on computed tomography (CT) and magnetic resonance imaging
(MRI). These are typically incidental findings.
Assessment with ultrasonography is required to further assess the character of the mass.
The use of CT or MRI in the assessment of an ovarian mass does not improve the sensitivity
or specificity obtained through ultrasonography in the detection of ovarian cancer. MRI may
be useful in assessment of large cysts that are difficult to assess on an ultrasound.[1]
Tumour markers
Serum Ca125
Serum Ca125 is a glycoprotein antigen and is the most widely used tumour marker in the
assessment of ovarian masses. In premenopausal women, Ca125 should be measured only if
the ultrasound appearance of a mass raises suspicion of malignancy. It is unreliable in
differentiating malignant from benign, as Ca125 >35 U/ml has a sensitivity and specificity
for ovarian cancer of <80% (potentially as low as 50–60%).[3]
It can also be raised in
conditions such as endometriosis, fibroids, adenomyosis and pelvic infection. If Ca125 is
elevated, consider repeating 4–6 weeks after the initial test.[7]
Rapidly rising levels are more
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likely to be associated with malignancy rather than levels that do not change. Discussion with
a gynaecological oncologist is recommended in patients with a Ca125 >250 U/ml.[1,3]
In postmenopausal women, Ca125 should be measured routinely. Ca125 of >35 U/ml has a
sensitivity of 69–97% and specificity 81–93% for the diagnosis of ovarian cancer.[3]
This
result should then be used in conjunction with ultrasound findings and menopause status in
RMI.
Human epididymis protein 4
Human epididymis protein 4 (HE4) is another tumour marker currently available for the
assessment of ovarian cancer. It has a similar sensitivity as that of Ca125 in comparing
ovarian cancer to healthy controls, but is not elevated in as many common benign
gynaecological conditions. It is used in conjunction with Ca125 in the Risk of Malignancy
Algorithm (ROMA).[8,9]
HE4 can be falsely elevated in patients with impaired renal function,
and can also be elevated in endometrial, primary liver and non-small cell lung cancer.10 The
American, UK and Australian guidelines do not address the usefulness of HE4 or ROMA in
assessing risk for ovarian cancer.
An HE4 level in isolation is difficult to interpret, and its usefulness in a clinical setting is
being reviewed. HE4 is currently used in the USA for monitoring recurrence or progression
of epithelial ovarian cancer.[3,8]
HE4 is not currently covered by Medicare and costs
approximately.[11]
It is not recommended as a screening test for ovarian cancer.
Other biochemical markers
Alpha-feta protein (AFP), human chorionic gonadotropin (hCG) and lactate dehydrogenase
(LDH) are also recommended in women under 40 years who have a complex mass on
ultrasound, as these can be elevated in germ cell tumours.[1,9]
Carcinoembryonic antigen
(CEA) and cancer antigen 19.9 (Ca19.9) are two other tumour markers that are commonly
ordered for the investigation of an ovarian mass; however, their application to clinical
practice is unclear. The usefulness of these tests is not discussed in the UK and Australian
guidelines. They are non-specific and can be elevated in benign and malignant non-
gynaecological conditions. Ca19.[9]
may be useful in the assessment of mature cystic
teratomas; however, its usefulness in differentiating mature cystic teratomas from ovarian
cancer is unclear.[12,13]
CEA seems to be an independent prognostic factor for mucinous
ovarian cancer.[14]
Further investigation is required.
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Risk of malignancy index
The risk of malignancy index (RMI) is the most widely used risk assessment for ovarian
malignancy. Developed in 1990, it uses serum Ca125, menopausal status and findings on
ultrasound (RMI = ultrasound findings x menopause status x Ca125 U/ml). It is particularly
useful in the assessment of postmenopausal women. Moderate risk is a RMI value between
25–200, and RMI >200 is considered high risk. An RMI >200 has a sensitivity of 87% and
specificity of 97% for ovarian cancer and therefore requires urgent assessment by a
gynaecological oncologist (Table 2).[1,6,15]
Ovarian cyst accidents and pregnancy
It was assumed in the past that ovarian cysts in pregnancy were more likely to undergo
torsion or rupture than in non-pregnant women. One study of women with ovarian torsion
found that 13.7% of the 87 women diagnosed with torsion were pregnant.[9]
A recent
retrospective review of women found to have ovarian cysts greater than 4 cm in diameter
found a torsion rate of 15%. However, in a study of 3000 consecutive pregnant women
Condous et al. found 166 cysts in 161 women, and followed them prospectively through
pregnancy. All cysts were managed expectantly initially and five (3%) underwent torsion.
Other prospective studies show a similarly low torsion rate of 0–6%. In conclusion, therefore,
expectant management of ovarian cysts in pregnancy is generally safe and surgery for a cyst
in pregnancy should only be performed for pain or because there is suspicion of malignancy
on ultrasound assessment, rather than because of a presumed risk of torsion or rupture.
The incidence of rupture in women with ovarian hyperstimulation has been reported to be
high, with one series reporting an incidence of 18% for ovarian torsion in 201 cases of
hyperstimulation (more in the pregnant than non-pregnant group).[14]
This however would
seem a higher prevalence of the disorder than is generally seen in gynaecological practice.
Haemorrhage in multiple cysts in a hyperstimulated ovary may also cause pain in such
women (Fig. 6).
Laparoscopic management of ovarian cysts in pregnancy, with trocar sites decided according
to the uterine size and the cyst location has been reported to be successful in many cases.
Although technically possible, laparoscopic surgery for benign teratoma during pregnancy is
associated with a high (93%) perioperative cyst rupture rate.
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MRI is thought to be a safe and accurate tool for diagnosis of pelvic pathology in pregnancy
and may be more appropriate than a CT scan in cases where ultrasound is inconclusive in a
pregnant woman.
Ovarian cyst accidents in children
Young girls presenting with pelvic pain should be considered to have adnexal torsion as a
differential diagnosis. In a large series of 102 girls treated for ovarian pathology in one
institution,
Fig. 6: TVS showing an enlarged hyperstimulated ovary, with haemorrhage within
several of the multiple follicles.
of those presenting with acute abdominal pain (n¼ 59), 25 (42%) had ovarian torsion. In 14,
the torsion was associated with a mature teratoma and only one (2%) had a malignant tumour.
In contrast, of those presenting with an abdominal mass (n¼ 23), six (26%) had malignancies.
There was no age difference between those with benign disease (9.9 _ 5.6 years; n¼ 96) and
those with malignant tumours (8.6_ 3.9 years; n ¼ 10). This highlights the need for those
working in acute gynaecology to be conversant with the features of different types of ovarian
pathology using ultrasonography.
Cass performed an extensive review of the pathophysiology, diagnosis and management of
torsion in children in 2005. Torsion is most common in the perimenarchal and early teenage
age group. It commonly occurs in the absence of ovarian pathology, though an unusually long
utero-ovarian pedicle has been described, which may be familial. The overall prevalence of
pathology in association with torsion is similar to adults. Pathology includes simple cysts,
mature teratoma and hydrosalpinx.
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Malignancy is rare in children as it is in the adult population with torsion, with very few cases
in the reported literature.
As with adult patients, traditional management of torsion involved adnexectomy but
laparoscopic detorsion is effective with similarly good outcomes (87–93%) in terms of
ovarian function as in adults. A review of the pathological specimens removed from children
treated with adnexectomy for torsion found viable ovarian tissue in 61% (38% of those
described operatively as ‘black’) and there was no difference in inflammatory markers such
as temperature and white cell count or time to diagnosis between those with without viable
ovarian tissue.
In cases where an ovarian cyst is suspected to be the cause of torsion, ovarian cystectomy
may be best performed as an interval procedure after repeat ultrasound scan at about 6 weeks
to assess whether a residual cyst exists when the oedema and vascularity associated with the
acute torsion have resolved.
Recurrent torsion in the same or contralateral ovary (‘asynchronous bilateral torsion’) is well
reported. In girls who have undergone adnexal torsion with or without preservation of the
ovary, prophylactic oophoropexy (ovariopexy) of the remaining ovary or ovaries should
therefore be seriously considered (as is performed for testicular torsion) to prevent the
potentially catastrophic consequences of recurrent torsion and loss of fertility if
oophorectomy is performed.
Oophoropexy, or surgical stabilisation of the ovarian tissue, is performed by suturing the
ovary (once de-torted laparoscopically) to the back of the uterus or by one of a variety of
other techniques including plication of the ovarian ligament, or fixation of the ovary to the
pelvic side wall. The techniques for oophoropexy are outlined in the Cass review.There
remains some uncertainty as to the long-term outcome with such a procedure especially in
terms of whether the vascular supply of the ovary might possibly be impaired by the
procedure.
Isolated fallopian tube torsion in the presence of a morphologically normal ipsilateral ovary is
also described and is reported to have been managed with salpingectomy.
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Management
There are three main forms of management– conservative, surveillance and surgical
management. Deciding which is the appropriate management is based on assessment of
symptoms, ultrasound findings, menopausal status, RMI (if applicable) and risk factors. An
approach to management is outlined in Figure 1.
Premenopausal women
Asymptomatic women with a simple ovariancyst <5 cm on ultrasound do not require follow-
up. These simple cysts will resolve within three menstrual cycles. For simple cysts of 5–7 cm,
a repeat ultrasound should be obtained, and for cysts of >7 cm surgical intervention should be
considered. If surgery is required, a laparoscopic cystectomy is the operation of choice, as
aspiration can cause recurrence.[16]
Postmenopausal women
Simple unilateral, unilocular ovarian cysts of <5 cm and low risk of malignancy (normal
Ca125) can be managed conservatively as the RMI would be zero and 50% of these will
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resolve spontaneously in 3 months. Cysts of 2–5 cm should be rescanned in 3–4 months.[18–20]
Women with a moderate-to-high risk RMI should be referred to a gynaecologist or
gynaecological oncologist for consideration of surgical management. In addition, any woman
who does not meet the criteria for conservative management should be offered surgical
management. If malignancy is suspected, an oophorectomy is recommended rather than a
cystectomy. This allows removal of the cyst intact and prevention of spillage into the
peritoneal cavity. A bilateral oophorectomy may be offered for postmenopausal women
because the contralateral ovary may also be affected; however, there are no studies that have
assessed malignancy after unilateral versus bilateral oophorectomy.
Use of the combined oral contraceptive pill
Commencing the combined oral contraceptive (COC) pill does not hasten resolution of
functional ovarian cysts, but can be used to prevent formation of cysts.[22,23]
Complications
Rupture and haemorrhage Ovarian cyst rupture and haemorrhage are essentially physiological
events during the ovarian cycle, involving the follicle or corpus luteum. The theca interna and
the corpus luteum are particularly liable to haemorrhage due to their increased vascularity.
Two-thirds of corpus luteum cysts involve the right ovary and rupture occurs most commonly
on days 20 to 26. The commonest cause of unilateral lower abdominal pain in early
pregnancy is a corpus luteal cyst, often seen with haemorrhage within it (Fig. 2). Women
experience follicular rupture at ovulation to varying degrees, with the term mittelschmerz
(‘middle pain’) used to describe the pain in those women who are aware of the midcycle
release of peritoneal fluid associated with rupture of the normal follicle at ovulation. These
events are so common that they may often not present to the gynaecologist as the symptoms
are not severe and settle spontaneously.
Pain from haemorrhage into a cyst probably occurs due to stretching of the ovarian capsule
and pain from ovarian cyst rupture is from peritoneal irritation. Whether a woman presents
for medical input probably depends on the volume of fluid released into the peritoneal cavity
or degree of haemorrhage into the cyst and her sensitivity to this.
There is no definition of when haemorrhage into a cyst or rupture of a cyst is pathological as
opposed to physiological, though if a cystic lesion is less than 25 mm in mean diameter it is
conventional to term this a follicle, and to use the term ‘cyst’ when the lesion is greater than
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25 mm in mean diameter. The normal size range for a corpus luteum is approximately 20 to
30 mm.[44]
Fig. 2: TVS showing bizarre echoes within an ovarian cyst (‘jelly like’ blood clot to the
left of the image and reticular pattern towards the right), diagnostic of a haemorrhagic
ovarian cyst.
Ovarian torsion
Ovarian torsion involves a partial or complete rotation of the ovary onto its supporting
ligaments, cutting off its blood supply. Presenting symptoms usually include sudden onset
lower abdominal pain, nausea and vomiting with a palpable adnexal mass. The primary risk
factor for ovarian torsion is an ovarian mass >5 cm.24–26 Ovarian torsion is primarily a
clinical diagnosis, but ultrasonography may be useful. One study showed a diagnostic
accuracy of ultrasonography as 74.6%, with abnormal ovarian blood flow and presence of
free fluid as the most diagnostic.
Despite this, ultrasonography is not reliable in excluding an ovarian torsion.26 Suspected
ovarian torsion requires urgent gynaecological review. Surgery usually involves laparoscopy
with de-torsion and ovarian conservation, but an oophorectomy may be performed if the
ovary is not viable. Torsion is most commonly associated with benign conditions.[25,27]
Pregnant women with ovarian cysts
Ovarian masses are usually an incidental finding. The majority of these masses are benign
and can be managed expectantly, as at least 50% resolve spontaneously during pregnancy.28
The reported rate of complications with expectant management is <2%.29 If a cyst is
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identified early on a dating ultrasound, a repeat ultrasound at 12–14 weeks should be
performed to check if it has resolved.29 Operative intervention is indicated if malignancy is
suspected, if there is an acute complication (eg torsion) or if the size is likely to cause
obstetric or other problems. The ideal time of operation is after the first trimester, as this
decreases the miscarriage rate and teratogenicity. The risk of ovarian cancer in pregnant
women who are noted to have a cyst on ultrasound is <1%.29,30.
Screening for ovarian cancer
For the general population, there are currently no national or international guidelines for
screening for ovarian cancer. No investigation to date has been shown to have adequate
sensitivity and specificity as a suitable screening test.
A precursor lesion has yet to be identified. In particular, screening with transvaginal
ultrasound has a high false-positive rate because of its inability to differentiate between
malignant and benign masses. Serum Ca125 can be affected in a number of benign conditions
and is elevated in <50% of women with stage 1 ovarian cancer.6 Women with a very strong
family history of breast and ovarian cancer should be referred for genetic counselling.
Women who are carriers of the BRCA1 mutation have a lifetime risk of ovarian cancer as
high as 60%, and BRCA2 as high as 40%.[6]
Key points
• Ultrasonography (transabdominal and transvaginal) is the main form of imaging in the
assessment of ovarian masses.
• Ca125 can be unreliable in premenopausal women as it can be elevated in a number of
benign conditions; however, it is useful in the assessment of postmenopausal women.
• RMI is used to assess risk of ovarian cancer and is based on menopause status, ultrasound
findings and Ca125 levels.
• Unilateral, simple ovarian cysts that are <5 cm in premenopausal women are likely be
functional cysts and no follow-up is required.
• Ovarian torsion is a clinical diagnosis and requires urgent gynaecological review.
• There is no routine screening for ovarian cancer for the general population.
• If concerned or unsure of management, seeking gynaecological advice is recommended.
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Surgery
Consideration of surgery should be made if the cyst does not meet the criteria for
conservative management. Conservative management may be appropriate in selected cases.
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, although no robust data on size and type of approach to surgery exists.
Complex ovarian cysts (unless thought to be haemorrhagic or corpus luteum).
NB Functional ovarian cysts do not occur in late postmenopausal women.
Postmenopausal simple cysts >5cm. The risk of malignancy is thought to be between 2%
and 9%.
Premenopausal simple cysts >7cm. There is concern regarding accurate assessment of the
cyst wall beyond 7cm. If conservative management is preferred, an MRI of the cyst may
be of value to characterise the cyst wall and exclude complex features.
Symptomatic.
Suspicion of malignancy.
A laparoscopic approach can be used when the risk of malignancy is considered to be low.
Thorough inspection of the peritoneal cavity should be performed and if features suggestive
of malignancy are encountered, a gynaecological oncologist should be consulted regarding
further evaluation and staging.
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.
Laparoscopic specimen retrieval should, where possible, be through the umbilical port. This
technique is associated with less postoperative pain, quicker retrieval time, improved
cosmesis and fewer incisional hernias.
Laparoscopic management of ovarian cysts in postmenopausal women should involve
salpingoophorectomy (usually bilateral) rather than cystectomy. Women should be
counselled preoperatively that if features of malignancy are suspected during laparoscopy,
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then the procedure may have to be abandoned with recourse to a laparotomy under the
oncology team at a later date.
Ovarian cystectomy and preservation of ovarian tissue is preferred when surgery is performed
for benign disease in women wishing to retain their fertility. The risk of oophorectomy, for
example to control bleeding, should be mentioned during consent.
SPECIAL SITUATIONS
Suspected endometrioma
Endometriomas can appear complex on ultrasound and can be associated with a raised CA
125. MRI can be useful when the diagnosis is unclear using ultrasound. Malignant
transformation occurs in 1%, with the majority occurring in cysts over 9cm and in women
over 45 years of age, although it is recommended that histology should be obtained from
endometriomas of greater than 30mm diameter.[16]
Endometriomas should be managed within
the spectrum of endometriosis and influenced by symptomatology. Development of solid
elements should raise concern.[5]
Pregnancy
Incidence- 30% in 1st trimester, of which 90% represent corpus luteum of pregnancy and
resolve spontaneously. The majority can be managed conservatively.
Complications
Torsion
Rupture
Haemorrhage
Malignancy (<1%)
Tumour markers tend to be elevated in pregnancy and are of limited use.
Indications for surgery
Complex cyst- with suspicion of malignancy (not obviously a dermoid cyst)
Increasing size
Symptoms suggestive of torsion, rupture or bleeding
MRI may be useful when evaluating suspicious cysts.
If surgery is necessary, this can be most safely performed early in the second trimester. In
experienced hands a laparoscopic approach appears safe.
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An ovarian cyst diagnosed at the time of caesarean section should be removed (cystectomy or
oophorectomy) rather than aspirated, unless it is obviously functional when it should be left
intact. Consultant involvement is recommended.
Indications for conservative management
Asymptomatic
Simple
Less than 10cm
If the cyst has not increased in size at the detailed 20 week scan, no further scan is necessary
until after delivery
Follow up ultrasound scan 6 weeks postpartum
Patients with suspicious adnexal masses detected during pregnancy should be discussed at the
gynaecological oncology multidisciplinary team meeting.
Follow up of borderline tumours
All decisions should be made following discussion at the Gynaecological Oncology MDT.
Robust data relating to the management of borderline tumours is limited at present, which
needs to be conveyed to the patient during management discussions.
If both ovaries are removed
Stage I - no follow up required as prognosis is excellent (5 year survival- 99%).
Stage II-IV- individualised.
If contra-lateral ovary or both remain (following cystectomy)
Stage I - Risk of recurrence is approximately 40%. Six monthly, ultrasound for 2 years, then
annually (with CA 125, if elevated at presentation (25%)). Patients should be offered removal
of remaining ovarian tissue +/- hysterectomy when family complete.
Stage II - IV - individualised
Follow up of ovarian cancers
See Anglia Cancer Network guidelines
Aspiration of ovarian cysts
This should not be performed routinely since:
Neoplastic cysts will recur
Malignant cysts will be upstaged
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Image guided aspiration can be considered if:
Significant medical co-morbidities contraindicating surgery
The cyst is causing significant symptoms
If a cyst is aspirated, fluid should not be sent for cytology as sensitivity and specificity are so
poor as to render the result meaningless.
MATERIALS AND METHODS
• Data Sources and Search terms
We conducted this review using a comprehensive search of MEDLINE, PubMed, EMBASE,
Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled
Trials from January 1, 1995, through January 1, 2017.
• Data Extraction
Two reviewers independently reviewed studies, abstracted data and resolved disagreements
by consensus. Studies were evaluated for quality. A review protocol was followed
throughout.
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[3]
, while malignant ovarian cysts
frequently do not cause symptoms until they reach an advanced stage.
Pain or anxiety may arise in the lower abdomen. Torsion (twisting) or rupture may lead to
more severe pain. Cyst rupture is characterized by sudden, unilateral, sharp pelvic pain. This
can be allied with trauma, exercise, or coitus. Furthermore, cyst rupture can lead to peritoneal
signs, abdominal distention and bleeding that is commonly self-imited.
RESULTS
Different methods for discriminating between benign and malignant ovarian cysts are
discussed. The diagnosis and the treatment are assessed in relation to age, menopausal status,
pregnancy, and whether the cyst is presumed to be benign or malignant.
In general, expectant management is the choice in premenopausal and pregnant women with
non-suspicious cysts and normal levels of CA-125. In postmenopausal women, unilocular,
anechoic cysts less than 5 cm in diameter together with a normal CA-125 may be followed
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up. Operation is recommended in women with cysts larger than 5 cm and/or elevated levels
of CA-125. Women with symptoms should be operated regardless of age, menopausal status,
or ultrasound findings.
Table I. Features of an ovarian cyst.
Numbers of locules
Presence of solid parts (septum and solid papillary proliferations)
The diameter of the cyst/tumor
Presence of cysts/tumors in the contralateral ovary
Fluid in the pouch of Douglas
Table II. Differences between non-suspicious and suspicious ovarian cysts
Non-suspicious ovarian
cyst
Unilocular cysts without solid parts or papillary
proliferations
Suspicious ovarian cyst At least two locules, mixed cystic solid or solid (more
than 80% solid), bilateral tumor
Table III. Management of ovarian cysts in pre- and perimenopausal and pregnant
women (women are considered perimenopausal in this study if less than 1 year after the
menopause).
Suspicious cysts and solid tumors should be removed surgically
Non-suspicious cyst with a diameter
<4 cm: no reason for follow up
4–7 cm: estimation of CA-125 followed by an ultrasound scan 3 months
later
>7 cm: laparoscopy/laparotomy after determination of CA-125
In pregnancy, surgery before 7 and after 24 weeks of gestation should be
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DISCUSSION
1. Investigation for an ovarian mass includes both transvaginal and transabdominal
ultrasound. Simple, anechoic cysts <5 cm in premenopausal women are likely to be benign
and do not require further follow-up. The use of the cancer antigen 125 (Ca125) tumour
marker can be unreliable in premenopausal women given the low sensitivity for ovarian
cancer; however, it is useful in postmenopausal women.
Ca125 is used in conjunction with ultrasound findings and is used to determine risk of
ovarian cancer through the risk of malignancy index (RMI). Gynaecological oncology
referral is reqired if RMI is >200. Complications of ovarian cysts include cyst rupture and
torsion. Torsion is a gynaecological emergency and requires urgent review.
2. Accurate preoperative discrimination between benign and malignant ovarian cysts remains
difficult despite recent advances in medical imaging.
Reliable prediction of the nature of an ovarian cyst is of crucial importance for treatment.
Preoperative detection of malignancy would allow selective referrals to the appropriate
centers for optimal care, whereas women with benign cysts could be offered more
conservative treatment. The opinion of the affected woman is clearly another important
component when the strategy for management of a unilocular cyst is to be settled. RMI is the
best discriminator between malignant and benign ovarian tumors described in the literature,
but the method has not been subjected to assessment in a randomized trial. However, a
significant problem in previously published data on RMI is the relatively poor performance
of the index in detecting nonepithelial ovarian cancers, borderline ovarian tumors and early-
stage cancers. In a recent study, the RMI was prospectively compared with Tailor’s
regression model, which includes ultrasonographic morphology and transvaginal color
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Doppler imaging of tumor blood flow. The simple RMI performed better than Tailor’s
regression model and better than individual demographic (e.g. age and menopausal status),
ultrasonographic and biochemical parameters. In the future, the incorporation of tumor blood
flow characteristics in risk evaluation models may improve the diagnostic accuracy On the
other hand, used in the daily clinic, pretreatment evaluation should be as simple as possible.
The RMI has proved useful in optimizing referral of patients with malignant tumors to
centralized primary surgery. Women with a RMI below the cut-off level 200, which has
given the best sensitivity and specificity at predicting malignancy, may be operated upon by
laparoscopic surgery if appropriate. Aspiration of cysts should be avoided, but in rare cases in
premenopausal women with several previous abdominal operations and complications, a
symptomatic cyst might be punctured, also as a diagnostic input if the symptoms disappear.
However, in case of malignancy, the woman’s prognosis may have deteriorated to a higher
FIGO stage.
Several studies indicate that oral contraception prescriptions are unlikely to prevent the
development of functional cysts or to hasten their disappearance.
The impact of HRT on ovarian cysts needs further clarification.
The diagnosis of ovarian cancer is still one of the hardest tasks in gynecology, and the search
for optimal diagnostic tools should continue.
Neural network models appear to be encouraging, eventhough at this moment complicated
scoring systems do not perform a better accuracy of the risk assessment for adnexal masses
than the scoring made by the clinicians. The initial reports on proteomic patterns in serum to
identify ovarian cancers seems promising, and in combination with other diagnostic tools
give hope for a more multimodal way of diagnosing ovarian cancer. Hopefully thereby
discrimination between benign and malignant cysts can be improved, to avoid unnecessary
surgery for functional.
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