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Ovarian cysts

Summary

Ovarian cysts are fluid-filled sacs within the ovary. The most common types are functional follicular cysts, corpus luteum cysts, and theca lutein cysts, which all develop as part of the menstrual cycle and are usually harmless and resolve on their own. Nonfunctional cysts include chocolate cysts, which are related to endometriosis, dermoid cysts, cystadenomas, and malignant cysts (a type of ovarian cancer). All types can be diagnosed via pelvic ultrasound. While ovarian cysts are usually asymptomatic, complications due to rupture of a cyst can occur and may require treatment. Moreover, individuals with ovarian cysts are at increased risk of ovarian torsion, which requires surgical correction.

Overview

Definition

Ovarian cysts are fluid-filled sacs within the ovary.

Types

Clinical features

Diagnosis

Complications

Treatment

  • In most patients with functional cysts, watchful waiting is recommended, as cysts often regress spontaneously.
  • NSAIDs in the case of painful cysts
  • Surgery in the case of complications, large cysts, or persistent cysts that are painful
  • Treatment of underlying conditions such as PCOS, endometriosis, or ovarian cancer

References:[1][2]

Ruptured ovarian cyst

Etiology [3]

  • Rupture is caused by an increase in intracystic pressure.
  • Most common type of ruptured cyst: corpus luteum cyst [4]
  • Risk factors
    • Vigorous physical activity
    • Vaginal intercourse
    • Large cysts
    • Reproductive age

Clinical features

Diagnostics [5]

Free fluid in the pouch of Douglas in a pregnant patient should raise concern for ruptured ectopic pregnancy (see ''Treatment'' in ectopic pregnancy).

Treatment

  • Hemodynamically unstable patients: emergency exploratory laparoscopy/laparotomy to obtain hemostasis
    • Suturing or cauterization of the ruptured section or cystectomy
    • Consider oophorectomy in intractable hemorrhage
  • Hemodynamically stable patients: conservative management with analgesics and observation (see acute pain management).
    • Consider outpatient treatment in patients with a small hemoperitoneum and no evidence of ongoing hemorrhage on imaging
    • Inpatient management is recommended in patients if there is evidence of significant blood loss and/or ongoing hemorrhage [5]
  • All patients: consider blood transfusion as needed (see blood transfusion)

Differential diagnoses

Acute management checklist for ruptured ovarian cyst

Ovarian torsion

Definition

Etiology

Pathophysiology

Clinical features

Diagnostics

Laboratory studies

Imaging [6][8]

  • Transabdominal/transvaginal pelvic ultrasound with Doppler: imaging modality of choice [13]
  • MRI abdomen and pelvis with contrast [6]
    • Indication: inconclusive findings on ultrasound
    • Supportive findings
      • Enlarged ovary with thickening of the ipsilateral fallopian tube
      • Deviation of the uterus to the ipsilateral side
      • Decreased contrast enhancement of the affected ovary
      • Twisted vascular pedicle (whirlpool sign)
      • Ascites (usually minimal)
  • CT abdomen and pelvis with IV contrast: not routinely recommended [6]

Treatment

Surgery with adnexal detorsion and preservation of ovaries is the mainstay of treatment.

Diagnostic laparoscopy should be performed if there is strong clinical suspicion for ovarian torsion despite inconclusive imaging findings.

Differential diagnoses

Acute management checklist for ovarian torsion [15]

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  • 9. Hasson J, Tsafrir Z, Azem F, et al. Comparison of adnexal torsion between pregnant and nonpregnant women. Am J Obstet Gynecol. 2010; 202(6): pp. 536.e1–536.e6. doi: 10.1016/j.ajog.2009.11.028.
  • 10. Committee on Adolescent Health Care. Adnexal Torsion in Adolescents, ACOG Committee Opinion No. 783. Obstet Gynecol. 2019; 134(2): pp. e56–e63. doi: 10.1097/aog.0000000000003373.
  • 11. Liu YP et al. Sudden onset of right lower quadrant pain after heavy exercise. Am Fam Physician. 2008; 78(3): pp. 379–80, 384. pmid: 18711954.
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  • Lee JK, Bodur S, Guido R. The management of gynecological hemoperitoneum found to be associated with a ruptured corpus luteum cyst. Gynecol Surg. 2016; 13(4): pp. 305–311. doi: 10.1007/s10397-016-0951-7.
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last updated 05/11/2020
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