Benign Ovarian Pathology

Adnexal Mass Evaluation

Patient history is important, document all findings including location, shape, ultrasound appearance, and measurements in sag, trv, and AP.

Cyst Characteristics

Smooth well-defined borders, lack of internal echoes, and posterior enhancement.

Cyst Size and Management

< 3 cm usually resolves (follicular), 3 - 5 cm followed by US most resolve, but some enlarge, > 5 cm followed by US 60% resolve in 3 months, and > 10 cm rarely resolve (have more malignant potential; are surgically removed).

Physiologic Cysts

Ovarian follicles, Follicular cysts, Corpus luteum cysts, Hemorrhagic cysts, and Theca lutein cysts.

Ovarian Follicles Characteristics

Located on both ovaries, small anechoic structures, usually multiple, dominant follicle reaches 2.0-2.5 cm before ovulation occurs.

Follicular Cysts Characteristics

Over distension of a Graafian follicle that did not rupture or follicle that did not resolve, usually unilateral, 1.0 - 10.0 cm in size, follow up may be ordered, most resolve or change in size.

Corpus Luteum Cysts Characteristics (Menstruation)

Corpora lutea forms after dominant follicle ruptures, usually unilateral and simple, hemorrhage and rupture may cause pain, usually resolves within 14 days.

Corpus Luteum Cysts Characteristics (Pregnancy)

Remains if fertilization occurs, holds the pregnancy, produces progesterone, resolves between 10 and 16 weeks from LMP, rupture may cause pain.

Hemorrhagic Cysts Characteristics

Internal hemorrhage may occur in follicular cysts or, more commonly, in corpus luteal cysts; patient may present with acute onset of pelvic pain.

Peritoneal Inclusion Cysts

Not true cyst but peritoneal or ovarian fluid trapped by peritoneal adhesions.

Theca Lutein Cysts Characteristics

Caused by high levels if human chorionic gonadotropin, associated with gestational trophoblastic disease plus drug therapy for infertility, are bilateral, multilocular, and large (3-20 cm), may persist 2-4 months after evacuation of molar pregnancy.

Paraovarian Cysts Characteristics

Found in broad ligament, difficult to determine if ovarian or paraovarian, can be small up to 15 cm, does not regress or change with time, can be complicated by hemorrhage, torsion, rupture or infection. Differential diagnoses: Serous cystadenoma and Endometrioma.

Ovarian Torsion

Complete or incomplete rotation of ovary on its vascular pedicle, causes arterial, venous, or lymphatic occlusion, may cause congestion of parenchyma and ensuing hemorrhagic infarction, on ultrasound, may appear as a large ovary with hypoechoic and hyperechoic areas.

Ovarian Torsion (Occurrence & Symptoms)

Most common in childhood or women < 30 years of age. Signs and Symptoms: Acute onset of pelvic pain, Nausea, Vomiting.

Polycystic Ovaries (Signs and Symptoms)

Obesity, menstrual abnormalities (oligomenorrhea/ amenorrhea), virulization with hirsutism, infertility.

Polycystic Ovaries (Characteristics)

Endocrine disorder, high free serum testosterone, abnormal levels LH & FSH. Ultrasound appearance: Normal ovaries or bilaterally enlarged ovaries with multiple small follicles around periphery.

Ovarian Hyperstimulation Syndrome

A complication of ovulation induction. May be mild, moderate, and severe. With severe hyperstimulation, patient has severe pelvic pain, abdominal distention, and notably enlarged ovaries, measuring >10 cm in diameter. Associated ascites, pleural effusions, numerous large, thin-walled cysts throughout periphery of ovary.

Benign Ovarian Neoplasms

Growth of new tissue; 80% of all ovarian neoplasms are benign

Epithelial Neoplasms Types

Serous cystadenoma, Mucinous cystadenoma, Brenner tumor

Serous Cystadenoma Characteristics

More common than mucinous cystadenoma (not as large), contain serous fluid, bilateral 25% of time, usually unilocular, may have septations (thin) and papillary projections. Malignant counterpart: serous cystadenocarcinoma.

Mucinous Cystadenoma Characteristics

Larger than serous cystadenoma (up to 15-30 cm), filled with thick mucin, bilateral in < 5% of cases, cystic with multiple thicker septations, debris filled. With rupture---Pseudomyxoma Peritonei.

Brenner Tumor Characteristics

Not common (1 - 2% of all ovarian neoplasms), solid firm tumor, on US, may see solid echogenic or hypoechoic mass with anechoic spaces, small to 8 cm in size, most common in post menopausal patient, US unable to differentiate between other solid ovarian tumors.

Benign Cystic Teratoma (Occurrence)

Common germ cell tumors, most common in premenopausal women & ovarian tumor for women less than 20 years of age and have little malignant potential

Benign Cystic Teratoma (Characteristics)

Bilateral in 10-15% of patients, more than half measure 5-10 cm (can measure up to 40 cm), may contain teeth, hair, glandular tissue or thyroid tissue and connected to ovary by pedicle (can twist).

Benign Cystic Teratoma (Ultrasound Appearance)

Complex with internal echoes and posterior acoustic shadowing, tip of the iceberg sign, unilocular or multilocular cyst with internal echoes or mural echogenic projections, echogenic mass with acoustic shadowing, fat/fluid or hair/fluid level, echo poor mass with echogenic or echo poor central portion, dermoid plug, dermoid mesh.

Stromal Tumors

Fibroma, Thecoma, Granulosa cell tumor, Sertoli- Leydig

Fibroma Characteristics

5 % of ovarian tumors, more common in 50’ s or 60 ‘s, 90% unilateral, 5-16 cm in size, solid and hypoechoic - often shadow posteriorly; the most common tumor associated with Meigs’ syndrome.

Meigs’ Syndrome Definition

Benign ovarian tumor (fibroma), ascites, and pleural effusion. Symptoms subside after tumor removal.

Thecoma Characteristics

Estrogen producing, most common in post menopausal patients with abnormal uterine bleeding, may be large (up to 30 cm), unilateral and hypoechoic, may cast large shadow posteriorly.

Granulosa-Theca Cell Tumor

Most common in postmenopausal patients, abnormal uterine bleeding (estrogen), associated with endometrial hyperplasia or carcinoma, unilateral, solid and homogeneous.

Sertoli-Leydig Cell Tumor

Rare, less than .5% of ovarian tumors, most occur in patient < 30 years, secrete androgens. Signs and Symptoms: Pain, abdominal swelling and masculinization effects due to increased testosterone. US appearance: solid echogenic mass.