Benign Ovarian Cysts

Ovarian torsion

Mass + Symptoms of unilateral, intermittent, and then acutely worsening pelvic pain may indicate an

Infectious Etiology (tubo-ovarian abscess)

Mass + A indolent, progressive pelvic pain associated with fevers, chills, vomiting, and vaginal discharge may indicated

Endometrioma

Mass + Acute and chronic dysmenorrhea or pain with intercourse may have an

malignancy

Mass + Persistent bloating, generalized abdominal pain, and early satiety may be signs of

estrogen produced by sex cord-stromal tumors

Mass + Abnormal uterine bleeding or postmenopausal bleeding may be caused by

Vitals (stable/unstable), Lymph nodes, pulmonary, abdominal, and pelvic (visual inspection, bimanual palpation, with rectovaginal examination as indicated)

The physical exam for an adnexal mass should include:

TVUS (most common - assess the size, composition, laterality, presence of septations, mural nodules or free fluid); abdominal is a good back up plan

Imaging for an adnexal mass should include:

CT, MRI, PET

What imaging are we NOT doing for an adnexal mass?

readily available, less expensive 🤑, findings may be discussed immediately

Why is TVUS the go-to?

CA-125 (tumor marker - glycoprotein antigen, elevated in 50% of early disease)

What can be used to help distinguish between benign and malignant masses - especially in post-menopausal patients?

pregnancy, fibroids, ovarian cancer (used to monitor treatment response and 1000s), endometriosis (100s), liver disease, PID

CA-125 can be elevated in conditions such as

follicle has a diameter of at least 3 (presumptive diagnosis is made when a 5-8 cm mass is noted on bimanual)

How do you classify a functional cyst?

pelvic pain, dull sensation, heaviness in the pelvis

Symptoms of a functional cyst

mobile, unilateral, and not associated with ascites

In general a functional cyst is…

Low dose OCPs (suppress gonadotropin levels)

What can be given to prevent the development of an another cyst?

persist for longer than 6 weeks, symptomatic, large cyst 10 or more, you cannot r/o ovarian torsion

When should a cyst be referred to OB/GYN?

Ovarian Torsion

The complete or partial rotation of the ovary on its ligamentous support, that results in the impedance of the blood supply - gyn emergency

ovary rotates around the infundibulopelvic ligament and the utero-ovarian ligament

Mechanism of Torsion

ovarian functional cyst (more likely when 5+ cm)

What is the most likely factor to predispose someone to torsion?

loss of ovarian function, necrosis, hemorrhage, peritonitis

Complications of ovarian torsion

TVUS (shows lack of blood flow, but absence does not exclude), CT scan (1st choice in the ED), MRI

24 y/o female with a PMHx of ovarian cysts presents to the ED for the acute onset of 10/10 lower abdominal pain that comes in waves. She also notes N/V. On physical exam you note tenderness to palpation during the abdominal exam with guarding. As well as unilateral adnexal tenderness on bimanual examination, and presence of a latero-uterine mass. What do you want to order?

Surgery

Treatment plan for ovarian torsion

Dermoid Cyst (benign cystic teratoma)

What is the most common, slow growing ovarian neoplasm and is a type of germ cell tumor composed of sweat and sebaceous glands, hair follicles, and teeth.

Cystectomy or Oophorectomy if symptomatic (check the contralateral side 10-15% are bilateral)

Treatment for Dermoid Cyst

5 cm or less, asymptomatic

When is it okay to observe a dermoid cyst?

hydrosalpinx and pyosalpinx

The most common benign tumors of the fallopian tubes that are infectious or inflammatory

operative exporation

How do you confirm a hydrosalpinx and pyosalpinx?

Salpingectomy

Treatment plan for hydrosalpinx and pyosalpinx

Theca-Lutein Cyst

What type of cyst may develop in with an associated with high levels of hCG in patient with a hydatidiform mole or choriocarcinoma - may be due to gonadotropins or clomiphene (OHSS)

IV fluids, correct electrolytes, Stop medications

Treatment for Theca-Lutein Cyst due to Ovarian Hyperstimulation syndrome (confirmed on TVUS)

Usually bilateral, large (30 cm+), regress slowly after the gonadotropin level falls

What are the characteristics of Theca-Lutein Cyst?

evacuate the uterine content (dilation and curettage), afterwards HCG should regress

If a patient has a molar pregnancy, what is the treatment

NAH FAM

Is the pregnancy test is negative is it a Theca-Lutein Cyst?

Rupture Ovarian Cyst (look for fluid on U/S)

A common occurrence in women of reproductive age that is associated with mild mid-cycle pain (mittelschmerz) pain tends to start AFTER sexual intercourse

Vaginal intercourse, likelihood for ovulation

Risk factors for rupture ovarian cyst

observation, analgesics, rest, Surgery (maybe - but not for prevention)

Management plan for rupture ovarian cyst

Existing ovarian cysts, suspicion of malignancy, hypotension, tachycardia, NOT prevention of cyst rupture

What are the indications for surgery on an adnexal mass?

Urine hCG, CBC with diff, type and cross (peritoneal signs, unstable), STI panel (fever), Pelvic U/S 🥇 (fluid in the pelvis and an adnexal mass)

23 y/o female with a hx of ovarian cyst presents to the ER with sharp RUL pain that occurred suddenly after vaginal intercourse. On physical exam you note RUL tenderness on light palpation. What do you want to order?