Ovarian masses are a frequent finding in general gynecology, and most are cystic (Fig. 10-1). Histologically, ovarian cysts are often divided into those derived from neoplastic growth, ovarian cystic neoplasms, and those created by disruption of normal ovulation, functional ovarian cysts. Differentiation of these is not always clinically apparent using either imaging or tumor markers. Thus, ovarian cysts are often managed as a single composite clinical entity, and the next sections describe this general approach. Later sections discuss discrete pathologies.
Intraoperative photograph of a large benign mucinous cystadenoma. The fimbriated end of the fallopian tube is seen below the ovary, and the uterus lies at the lower right. (Reproduced with permission from Dr. Eddie McCord.)
The exact mechanisms leading to cyst formation are unclear. Angiogenesis is an essential component of both the follicular and luteal phases of the ovarian cycle. It is also a component of various pathologic ovarian processes. Some include follicular cyst formation, polycystic ovarian syndrome (PCOS), ovarian hyperstimulation syndrome, and benign and malignant ovarian neoplasms.
The incidence of ovarian cysts varies only slightly with patient demographics and ranges from 5 to 15 percent (Dorum, 2005; Millar, 1993). Functional ovarian cysts make up a large portion. Neoplasms constitute most of the remainder, and these predominantly are benign. In their review of U.S. inpatient hospitalizations for 2010, Whiteman and colleagues (2010) reported that approximately 7 percent of gynecologic admissions were for benign ovarian cysts.
Management goals include identifying malignancy and treating symptoms while preserving ovarian function when possible and minimizing overtreatment. However, despite continuous improvement in diagnostic methods, it is often impossible to clinically differentiate between benign and malignant conditions. Thus, management must balance the surgical morbidity from excision of an innocent lesion with the risk of not removing an ovarian malignancy.
Most women with ovarian cysts are asymptomatic. If symptoms develop, pain is common. Dysmenorrhea may indicate endometriosis and an associated endometrioma. Intermittent or acute severe pain with vomiting often accompanies torsion. Other causes of acute pain include cyst rupture or tuboovarian abscess. In contrast, pressure or ache may be the sole symptom and can result from ovarian capsule stretching or cyst bulk. In ovarian malignancies, diagnosis depends on providers having a high index of suspicion in symptomatic women (Schorge, 2010). In some affected individuals, evidence of hormonal disruption is found. For example, excess estrogen production from granulosa cell stimulation may disrupt normal menstruation or initiate bleeding even in prepubertal or postmenopausal patients. Increased androgen levels produced by theca cell stimulation can virilize women.
Many ovarian cysts are asymptomatic and found incidentally on routine pelvic examination or during imaging ...