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Management of Adnexal Cysts

Sep 2010 – by V. von Gruenigen, MD

A 35 year-old G.P. complains of a constant dull ache in her left lower pelvis over one week. Her medical history and review of systems is not significant. Pelvic exam is suspicious for an enlarged left ovary. An ultrasound reveals a 5 cm simple ovarian cyst.

An ovarian cyst is a sac or pocket filled with fluid that forms on the ovary. It is normal for a small cyst to develop on the ovary every month during the menstrual cycle. Most cysts are harmless and resolve on their own. A woman can develop one or many ovarian cysts which can vary in size.

There are many types of ovarian cysts which can be classified as benign or malignant. Malignant ovarian cysts are rare. The most common benign ovarian cysts are functional and are either follicular or corpus luteum cysts. Follicle cysts form when the follicle does not open to release the egg. Corpus luteum cysts form when the follicle that held the egg seals off after the egg is released. Both of these types of ovarian cysts usually resolve in 6-8 weeks. Other types of benign ovarian cysts include dermoids, cystadenomas and endometriomas.

Most ovarian cysts are small and do not cause symptoms. Some cysts may cause a dull or sharp ache in the pelvis and pain during certain physical activities. Larger cysts may cause torsion or develop hemorrhagic rupture that my lead to surgical intervention.

An ovarian cyst may be diagnosed during a routine pelvic exam and confirmed with a pelvic and transvaginal ultrasound. Unilocular, thin-walled sonolucent cysts with regular borders are usually benign, regardless of menopausal status or cyst size. Ultrasound findings that raise concern of ovarian cancer include a solid component, excrescences, ascites or mural nodules. The value of ordering a CA125 is in distinguishing between benign and malignant adnexal masses in postmenopausal women. CA 125 is not a perfect diagnostic test as it has low specificity. It is frequently elevated in many gynecological conditions such as uterine leiomyomata, endometriosis, pelvic inflammatory disease, ascites of any etiology and other types of inflammatory disease. In premenopausal women with an adnexal cyst a ?-hCG should be routinely ordered to rule out an early pregnancy or an ectopic.

Several treatment options for ovarian cysts are available and include observation, medical management or surgery. Treatment will depend upon the patient symptoms, type and size of the cyst, family history, and the patient's age. If the ovarian cyst is not causing symptoms or is cyclic in pattern, follow up ultrasound is an option as most functional cysts resolve after 1-3 menstrual cycles. For functional cysts, hormonal medications such as oral contraception may be an option to prevent new cysts. If the ovarian cyst is large and causing significant symptoms then surgery may be necessary. Minimally invasive surgery with laparoscopy is favored over an open surgical approach. Ovarian cystectomy is the preferred procedure to preserve ovarian function.