Ovarian Cysts in Emergency Medicine Clinical Presentation

  • Author: Walter W Valesky Jr; Chief Editor: Pamela L Dyne, MD   more...
 
Updated: Jul 19, 2010
 

History

  • Most ovarian cysts are asymptomatic and are discovered incidentally during ultrasonography or routine pelvic examination.
    • Most symptomatic ovarian cysts produce a transient dull, vague, unilateral sensation of pelvic pain or heaviness.
    • Some patients may experience tenesmus or dyspareunia.
    • The intermenstrual interval may be prolonged, followed by menorrhagia.[2]
    • Cyst rupture is characterized by sudden, unilateral, sharp pelvic pain. This can be associated with trauma, exercise, or coitus.[3, 7]
    • Cyst rupture can lead to peritoneal signs, abdominal distention, and bleeding that is usually self limited.
    • Theca lutein cysts are commonly bilateral and thus can cause bilateral, dull pelvic pain.[2] Theca lutein cysts may be associated with excess stimulation, as is seen in pregnancy (in particular twins), a large placenta, and diabetes. Newborns may also develop theca lutein cysts due to the effects of maternal gonadotropins. In rare cases, these cysts may develop in the setting of hypothyroidism owing to similarities between the alpha subunit of thyroid-stimulating hormone (TSH) and bhCG.[1, 2]
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Physical

  • Hemorrhage due to cyst rupture may lead to tachycardia and hypotension. Blood pressure monitoring may show orthostatic hypotension.
  • Some complications of ovarian cysts, such as ovarian torsion, may result in hyperpyrexia.[3]
  • Examination reveals moderate-to-severe unilateral or bilateral lower abdominal tenderness in some women with an ovarian cyst.
  • Some complications of ovarian cysts may result in adnexal tenderness or cervical motion tenderness. However, pelvic examination reveals that up to 88% of ovarian cysts are benign.[8]
  • Ovarian cysts may be palpable on abdominal or bimanual examination. An examiner may also palpate large ovaries in a patient with hyperreactio luteinalis.
  • If hemorrhage or peritonitis ensues, the patient may present with a diffusely tender abdomen with rebound tenderness and guarding; in addition, a distended abdomen may be found on abdominal examination.
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Causes

  • Factors that can increase the risk for ovarian cysts include disorders that increase ovarian stimulation, such as gestational trophoblastic disease, multiple gestation pregnancies, and exogenous ovarian stimulation.
  • In pregnant women, ovarian cysts may form in the second trimester, when bhCG levels peak.[2]
  • Because of similarities between the alpha subunit of TSH and bhCG, hypothyroidism may stimulate ovarian and cyst growth.[1]
  • The transplacental effects of maternal gonadotropins may lead to the development of neonatal and fetal ovarian cysts.[9]
  • The risk of functional ovarian cysts is increased with cigarette smoking and possibly increased further with a decreased body mass index (BMI).[10, 11]
  • Functional cysts have been associated with tubal ligation sterilizations.[12]
  • There may be an inverse relationship between ovarian cysts and breast cancer.[13, 14]
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Contributor Information and Disclosures
Author

Walter W Valesky Jr  MD, Clinical Assistant Instructor, Department of Emergency Medicine, State University of New York Downstate, Brooklyn

Disclosure: Nothing to disclose.

Coauthor(s)

Mark A Silverberg, MD, FACEP, MMB  Assistant Professor, Assistant Residency Director, Department of Emergency Medicine, State University of New York Downstate College of Medicine; Consulting Staff, Department of Emergency Medicine, Staten Island University Hospital, Kings County Hospital, University Hospital, State University of New York Downstate at Brooklyn

Mark A Silverberg, MD, FACEP, MMB is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Andrew A Aronson, MD, FACEP  Vice President, Physician Practices, Bravo Health Advanced Care Center; Consulting Staff, Department of Emergency Medicine, Taylor Hospital, Ridley Park, Pennsylvania

Andrew A Aronson, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, Massachusetts Medical Society, and Society of Hospital Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Dana A Stearns, MD  Assistant Director of Undergraduate Education, Department of Emergency Medicine, Massachusetts General Hospital

Dana A Stearns, MD is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Mark Zwanger, MD, MBA  Assistant Professor, Department of Emergency Medicine, Thomas Jefferson University

Mark Zwanger, MD, MBA is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and American Medical Association

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Pamela L Dyne, MD  Professor of Clinical Medicine/Emergency Medicine, David Geffen School of Medicine at UCLA; Attending Physician, Department of Emergency Medicine, Olive View-UCLA Medical Center

Pamela L Dyne, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

References

  1. Katz. Comprehensive Gynecology. 5th ed. 2007.

  2. Stany MP, Hamilton CA. Benign disorders of the ovary. Obstet Gynecol Clin North Am. Jun 2008;35(2):271-84, ix. [Medline].

  3. Bottomley C, Bourne T. Diagnosis and management of ovarian cyst accidents. Best Pract Res Clin Obstet Gynaecol. Mar 17 2009;[Medline].

  4. Schmeler KM, Mayo-Smith WW, Peipert JF, Weitzen S, Manuel MD, Gordinier ME. Adnexal masses in pregnancy: surgery compared with observation. Obstet Gynecol. May 2005;105(5 Pt 1):1098-103. [Medline].

  5. Kwak DW, Sohn YS, Kim SK, Kim IK, Park YW, Kim YH. Clinical experiences of fetal ovarian cyst: diagnosis and consequence. J Korean Med Sci. Aug 2006;21(4):690-4. [Medline].

  6. Glanc P, Salem S, Farine D. Adnexal masses in the pregnant patient: a diagnostic and management challenge. Ultrasound Q. Dec 2008;24(4):225-40. [Medline].

  7. Lambert MJ, Villa M. Gynecologic ultrasound in emergency medicine. Emerg Med Clin North Am. Aug 2004;22(3):683-96. [Medline].

  8. Castillo G, Alcazar JL, Jurado M. Natural history of sonographically detected simple unilocular adnexal cysts in asymptomatic postmenopausal women. Gynecol Oncol. Mar 2004;92(3):965-9. [Medline].

  9. Heling KS, Chaoui R, Kirchmair F, Stadie S, Bollmann R. Fetal ovarian cysts: prenatal diagnosis, management and postnatal outcome. Ultrasound Obstet Gynecol. Jul 2002;20(1):47-50. [Medline].

  10. Wyshak G, Frisch RE, Albright TE, Albright NL, Schiff I. Smoking and cysts of the ovary. Int J Fertil. Nov-Dec 1988;33(6):398-404. [Medline].

  11. Holt VL, Cushing-Haugen KL, Daling JR. Risk of functional ovarian cyst: effects of smoking and marijuana use according to body mass index. Am J Epidemiol. Mar 15 2005;161(6):520-5. [Medline].

  12. Holt VL, Cushing-Haugen KL, Daling JR. Oral contraceptives, tubal sterilization, and functional ovarian cyst risk. Obstet Gynecol. Aug 2003;102(2):252-8. [Medline].

  13. Knight JA, Lesosky M, Blackmore KM, Voigt LF, Holt VL, Bernstein L, et al. Ovarian cysts and breast cancer: results from the Women's Contraceptive and Reproductive Experiences Study. Breast Cancer Res Treat. May 2008;109(1):157-64. [Medline].

  14. Bosetti C, Scotti L, Negri E, Talamini R, Levi F, Franceschi S. Benign ovarian cysts and breast cancer risk. Int J Cancer. Oct 1 2006;119(7):1679-82. [Medline].

  15. McDonald JM, Modesitt SC. The incidental postmenopausal adnexal mass. Clin Obstet Gynecol. Sep 2006;49(3):506-16. [Medline].

  16. Vandermeer FQ, Wong-You-Cheong JJ. Imaging of acute pelvic pain. Clin Obstet Gynecol. Mar 2009;52(1):2-20. [Medline].

  17. Leiserowitz GS. Managing ovarian masses during pregnancy. Obstet Gynecol Surv. Jul 2006;61(7):463-70. [Medline].

  18. Grimes DA, Jones LB, Lopez LM, Schulz KF. Oral contraceptives for functional ovarian cysts. Cochrane Database Syst Rev. Apr 15 2009;CD006134. [Medline].

  19. Giuntoli RL 2nd, Vang RS, Bristow RE. Evaluation and management of adnexal masses during pregnancy. Clin Obstet Gynecol. Sep 2006;49(3):492-505. [Medline].

 
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Theca lutein cysts replacing an ovary in a patient with a molar pregnancy. Despite their size, these cysts are benign and usually resolve after treatment of the underlying disease.
A 24-cm diameter multilocular right ovarian cyst is seen with adjacent fallopian tube and uterus. The infundibulopelvic ligament carrying the ovarian artery and vein has been divided.
Transabdominal sonogram of the cyst in multimedia file 2 demonstrating a large, complex, cystic mass with septations. Color Doppler image shows vascularity within the septations. Red and blue colors show blood flow toward and away from the transducer. The resistive index was low. Histology reported a mucinous cystadenocarcinoma of low malignant potential. Courtesy of Patrick O'Kane, MD.
The cyst in multimedia files 2-3 has been removed and cut open. It has a smooth surface and a multicystic internal structure.
 
 
 
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