eMedicine Specialties > Emergency Medicine > Obstetrics & Gynecology

Ovarian Cysts

Author: Walter W Valesky Jr, MD, Clinical Assistant Instructor, Department of Emergency Medicine, State University of New York Downstate, Brooklyn
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; Andrew A Aronson, MD, Assistant Professor of Emergency Medicine, Drexel University School of Medicine; Consulting Staff, Department of Emergency Medicine, Allegheny General Hospital
Contributor Information and Disclosures

Updated: Aug 11, 2009

Introduction

Background

An ovarian cyst is a fluid-filled sac in an ovary. They can develop from the neonatal period to postmenopause. Most ovarian cysts occur during infancy and adolescence, which are hormonally active periods of development. Most are functional in nature and resolve with minimal treatment. However, ovarian cysts can herald an underlying malignant process or, possibly, distract the emergency clinician from a more dangerous condition, such as ectopic pregnancy, ovarian torsion, or appendicitis. When ovarian cysts are large, persistent, or painful, surgery may be required, sometimes resulting in removal of the ovary. With the more frequent use of ultrasonography in recent years, the diagnosis of ovarian cysts has become more common.

Abdominal pain in the female can be one of the most difficult cases to diagnose correctly in the emergency department (ED). The spectrum of gynecological disease is broad, spanning all age ranges and representing various degrees of severity, from benign cysts that eventually resolve on their own to ruptured ectopic pregnancy that causes life-threatening hemorrhage.

When presented with this scenario, the goal of the emergency physician is to rule out acute causes of abdominal pain associated with high morbidity and mortality, such as appendicitis or ectopic pregnancy, to assess for the possibility of neoplasm or malignancy, and either to refer the patient to the appropriate consultant or to discharge them with a clear plan for follow-up with an obstetrician/gynecologist.

Pathophysiology

The median menstrual cycle lasts 28 days, beginning with the first day of menstrual bleeding and ending just before the subsequent menstrual period. The variable first half of this cycle is termed the follicular phase and is characterized by increasing follicle-stimulating hormone (FSH) production, leading to the selection of a dominant follicle that is primed for release from the ovary. In a normally functioning ovary, simultaneous estrogen production from the dominant follicle leads to a surge of leuteinizing hormone (LH), resulting in ovulation and release of the dominant follicle from the ovary and commencing the leuteinizing phase of ovulation.

After ovulation, the follicular remnants form a corpus luteum, which produces progesterone. This, in turn, supports the released ovum and inhibits FSH and LH production. As luteal degeneration occurs in the absence of pregnancy, the progesterone levels decline, while the FSH and LH levels begin to rise before the onset of the next menstrual period.

Different kinds of functional ovarian cysts can form during this cycle. In the follicular phase, follicular cysts may result from a lack of physiological release of the ovum due to excessive FSH stimulation or lack of the normal LH surge at mid cycle just before ovulation. Hormonal stimulation causes these cysts to continue to grow. Follicular cysts are typically larger than 2.5 cm in diameter and manifest as pelvic discomfort and heaviness. Granulosa cells that line the follicle may also persist, leading to excess estradiol production, which, in turn, leads to decreased frequency of menstruation and menorrhagia.¹

In the absence of pregnancy, the lifespan of the corpus luteum is 14 days. If the ovum is fertilized, the corpus luteum continues to secrete progesterone for 5-9 weeks until its eventual dissolution in 14 weeks time, when the cyst undergoes central hemorrhage. Failure of dissolution to occur may result in a corpus luteal cyst, which is arbitrarily defined as a corpus luteum that grows to 3 cm in diameter. The cyst can cause dull, unilateral pelvic pain and may be complicated by rupture, which causes acute pain and possibly massive blood loss.

Theca lutein cysts are caused by luteinization and hypertrophy of the theca interna cell layer in response to excessive stimulation of beta-human chorionic gonadotropin (bhCG). This type of cyst can occur in the setting of gestational trophoblastic disease, multiple gestation, or exogenous ovarian hyperstimulation. These cysts are associated with maternal androgen excess in up to 30% of cases but usually resolve spontaneously as the bhCG level falls. Theca lutein cysts are usually bilateral and result in massive ovarian enlargement, a condition termed hyperreactio luteinalis.²

Frequency

United States

Ovarian cysts are extremely prevalent, affecting an estimated 7% of premenopausal and postmenopausal woman. Furthermore, up to 4% of women will be admitted to the hospital with a primary diagnosis of ovarian cysts³ ; 1%-4% of pregnant women are diagnosed with an adnexal mass, with ovarian cysts accounting for most.⁴ Ovarian cysts are the most common fetal and infant tumor, with a prevalence exceeding 30%.⁵

Mortality/Morbidity

• Ovarian cysts can result in pain and other morbidity, including menorrhagia, an increased intermenstrual interval, dysmenorrhea, pelvic discomfort, and abdominal distention.
• Approximately 3% of theca lutein cysts are complicated by torsion or hemorrhage, and approximately 30% of these cysts can cause maternal androgen excess.²
• Follicular cysts can cause excess estradiol production, leading to metrorrhagia and menorrhagia.
• Ovarian cysts, and more specifically corpus luteal cysts, can rupture, causing hemoperitoneum, hypotension, and peritonitis. This can be exacerbated in women with bleeding dyscrasias, such as those with von Willebrand disease and those receiving anticoagulation therapy.
• Ovarian torsion can complicate ovarian cysts and can result in ovarian infarction, necrosis, infertility, premature ovarian menopause, and preterm labor.⁶

Race

No racial discrepancies regarding ovarian cysts are reported in the literature. This disease affects all racial groups.

Age

Ovarian cysts affect all age ranges of females, from those in utero to postmenopausal women. Even benign-appearing ovarian cysts in postmenopausal patients may require aggressive treatment owing to the increased risk of malignancy in this population.

Clinical

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

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.

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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