eMedicine Specialties > Emergency Medicine > Obstetrics & Gynecology

Ovarian Cysts

Author: Kimberly Duklewski Abel, MD, Staff Physician, Department of Emergency Medicine, Franklin Memorial Hospital, Carilion Health System
Coauthor(s): 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: Jun 18, 2007

Introduction

Background

An ovarian cyst is a fluid-filled sac in an ovary. They can be present 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 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, their diagnosis has become more common.

Pathophysiology

From fetal life through a woman's reproductive life, ovarian follicles undergo varying rates of maturation and involution under the guidance of the hypopituitary axis.

Multiple follicles are recruited every month during the proliferative phase of the menstrual cycle. However, only one follicle reaches maturity and produces estrogen, releasing a mature oocyte at mid cycle. The follicular cyst transforms into a corpus luteum following ovulation and produces progesterone until the beginning of the next cycle. In the absence of fertilization of the oocyte, it continues to atrophy.

Follicular dysgenesis occurs with hypothalamic-pituitary dysfunction or because of native anatomic defects in the reproductive system. When follicular development into a corpus luteum is arrested, a luteal ovarian cyst can result.

Two functional ovarian cysts may develop: follicular cysts (ie, graafian follicular cysts) occur in the first 2 weeks of the cycle, and corpus luteal cysts occur in the later half of the cycle. The rupture of the follicular cyst can lead to sharp, severe, unilateral pain of mittelschmerz (occurring mid cycle), and it is experienced by approximately 25% of menstruating women. Similarly, failure of corpus luteum degeneration leads to a luteal cyst formation. These cysts may become inflamed or spontaneously hemorrhage, producing symptoms during the later half of the menstrual cycle.

Carcinomatous processes of the ovary, both primary and metastatic, frequently are complicated by cystic degeneration. The formation of inclusions of the ovary's germinal epithelium may lead to cystic development.

Endometriomas are cysts filled with blood from the ectopic endometrium.

Frequency

United States

Ovarian cysts occur in 50% of females with irregular menses, 30% of females with regular menses, and 6% of postmenopausal women. Ovarian cyst is a frequent diagnosis made in the ED for women with lower abdominal or pelvic pain.

Mortality/Morbidity

Mortality and morbidity are caused by pain from rupture, peritonitis, adnexal torsion, infertility, irregular vaginal bleeding, dysmenorrhea, dyspareunia, and underlying malignancy.

Given that ovarian cancer remains the leading cause of gynecologic cancer – related deaths in the United States, one must maintain a heightened sense of caution when attributing symptoms to the presence of an intact ovarian cyst, as differentiating malignant ovarian cysts from benign ovarian cysts may be difficult.

Race

With the exception of malignant epithelial ovarian cystadenocarcinomas, ovarian cysts are not associated with racial differences. The most frequently affected are those from northern and western Europe and North America. Women from Asia, Africa, and Latin America are affected least frequently.

Age

The domain of ovarian cysts is perinatal to postmenopausal, with a preponderance in the childbearing years. Both premenarchal females and postmenopausal females have increased incidences of malignancies.

Clinical

History

• Ovarian cysts are usually asymptomatic and are often an incidental finding during ultrasonography performed for other reasons.
• Lower abdominal pain is the most common symptom reported, with pain being sharp, intermittent, sudden, and severe.
• A sudden onset of abdominal pain may suggest cyst rupture but more serious etiologies, including adnexal torsion, perforated viscus, ectopic pregnancy, or appendicitis, must be considered.
• Strenuous activities, such as exercise or sexual intercourse, may precede torsion or rupture.
• Nausea and/or vomiting are nonspecific symptoms often associated with any of the above presentations in the differential diagnosis of lower abdominal pain.
• Urinary urgency may occur due to pressure on the bladder.
• Vaginal spotting and irregular menses may occur from decreased estrogen levels and hormonal imbalances.
• Endometriomas can be seen with endometriosis, which causes painful heavy periods and dyspareunia (painful intercourse).

Physical

• Vital signs are usually within reference range. However, a low-grade fever may be observed and tachycardia may exist because of pain or hypovolemia (occasionally orthostatic).
• Patients with cysts complicated with inflammation, necrosis, and bacterial infection or those with hemorrhagic complications may present in florid septic or hypovolemic shock.
• Abdominal tenderness usually is unilateral in a lower quadrant.
• Tenderness ranges from the usual mild-to-moderate tenderness (mainly with cystic rupture) to overt peritonitis (from cystic content rupture or intraperitoneal hemorrhagic, infectious, or purulent processes).
• A pelvic mass may be palpated.
• Cervical motion tenderness may be elicited with an ovarian cyst but is more commonly related to cervicitis or pelvic inflammatory disease.
• In thin premenopausal women, normal ovaries may be palpable during the pelvic examination. However, in postmenopausal women, a palpable ovary should be considered abnormal and a thorough search to exclude a malignancy or a benign tumor is mandated. If a patient is obese, palpating ovaries or even larger cysts is more difficult.
• A rectal examination may reveal localized pain or aid in the palpation of a mass lesion.

Causes

The etiology varies based on the developmental stage of the patient and the hormonal stimulation present. 

• Early menarche
• Infertility (4-fold increase)
• Hypothyroidism
• Patients undergoing ovulation induction therapy for infertility with gonadotropins, such as clomiphene citrate, can develop cysts due to hyperstimulation of the ovary. They have a significantly higher risk of cyst formation and ovarian torsion.
• Neonatal cysts (increased frequency in babies of mothers with diabetes, toxemia, and Rh immunization)
• Risk factors for ovarian cystadenocarcinoma include family history, history of breast cancer, advancing age, infertility, and nulliparity.
• Tamoxifen treatment of breast cancer is associated with a 10% increase in the incidence of cysts. These most often resolve following treatment discontinuation.
• Smoking is a controversial risk factor.

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