eMedicine Specialties > Emergency Medicine > Obstetrics & Gynecology

Ovarian Cysts

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

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

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.

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

Differential Diagnoses

Other Problems to Be Considered

During the ED workup, it is imperative that life-threatening or causes of abdominal and/or pelvic pain associated with high morbidity be excluded before ovarian cyst is diagnosed. This includes ruling out emergent female gynecological and urological symptoms such as ectopic pregnancy, ovarian torsion, or even tubo-ovarian abscess and abdominal causes of lower abdominal pain such as appendicitis.

After etiologies of acute abdominal pain are ruled out, the physician's primary concern is to assess whether the pain or pelvic mass reflects a possible neoplastic etiology, which must be assessed further by a gynecologist in the ED or in an outpatient setting in an appropriate time frame.

Workup

Laboratory Studies

• A urinary pregnancy test should always be performed in all women of childbearing age with abdominal pain or similar complaints.
• A complete blood cell (CBC) count should be obtained, focusing on the hematocrit and hemoglobin levels to evaluate for anemia caused by acute bleeding. The white blood cell (WBC) count may be elevated, not only in complications of ovarian cyst, especially torsion, but also in infectious abdominal pathologic conditions such as appendicitis.
• Urinalysis should be obtained to rule out other possible causes of abdominal or pelvic pain, such as urinary tract infections or kidney stone.
• If pelvic inflammatory disease is among the differential diagnoses, endocervical swabs should be obtained to assess for chlamydia and gonorrhea.
• A type and screen with Rh status should be obtained in all pregnant patients with vaginal bleeding in the ED to screen for potential isoimmunization. Patients who are Rh-negative should be given anti-RhD immunoglobulin G (IgG) within 72 hours to prevent Rh disease in subsequent pregnancies.³
• CA-125 should not be drawn in pregnant patients with ovarian cysts or in the acute setting with ovarian cyst accidents, as this marker is raised in peritonitis, hemorrhage, cyst rupture, and infection, as well as in menstruation, fibroids, and endometriosis. It is prudent to draw this marker in the postmenopausal patient for workup of an ovarian cyst and for distinction from an ovarian neoplasm, along with ultrasonography.^3,15

Imaging Studies

• Ultrasonography
  • Ultrasonography is the most favored imaging modality to assess ovarian cysts. Transabdominal ultrasonography allows for a better overall view of the abdomen and pelvis in visualizing large ovarian masses and their subsequent complications, such as hydronephrosis or free fluid. It is best performed with a full bladder to use as an acoustic window in order to better visualize structures. Transvaginal ultrasonography with a higher-frequency probe allows better resolution of the ovary than a transabdominal lower-frequency probe.
  • A normal ovary is 2.5-5 cm long, 1.5-3 cm wide, and 0.6-1.5 cm thick. In the follicular phase, several follicles are usually visible within the ovarian tissue.
  • On a sonogram, ovarian cysts have a thin rounded wall and a unilocular appearance that is either hypoechoic or anechoic. They usually measure 2.5-15 cm in diameter, and posterior acoustic enhancement (a hyperechoic area) may be visible deep to the fluid-filled cyst.⁷
  • The corpus luteum (especially in pregnancy) tends to be larger and more symptomatic than the follicular cyst and is prone to hemorrhage and rupture. On a sonogram, it has a varied appearance ranging from a simple cyst to a complex cystic lesion with internal debris and thick walls.⁶
  • A corpus luteal cyst is typically surrounded by a circumferential rim of color on Doppler flow referred to as "the ring of fire." Compared with a follicular cyst, a corpus luteal cyst has thicker, more echogenic, and more vascular walls. A hemorrhagic corpus luteal cyst has a variable echogenic pattern on ultrasonography, depending on clot formation and lysis in the cyst.² Fresh blood appears acutely anechoic. There is mixed echogenicity subacutely; chronically, the blood appears anechoic again, which is consistent with clot formation, retraction, and lysis.⁷
  • Hemorrhage into the cyst appears diffuse with a reticular pattern described as a "fishnet pattern" or "spider web" appearance. Color Doppler shows no vascularity within the clot, whereas a solid nodule may show vascularity.
  • The ultrasonographic appearance of ovarian torsion varies, but, most commonly, the ovary is enlarged. Massive ovarian edema may be seen with torsion, as the twisting of the pedicle impedes lymphatic drainage and venous outflow, leading to ovarian enlargement. Torsion may be intermittent and recurrent with spontaneous detorsion, allowing both arterial and venous flow to the ovary to be observed on ultrasonography. Occasionally, a twisted vascular pedicle (referred to as the "whirlpool sign") may be visible during active torsion. However this is not a sensitive finding.⁶
  • If the ultrasonographic features are not typical of an ovarian cyst, follow-up ultrasonography can be performed to exclude ovarian neoplasm. Follow-up ultrasonography can show resolution of cyst.¹⁶
• CT scanning
  • CT scanning is more sensitive but less specific than ultrasonography in detecting ovarian cysts. The addition of CT scanning in the workup of ovarian cysts offers very little additional information and usually does not alter treatment plans.¹⁵
  • CT scanning is best in imaging hemorrhagic ovarian cysts or hemoperitoneum due to cyst rupture. It can also be used to distinguish other intra-abdominal causes of acute hemorrhage from cyst rupture.¹⁶ However, CT scanning should be avoided in pregnancy, if possible, to prevent radiation exposure to the fetus. MRI is a better option in these patients when ultrasonography cannot clearly elucidate the adnexal mass.
• MRI
  • MRI in conjunction with ultrasonography may provide marginal improvements in specificity, but, in most cases, the additional cost in not justified.¹⁵
  • MRI is reserved for cases in which ultrasonography and CT scanning findings are indeterminate in identifying the mass as an ovarian cyst safely in a pregnant patient.
  • Simple ovarian cysts show a low signal intensity with T1-weighted images and a high signal intensity with T2-weighted images owing to the intracystic fluid.
  • Hemorrhagic cysts result in a high signal on T1-weighted images and intermediate to high signal on T2-weighted images. Hemoperitoneum after cyst rupture appears bright on T2-weighted images and slightly hyperintense on T1-weighted images.¹⁶

Procedures

• Culdocentesis, a procedure largely of historical interest because of its associated complications (bowel perforation, abscess rupture, trauma to a pelvic kidney), is used to look for intraperitoneal fluid. Its use has largely been replaced by ultrasonography.
• Laparoscopy offers the advantage of decreased morbidity, improved postoperative recovery, and decreased cost compared with laparotomy.
• Bilateral oophorectomy and, often, hysterectomy are performed in many postmenopausal women with ovarian cysts because of the increased incidence of neoplasms in this population.

Treatment

Prehospital Care

• Assess the patient's airway, breathing, and circulation and evaluate for signs of hemorrhagic shock.
• Secure intravenous access, provide oxygen, and monitor all potentially unstable patients.

Emergency Department Care

• Airway, breathing, and circulation remain of paramount importance. Monitor and aggressively resuscitate patients with signs of shock.
• Obtain appropriate laboratory workup and studies to aid diagnosis and involve an obstetrician/gynecologist in consultation, when appropriate.

Consultations

• Consult a general surgeon in the ED when the clinical presentation indicates an intraperitoneal process that is not clearly obstetric or gynecologic.
• Consult an obstetrician/gynecologist when an ovarian-, uterine-, or pregnancy-related emergency is suspected.
• It is imperative to expedite hemodynamically unstable patients to the operating room, with consulting services mobilized, while the initial resuscitation in the ED is in progress.

Medication

The goals of pharmacotherapy are to reduce morbidity and to prevent complications.

Analgesic, Narcotic

These agents are used to relieve moderate-to-severe pain. Pain relief is of paramount concern, but it must be remedied with agents chosen for the given clinical situation.

Morphine sulfate (Astramorph, MS Contin, MSIR, Oramorph)

DOC for analgesia due to reliable and predictable effects, safety profile, and ease of reversibility with naloxone.
Various IV doses are used; commonly titrated until desired effect obtained.

Dosing

Adult

Starting dose: 0.1 mg/kg IV/IM/SC
Maintenance dose: 5-20 mg/70 kg IV/IM/SC q4h
Relatively hypovolemic patients: Start with 2 mg IV/IM/SC; reassess hemodynamic effects of dose

Pediatric

Infants and children: 0.1-0.2 mg/kg dose IV/IM/SC q2-4h prn; not to exceed 15 mg/dose; may initiate at 0.05 mg/kg/dose

Interactions

Phenothiazines may antagonize analgesic effects of opiate agonists; tricyclic antidepressants, MAO inhibitors, and other CNS depressants may potentiate adverse effects of morphine

Contraindications

Documented hypersensitivity; hypotension; potentially compromised airway where establishing rapid airway control would be difficult

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in hypotension, respiratory depression, nausea, emesis, constipation, urinary retention, atrial flutter, and other supraventricular tachycardias; has vagolytic action and may increase ventricular response rate

Oxycodone (OxyContin, OxyIR, Roxicodone)

Indicated for the relief of moderate to severe pain.

Dosing

Adult

Immediate release: 5 mg PO q6h prn
Controlled release: 10 mg PO bid

Pediatric

Immediate release:
<6 years: Not established
6-12 years: 1.25 mg q6h PO prn
>12 years: 2.5 mg q6h PO prn
Controlled release: Not established

Interactions

Phenothiazines may antagonize analgesic effects; MAOIs, general anesthesia, CNS depressants, and tricyclic antidepressants may increase toxicity

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in COPD, emphysema, and renal insufficiency

Analgesic Nonsteroidal Anti-inflammatory Drug

These agents are used for relief of mild-to-moderate pain. They inhibit inflammatory reactions and pain by decreasing activity of cyclooxygenase (COX), which results in a decrease of prostaglandin synthesis.

Ibuprofen (Advil, Motrin, Excedrin IB, Ibuprin)

DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.

Dosing

Adult

200-400 mg PO q4-6h while symptoms persist; not to exceed 3.2 g/d

Pediatric

<6 months: Not established
6 months to 12 years: 4-10 mg/kg/dose PO tid/qid
>12 years: Administer as in adults

Interactions

Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; simultaneous administration with low-dose aspirin may decrease aspirin's cardioprotective and stroke preventive effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, beta-blockers, and diuretic effect of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; may increase phenytoin or lithium serum levels

Contraindications

Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in coagulation abnormalities or during anticoagulant therapy

Ketorolac (Toradol)

Inhibits prostaglandin synthesis by decreasing the activity of COX, which results in decreased formation of prostaglandin precursors.

Dosing

Adult

30-60 mg IM initially; followed by 15-30 mg q6h prn; not to exceed 5 d of treatment

Pediatric

Not established; recommended dose is 0.4-1 mg/kg IM once

Interactions

Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently

Contraindications

Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding; do not administer into CNS

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases risk of acute renal failure in patients with preexisting renal disease or compromised renal perfusion; low WBC counts (rare) usually return to normal during ongoing therapy; discontinue therapy if leukopenia, granulocytopenia, or thrombocytopenia persists

Follow-up

Further Outpatient Care

Timing of outpatient care of ovarian cysts depends on the patient’s age and pregnancy status.

• In pregnant patients, most ovarian cysts resolve at 16-20 weeks’ gestation.
  • Patients with benign-appearing ovarian cysts that are unilocular and smaller than 5-6 cm in diameter require no further follow-up for the cyst during pregnancy and require only routine prenatal visits.
  • If the cyst is larger than 5-6 cm or is multicystic, the patient should undergo follow-up ultrasonography at 16 weeks' gestation to allow time for cyst resolution. Persistent complex masses may be further characterized by MRI, either during or after pregnancy, to search for distinctive features that would guide diagnosis.⁶
  • Ovarian cysts that are strongly suggestive of malignancy or that are larger than 8-10 cm in diameter, are symptomatic, or are at an increased risk for torsion, cyst rupture, or obstruction of labor are more likely to require surgical intervention¹⁷ and necessitate more urgent follow-up with an obstetrician and, possibly, a multidisciplinary approach in a timely fashion. If surgery is required, it is most advantageous to perform it in the early second trimester, as the risk of spontaneous abortion during this period is lower than in the first trimester. Surgical intervention is better to avoid during the third trimester, if possible, to prevent inducing preterm delivery and to avoid technical issues in dealing with a larger uterus.
• In postpartum patients, the size and complexity of the ovarian cyst and the CA-125 level are used to determine management. Unilocular cysts smaller than 5 cm in diameter should be monitored with transvaginal ultrasonography and CA-125 studies at 6-month intervals. Complex ovarian cysts that are smaller than 5 cm in diameter in the presence of normal CA-125 levels (defined as <35-65 U/mL) should be monitored in 4 weeks with repeat ultrasonography and CA-125 studies. Surgery may be indicated for complex ovarian tumors smaller than 5 cm in diameter when CA-125 levels are elevated (>35-65 U/mL) and for complex tumors larger than 5 cm in diameter.¹⁵
• In nonpregnant premenopausal patients, various studies have examined cyst resolution with various time frames being used as indices for cyst resolution. Most of these studies showed cyst resolution by 2-3 months, dictating ultrasonography with or without gynecological follow-up in these patients.¹⁸

Inpatient & Outpatient Medications

Epidemiological studies from the 1970s-1990s reported inverse relationships between oral contraceptive pill (OCP) use and surgically confirmed functional ovarian cysts. Short-term treatment with OCPs was thus used for initial management of ovarian cysts. However, recent meta-analyses have shown that there is no difference between OCP use and placebo in terms of treatment outcomes in ovarian cysts and that these masses should be monitored expectantly for several menstrual cycles. If a cystic mass does not resolve after this time frame, it is unlikely to be a functional cyst, and further workup may be indicated.¹⁸

Transfer

• When a female patient presents with abdominal pain and signs or symptoms of an intraperitoneal process of unclear etiology, transfer is indicated if any of the following conditions are met:
  • Backup surgical, obstetric, or gynecologic support is not available to the ED.
  • Operative capacity is not available at the health care delivery site.
  • Imaging capacity is not available at the facility.
• Unstable patients should not be transferred unless the facility is truly unable to provide appropriate treatment or evaluation. The patient is the responsibility of the transferring physician until arrival at the next hospital.

Complications

• Ovarian cysts have a broad range of potential outcomes. In most cases, the cyst is benign and asymptomatic, requires no further management, and will resolve on its own. In other cases, ovarian cyst–related accidents, such as rupture and hemorrhage or torsion, occur.
• Ovarian torsion involves the rotation of the ovarian vascular pedicle, causing obstruction to venous and, eventually, arterial flow that can lead to infarction. Most torsion cases occur in premenopausal females of child-bearing age, but up to 17% of cases affect prepubertal and postmenopausal women. It is also strongly associated with ovarian stimulation and polycystic ovarian syndrome. Ovarian torsion is more common on the right side owing to the sigmoid colon restricting the mobility of the left ovary. Malignancy may be seen in up to 2% of cases of ovarian torsion. The most common ovarian mass associated with torsion is a dermoid cyst. CT scanning and ultrasonography can assist with diagnosis. Treatment consists of laparoscopic detorsion and adnexal preservation in premenopausal women and bilateral oophorectomy in postmenopausal women.
• Ovarian cyst rupture commonly occurs with corpus luteal cysts. They involve the right ovary in two thirds of cases and usually occur on days 20-26 of the woman’s menstrual cycle. Mittelschmerz is a form of physiological cyst rupture. In pregnant women, hemorrhagic corpus luteal cysts are usually seen in the first trimester, with most resolving by 12 weeks' gestation. Hemorrhage and shock may occur and may present late in the symptomatology.
• In ovarian cyst rupture, ultrasonography may demonstrate free fluid in the pouch of Douglas in 40% of cases. Cyst rupture and hemorrhage may be treated conservatively with observation if the patient is stable, with follow-up scanning in 6 weeks to confirm hemorrhage resolution. Laparoscopy is indicated in hemodynamic compromise, possibility of torsion, no relief of symptoms within 48 hours, or increasing hemoperitoneum or falling hemoglobin concentration.
• Malignancy is also among the differential diagnoses of ovarian cysts. While not an ED diagnosis, appropriate follow-up must be available to ensure resolution of cyst, or further evaluation must be undertaken.³

Prognosis

• The prognosis of ovarian cysts varies depending on the patient’s age and pregnancy status. Overall, 70%-80% of follicular cysts resolve spontaneously. Malignancy is a common concern among patients with ovarian cysts. Pregnant patients with simple cysts smaller than 6 cm in diameter have a malignancy risk of less than 1%. Most of these cysts resolve by 16-20 weeks' gestation, with 96% of these masses resolving spontaneously.¹⁹ In postmenopausal patients with unilocular cysts, malignancy develops in 0.3% of cases. In complex multiloculated cysts, the risk of malignancy climbs to 36%. If cancer is diagnosed, regional or distant spread may be present in up to 70% of cases, and only 25% of new cases will be limited to stage I disease.¹⁵  
• Ovarian cysts larger than 4 cm in diameter have been shown to have a torsion rate of approximately 15%. Ovarian function may be preserved with laparoscopic detorsion in 90% of cases.
• The outcome of ovarian cyst rupture is evaluated based on associated symptoms and will dictate whether patient may be discharged or admitted for laparoscopy.

Patient Education

For patient education resources, visit the eMedicine Women's Health Center and Cancer and Tumors Center; also, see the patient education articles Ovarian Cysts and Ovarian Cancer.

Miscellaneous

Medicolegal Pitfalls

• Delays in consultations, operative, or resuscitative interventions for patients in shock
• Failure to make the correct diagnosis, such as ectopic pregnancy
• Inadequate documentation of initial examinations, findings, consultations, and ED course
• Failure to provide patients with adequate discharge and follow-up instructions, including documentation of the potential risks of infertility, disability, and malignancy caused by delays or noncompliance

Special Concerns

• Fetal/neonatal
  • In female newborns, ovarian cysts are the most frequent type of abdominal tumor, with an estimated incidence of more than 30%.^5,9
  • Fetal ovarian cysts are believed to be caused by hormonal stimulation, such as fetal gonadotropins, maternal estrogen, and placental human chorionic gonadotropin. An association between fetal ovarian cysts and maternal diabetes and fetal hypothyroidism has been identified.
  • Most fetal ovarian cysts are small and involute within the first few months of life and are not of clinical significance. They are generally diagnosed in the third trimester of pregnancy, and most tend to resolve at 2-10 weeks postnatally.⁹
  • Differential diagnoses of these cysts include urachal cysts, intestinal duplication abnormalities, cystic teratoma, and intestinal obstruction. Intrauterine ultrasonography is necessary to differentiate ovarian cysts from these other possibilities.⁵
  • Aspiration of these cysts can be performed but is associated with complications such as reformation of cyst, infection, and premature labor.⁹
  • Once the diagnosis of a fetal ovarian cyst is made, it is important to perform serial ultrasonographic examinations to detect any structural changes in size or appearance or complications such as hydramnios, ascites, or torsion.⁵
  • Of these complications, ovarian torsion is the most serious complication of fetal ovarian cyst and may manifest as fetal tachycardia due to peritoneal irritation.
  • Proper management includes serial ultrasonography to look for signs of regression or postnatal surgery if the cyst is complicated or larger than 5 cm in diameter.⁹
• Pregnancy
  • The corpus luteum is responsible for progesterone production during pregnancy and normally regresses around 8 weeks’ gestation.⁶
  • Most pregnancy-associated cysts, such as corpus luteal and follicular cysts, resolve by gestational age 14-16 weeks and are hormonally responsive, allowing conservative management.⁶ By gestational age 16-20 weeks, up to 96% of masses resolve spontaneously. Simple cysts smaller than 6 cm in diameter have a risk of malignancy of less than 1%.¹⁹
  • Corpus luteal cysts tend to be larger and more symptomatic than follicular cysts and are more prone to hemorrhage and rupture. Follicular cysts are usually smaller, with internal hemorrhage being relatively uncommon.
  • Masses that persist longer may warrant further workup for potential neoplastic disease based on clinical findings and radiological evidence.⁶ Serum CA-125 studies are not recommended in pregnancy, as levels can fluctuate widely in normal pregnancy, particularly in the first and second trimesters, and can be elevated in many benign conditions. One group suggests observation with postpartum surgery in select patients with large persistent adnexal masses in whom ultrasonography findings are not highly suggestive of malignancy.⁴ If malignancy is a possibility and peripartum surgery is warranted, the risks of harming the pregnancy is weighed against a delay in treatment, but surgery is generally delayed until the mid-second trimester, when most cysts have resolved.¹⁹
  • Some ovarian conditions unique to pregnancy include the hyperstimulated ovary, ovarian hyperstimulation syndrome, hyperreactio luteinalis, theca lutein cysts, and luteoma of pregnancy. Hyperstimulated ovaries represent a normal ovarian response to circulating bhCG levels and are typically seen in women who have undergone ovulation induction.
  • Patients with polycystic ovarian syndrome and anovulatory patients are at an increased risk of developing hyperstimulated ovary, as these conditions cause increased estradiol levels at baseline.
  • Ovarian hyperstimulation syndrome is seen with hyperstimulated ovaries and fluid shifts. It is graded on a spectrum from mild to severe based on weight gain and size of ovarian enlargement with accompanying nausea and vomiting. These patients are treated with bedrest, serial ultrasonography, and repeat electrolyte and hematocrit studies. Complications include rupture, ascites, pleural and pericardial effusions with subsequent hypovolemia, hemoconcentration, and electrolyte abnormalities.
  • Hyperreactio luteinalis is an abnormal hypersensitive response of the ovaries to circulating levels of bhCG in the absence of ovulation induction therapy, with either normal or elevated bhCG levels. Hyperreactio luteinalis is typically asymptomatic or minimally symptomatic, but as many as 25% of cases can result in maternal virilization. The incidence can be increased in polycystic ovarian syndrome and other states that cause hyperandrogenism. Hyperreactio luteinalis is usually seen in the third trimester in patients with bilateral enlarged multicystic ovaries.
  • Theca lutein cysts have a similar appearance to hyperreactio luteinalis, with bilaterally enlarged ovaries with multiple cysts. They are predisposed to torsion, hemorrhage, and rupture and represent a normal response of ovaries to elevated levels of bhCG and are also associated with gestational trophoblastic disease.
  • A luteoma of pregnancy results when ovarian parenchyma is replaced by proliferation of luteinized stromal cells that may become hormonally active with production of androgens. Maternal virilization can occur in up to 30% of cases, with a 50% risk of virilization of the female fetus; male fetuses are unaffected. Luteoma of pregnancy appears as complex, heterogenous, hypoechoic mass on ultrasonography. After completion of pregnancy, the mass typically resolves and testosterone levels typically normalize.⁶
• Postmenopause
  • Most studies estimate the prevalence of simple unilocular adnexal cysts in asymptomatic postmenopausal women at 3%-18%, with most being smaller than 5 cm in diameter.
  • Early studies have shown the risk of malignancy of these asymptomatic adnexal cysts in postmenopausal patients to be as high as 7%, but more recent studies show the prevalence to be less than 1% in small cysts.⁸
  • In these patients, repeat ultrasonography at 4-6 weeks can be performed along with CA-125 studies in an outpatient setting.
  • Half of asymptomatic cysts smaller than 5 cm resolve in 2 months, but rising CA-125 levels or increasing cyst size or complexity may warrant surgery.
  • Follow-up care is important, as the risk of an ovarian neoplasm being malignant rises from 13% in premenopausal patients to 45% in postmenopausal patients.¹⁵

Multimedia

Media file 1: 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.

Media file 2: 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.

Media file 3: 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.

Media file 4: The cyst in multimedia files 2-3 has been removed and cut open. It has a smooth surface and a multicystic internal structure.

References

1. Katz. Comprehensive Gynecology. 5^th 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].

Keywords

ovarian cyst, cyst in ovary, cystic ovary, follicular cysts, graafian cyst, corpus luteal cyst, corpus luteum cyst, corpus luteal cyst, theca lutein cyst, hyperreactio luteinalis, adnexal torsion, ovarian necrosis, ectopic pregnancy, irregular menstrual bleeding, dysmenorrhea, dyspareunia, abdominal pain, septic shock, hypovolemic shock, adnexal mass, ovarian cancer

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, Assistant Professor of Emergency Medicine, Drexel University School of Medicine; Consulting Staff, Department of Emergency Medicine, Allegheny General Hospital
Andrew A Aronson, MD is a member of the following medical societies: American College of Emergency Physicians, Massachusetts Medical Society, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

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.

Pharmacy Editor

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Disclosure: eMedicine Salary Employment

Managing Editor

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: Medicines Company Consulting fee Consulting; Pfizer Salary Employment

CME Editor

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
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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
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The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors, A Antoine Kazzi, MD, Robin Roberts, MD, and Kimberly Duklewski Abel, MD, to the development and writing of this article.

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