History
Most patients with ovarian cysts are asymptomatic, with the cysts being discovered incidentally during ultrasonography or routine pelvic examination. Some cysts, however, may be associated with a range of symptoms, sometimes severe, [1] although malignant ovarian cysts commonly do not cause symptoms until they reach an advanced stage.
Pain or discomfort may occur in the lower abdomen. Torsion (twisting) or rupture may lead to more severe pain. Cyst rupture is characterized by sudden, unilateral, sharp pelvic pain. This can be associated with trauma, exercise, or coitus. [1, 2] In addition, cyst rupture can lead to peritoneal signs, abdominal distention, and bleeding that is usually self-limited.
Other symptoms include the following:
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Patients may experience discomfort with intercourse, particularly deep penetration
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Having bowel movements may be difficult, or pressure may develop, leading to a desire to defecate
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Micturition may occur frequently, due to pressure on the bladder
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Irregularity of the menstrual cycle and abnormal vaginal bleeding may occur; the intermenstrual interval may be prolonged, followed by menorrhagia [3]
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Young children may present with precocious puberty and early onset of menarche
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Patients may experience abdominal fullness and bloating
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Patients may experience indigestion, heartburn, or early satiety
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Endometriomas are associated with endometriosis, which may cause dysmenorrhea or dyspareunia
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Polycystic ovaries may be part of the polycystic ovarian syndrome, which includes hirsutism, infertility, oligomenorrhea, obesity, and acne
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Some patients may experience tenesmus
Theca-lutein cysts are commonly bilateral and thus can cause bilateral, dull pelvic pain. [13] These 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 TSH and hCG. [13, 12]
Physical Examination
Palpation
A large cyst may be palpable on abdominal examination, but gross ascites may interfere with palpation of an intra-abdominal mass.
Although normal ovaries may be palpable during the pelvic examination in thin, premenopausal patients, a palpable ovary should be considered abnormal in a postmenopausal woman. If a patient is obese, palpating cysts of any size may prove difficult.
Sometimes, discerning the cystic nature of an ovarian cyst may be possible, and it may be tender to palpation. The cervix and uterus may be pushed to one side.
Other masses may be palpable, including fibroids and nodules in the uterosacral ligament consistent with malignancy or endometriosis.
Other symptoms
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. [1]
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, up to 88% of ovarian cysts may be asymptomatic and missed on pelvic exam. [29]
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.
Advanced malignant disease may be associated with cachexia and weight loss, lymphadenopathy, shortness of breath, and signs of pleural effusion.
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A multilocular right ovarian cyst that is 24 cm in diameter. It is seen with the adjacent fallopian tube and uterus. The infundibulo-pelvic ligament carrying the ovarian artery and vein has been divided. Histology reported a mucinous cystadenocarcinoma of low malignant potential. Image courtesy of C. William Helm, MBBChir.
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Transabdominal sonogram of a multilocular right ovarian cyst that is 24 cm in diameter, with the adjacent fallopian tube and uterus. The infundibulo-pelvic ligament carrying the ovarian artery and vein has been divided. This sonogram demonstrates a large, complex cystic mass with vascularity within the septations. Red and blue colors show blood flow towards and away from the transducer. The resistive index was low. Histology reported a mucinous cystadenocarcinoma of low malignant potential. Courtesy Patrick O'Kane, MD.
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A multilocular right ovarian cyst that is 24 cm in diameter has been removed and cut open. It has a smooth surface and a multicystic internal structure. Image courtesy of C. William Helm, MBBChir.
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An ovarian cyst that underwent torsion (twisting of the vascular pedicle). The patient presented with a short history of severe lower abdominal pain. The twisted pedicle can be seen attached to the cyst, which has turned dusky due to ischemia. No viable epithelial lining was available for histologic diagnosis. Image courtesy of C. William Helm, MBBChir.
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Endovaginal sonogram shows a striking echogenic mass lateral to the uterus, with posterior acoustic shadowing giving a "tip-of-the-iceberg" appearance. This is pathognomonic for a dermoid cyst. Occasionally, this appearance may be mistaken for a gas-filled bowel. Courtesy of Patrick O'Kane, MD.
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A dermoid cyst (mature cystic teratoma) after opening the abdomen. Note the yellowish color of the contents seen through the wall. Image courtesy of C. William Helm, MBBChir.
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A dermoid cyst has been opened in the operating room to reveal copious sebaceous fluid. This cyst also contained hair. Image courtesy of C. William Helm, MBBChir.
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A dermoid cyst has been opened and contains teeth. Image courtesy of C. William Helm, MBBChir.
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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. Image courtesy of C. William Helm, MBBChir.
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Cross-section of a clear cell carcinoma of the ovary. Note the cystic spaces intermingled with solid areas. Image courtesy of C. William Helm, MBBChir.
