Benign Lesions of the Ovaries

Follicle cysts of the ovary are the most common cystic structures found in healthy ovaries. These cysts arise from temporary pathologic variations of a normal physiologic process and are not neoplastic. The tumors result from either failure of a dominant mature follicle to rupture or failure of an immature follicle to undergo the normal process of atresia. Many follicle cysts lose the ability to produce estrogen; in other instances, the granulosa cells remain productive, with prolonged secretion of estrogen.

Solitary follicle cysts are common and occur during all stages of life, from the fetal stage to the postmenopausal period. Follicle cysts are lined with an inner layer of granulosa cells and an outer layer of theca interna cells. The cysts are thin-walled and unilocular, usually ranging from several millimeters to 8 cm in diameter (average, 2 cm). Usually, cysts with dimensions less than 2.5 cm are classified as follicles and therefore are not of clinical significance.

Corpus luteum cysts are less prevalent than follicular cysts. They mainly result from intracystic hemorrhage and may be seen in the second half of the menstrual cycle. They are hormonally inactive but may tend to rupture with intraperitoneal bleeding, especially in patients on anticoagulant therapy.

Treatment

Generally, no treatment is required, and many of these cysts resolve spontaneously within 6-12 weeks.

A 2-year interim analysis from the International Ovarian Tumor Analysis Phase 5 (IOTA5) study showed that 80% of ovarian cysts considered benign on ultrasonography either disappeared or required no intervention. Only 12 of the 1919 women in the study received a diagnosis of ovarian cancer; thus, the 2-year cumulative risk of cancer was 0.4%. ^{[1, 2]}

In all postmenopausal women with a pelvic mass, the cancer antigen 125 (CA-125) level, though an imprecise indicator, should be ordered and pelvic ultrasonography performed. (Newer markers for ovarian cancer are on the horizon.) If the CA-125 level is elevated or the ultrasonographic features of the mass suggest malignancy, the patient should be referred for evaluation by a gynecologic oncologist. A systematic review and meta-analysis by Liu et al found that the malignancy rate, including borderline tumors, for simple ovarian cysts in postmenopausal women was approximately 1 in 10,000. ^[3]

In premenopausal women with a pelvic mass, an ultrasonogram generally suffices for the initial evaluation and often for follow-up as well.

In rare situations (eg, torsion, rupture, and hemorrhage), operative intervention may be needed to treat these cystic masses.

Epithelial cystic tumors account for about 60% of all true ovarian neoplasms. One third of all ovarian tumors are serous, and two thirds of these serous tumors are benign. By definition, serous tumors are characterized by a proliferation of epithelium resembling that lining the fallopian tubes. They are virtually all cystic, are most commonly seen in women in their 40s and 50s, and are bilateral in 15-20% of cases. Benign lesions (eg, mucinous cystadenoma) may be unilocular or multilocular; have a smooth lining surface; and contain thin, clear, yellow fluid.

Mucinous epithelial tumors account for approximately 10-15% of all epithelial ovarian neoplasms. Of these tumors, 75% are benign and are found in women aged 30-50 years. Mucinous cysts are usually smooth-walled; compared with the serous variety, they rarely are associated with true papillae. The tumors are generally multilocular, and the mucus-containing loculi appear blue through the tense capsules.

These tumors can grow quite large, measuring up to 30 cm; patients often present with ovarian torsion. Mucinous tumors are most common in the third to fifth decades of life and are only rarely bilateral. The larger varieties are associated with an increased risk of rupture, with resultant pseudomyxoma peritonei.

Treatment

For women of childbearing age, simple unilateral oophorectomy via laparoscopy or laparotomy is adequate, provided that the contralateral ovary appears grossly normal. In women desiring future fertility who have stage IA low-risk ovarian cancer, conservative surgical therapy is appropriate, provided that close follow-up can be maintained. At the completion of childbearing, usually the remaining ovary and uterus are removed.

Total abdominal hysterectomy and bilateral salpingo-oophorectomy (with or without staging) are reasonable options and are recommended by many authorities for women of perimenopausal age.

Solid epithelial ovarian tumors are almost invariably malignant. Approximately 80% of epithelial tumors are of the serous type, 10% are mucinous, and 10% are endometrioid, with rarer varieties including clear cell tumors, Brenner tumors, and undifferentiated ovarian carcinomas.

Brenner tumors are usually found incidentally at pathologic evaluation, often in conjunction with a mucinous cystadenoma or dermoid cyst. They are relatively rare tumors and are most common in the fifth to sixth decades of life. Brenner tumors may be benign, intermediate, or malignant transitional cell tumors. These tumors are usually small, firm, and solid, and when confined to the ovary, they carry a good-to-excellent prognosis, depending on the malignancy status. ^[4]

Common benign solid tumors include fibromas and thecomas. ^[5] Fibromas are the most common benign ovarian neoplasms. These tumors occur most commonly in women of postmenopausal age. They are unilateral and are often at least 3 cm in size. Fibromas are connective-tissue tumors that arise from the ovarian cortical stroma. If the stroma is estrogenic or luteinized, the tumors are actually thecomas.

Solid mature teratomas are tumors consisting of differentiated tissue from all 3 germ layers. Benign teratomas (also known as mature teratomas or dermoid cysts) are likely to contain more of the recognizable organic structures, such as thyroid, bronchial, and central nervous system tissue. ^[6] In dermoid cysts, ectodermal structures such as hair, teeth, and skin predominate.

Treatment

In most instances, simple excision of the solid tumors is adequate therapy, particularly for women of reproductive age.

Laparoscopic treatment of benign cystic teratomas of the ovaries has also been recommended (ie, laparoscopic ovarian cystectomy). In this procedure, in premenopausal women, the contralateral ovary is preserved, and every effort is made to excise only the dermoid cyst itself, thereby leaving both ovaries in situ.

Although the data regarding the recurrence risk of dermoid tumors are severely limited, most clinicians favor ovarian conservation in premenopausal women if it is surgically possible. In menopausal patients, a total hysterectomy and bilateral salpingo-oophorectomy are indicated, thus obviating the need for future gynecologic surgery.

Tubo-ovarian abscesses (TOAs) are present in 14-38% of patients hospitalized with pelvic inflammatory disease (PID) and are still commonly seen in patients with scant or poor access to routine gynecologic care. Initial inflammation of the endometrium may spread to the adnexa by the fallopian tubes, which connect with the endometrial cavity via the interstitial portion and then run laterally in the free edges of the broad ligament. When some or all of the interstitial portion of the ovaries is in communication with the inflamed tube, a true TOA develops.

The traditional criteria for the diagnosis of PID include subjective bilateral abdominal pain per patient report and positive physical examination findings for bilateral adnexal tenderness to palpation and cervical motion tenderness. Currently, however, these diagnostic criteria have been expanded to encompass a more diverse range of symptoms and objective findings. Therefore, other minor criteria are also used, including fever, excessive vaginal discharge, menorrhagia, genitourinary symptoms, or chills.

Abnormal laboratory findings may include leukocytosis, elevated erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) level, and positive findings on endometrial biopsy or gonorrheal or chlamydial culture. Historically, the standard for diagnosis, though seldom used in current clinical practice, involved visual identification of purulent material from the fimbriated ends of the fallopian tubes (salpingitis) noted during diagnostic laparoscopy.

The commonly reported symptoms of TOAs are dyspareunia and rectal discomfort, partial intestinal obstruction, dysuria, urinary frequency, and sterility. Occasionally, fever with the symptoms of pelvic peritonitis develops.

Pelvic examination findings are characteristic. The uterus is retroverted, and cervical motion produces pain. Lateral to the uterus, enlarged masses adherent to the cul-de-sac may be felt. The adnexa may be indurated with soft cystic areas. The tumors are often bilateral, and all pelvic structures are immobilized (ie, “frozen pelvis”).

Ultrasonographic characteristics of PID vary and are related to the stage of the disease process. A pyosalpinx (pus-filled fallopian tube) appears as a hyperechoic dilated mass in the adnexal region, often with low-level echoes. Often, the tubal contour cannot be clearly delineated, and therefore, ultrasonography simply shows a dilated, tortuous structure. Dilated fallopian tubes appear as tubular fluid collections. A hydrosalpinx is generally anechoic, whereas a pyosalpinx may have increased echoes within the fluid. Fluid also may be present in the cul-de-sac.

Transvaginal scanning is most useful in the evaluation of a TOA. Extension of the inflammation to the ovary leads to lack of definition of the ovarian outline and thickening of the periovarian tissue. Early in the course of the disease in most patients (and in patients with infection confined to the uterus), no abnormalities are identified. Endometritis may be considered likely with the presence of fluid in the endometrial cavity, uterine enlargement, ill-defined uterine contour, or an indistinct central endometrial echo.

A few entities simulate chronic pelvic inflammation and TOA; these include ectopic pregnancy, endometriotic cysts, malignant disease, and torsion of an ovarian cyst.

Treatment

Before embarking on a surgical approach, make every effort to treat the local infection with intravenous (IV) antibiotics. ^{[7, 8]} If an intrauterine device is in situ, prompt removal of the device and commencement of high-dose antibiotics is generally recommended. ^{[9, 10]} IV antibiotics may be continued once the device has been removed. Antimicrobial therapy should involve drugs that best penetrate into the abscesses, such as imipenem, imipenem-cilastatin, or metronidazole.

Triple-antibiotic therapy with ampicillin, gentamicin, and clindamycin or metronidazole is also commonly used, with the aim of providing polymicrobial coverage against gram-positive, gram-negative, and anaerobic bacteria. No data strongly support the use of one combination regimen over another. This form of therapy is used as a preliminary step preceding radical surgery, with the goal of reducing the technical difficulties of surgical extirpation of the pelvic organs. If the abscess is incompletely removed, recurrence in the form of an inflammatory tumor is possible.

In patients who do not respond to antibiotic therapy (as evidenced by persistent pain and fever), placing a drain or drains into the abscess or abscesses may be helpful. Urgent abdominal exploration is required only in cases of severe sepsis. Ideally, surgical exploration should be delayed until adequate antibiotic treatment has occurred. In most instances, total abdominal hysterectomy and bilateral salpingo-oophorectomy are necessary.

In rare cases and in young women desiring fertility, less radical surgery could be considered, such as unilateral or bilateral salpingectomy. Such women often require in vitro fertilization (IVF) to achieve pregnancy.

Endometriosis is frequently encountered in everyday gynecologic practice. ^[11] It is currently the most commonly diagnosed disease in females of childbearing age: Approximately 10-15% of reproductive-aged women have endometriosis. A family history of first-degree relatives with endometriosis increases the risk of having endometriosis tenfold. Despite its prevalence, however, endometriosis remains one of the most enigmatic disorders in gynecology.

Histologically, endometriosis is defined by the presence of endometrial tissue in an ectopic location exclusive of the myometrium. Many etiologic theories have been advanced over the years. Although each of the proposed mechanisms is possible and each may contribute to some cases of endometriosis, whether any fully explains the major source of the disease is doubtful.

The typical age at which endometriosis is diagnosed is 25-29 years; however, teenagers can also have endometriosis. A systematic review and meta-analysis revealed a high prevalence of endometriosis among adolescent females with pelvic pain. Of 1011 symptomatic adolescents who underwent laparoscopic investigation, 648 (64%) were found to have endometriosis. ^[12] Severe dysmenorrhea and other pelvic pain complaints should be taken seriously in teenagers. Endometriosis is commonly believed to be frequent in females of childbearing age and rare in menopausal women.

The most common symptoms of endometriosis are pelvic pain, secondary dysmenorrhea, dyspareunia, and infertility. Primary dysmenorrhea or dysmenorrhea occurring from the onset of menses should increase a clinician’s suspicion for endometriosis. Clinical symptoms result from implantation of endometrial tissue on the pelvic organs. Thus, endometriosis may result in bowel-related symptoms (eg, tenesmus) and urinary tract symptoms.

Physical findings associated with endometriosis are variable and are dependent on the severity and location of the disease. Common findings include characteristic tender nodularity and tenderness of the obliterated cul-de-sac, parametrial thickening, and adnexal masses.

Patients with more advanced disease present with bilateral endometrial cysts, ^[13] known as endometriomas. These typically appear on ultrasonograms as complex ovarian masses with low-level echoes, consistent with blood. They are often bilateral, and they can range in size from small to medium (5-6 cm). Characteristic physical examination findings help confirm the diagnosis of advanced forms of endometriosis.

Significant predictive factors for the presence of malignant transformation of endometriosis appear to include age older than 49 years and cysts that are multilocular and have solid components. ^[14] Although elevated, levels of serum cancer antigen 125 (CA-125) do not appear to be a significant predictor of malignant transformation of endometriosis.

Imaging methods in these cases are complementary. Ultrasonographic examination may reveal endometriotic cysts as hypoechoic areas. ^[15] Commonly, CA-125 levels are elevated but do not exceed 100 U/L. Laparoscopy remains the optimal diagnostic method for endometriosis.

Treatment

Compared with medical (hormonal) management or simple palliative treatment, laparoscopic excision, fulguration, or laser treatment of implants remains the most effective therapy for this disease. Sending excisional biopsies for pathology is important. Some gynecologic surgeons also perform laparoscopic uterosacral nerve ablation (LUNA) procedures at laparoscopy. LUNA targets Frankenhauser’s plexus and has been shown to be effective for pelvic pain in some patients. ^[16]

Over the years, various treatment options have been developed to combat endometriosis. Recommended medical therapies have included gestagens, oral contraceptive pills, nonsteroidal anti-inflammatory drugs (NSAIDs), and gonadotropin-releasing hormone (GnRH) analogues. ^{[17, 18, 19]} Danazol, the isoxazole derivative of 17-alpha-ethinyl testosterone, was previously used and was effective, but it proved to have severe androgenic side effects and thus is no longer used.

The goals of surgery are to restore normal pelvic anatomy, to remove visible endometriotic changes, and to eliminate pelvic pain. ^[20] Such surgery is generally considered conservative in nature. The number of recurrences is very high. Radical treatment, if required, is accomplished with abdominal hysterectomy and bilateral salpingo-oophorectomy. Approximately 90% of women with pain associated with endometriosis will experience relief of their chronic pelvic pain.

After definitive surgery, consider adjuvant therapy. In premenopausal women with severe endometriosis, most adjuvant therapy is readily accomplished by giving a GnRH analogue for suppression, with a progesterone or estrogen add-back to protect skeletal health and help ameliorate the iatrogenic menopausal symptoms. In patients with less severe disease, continuous oral contraceptives can be used for ovarian suppression, with good clinical results and few adverse effects.

For women in whom a hysterectomy and bilateral salpingo-oophorectomy did not accomplish pain relief, a presacral neurectomy can be effective.

In women with a pelvic mass, clinical assessment (including combined physical examination, imaging studies, and levels of cancer antigen 125 [CA-125]) used in conjunction with the Risk of Ovarian Malignancy Algorithm (ROMA) appears to be effective in stratifying women into low- and high-risk groups for ovarian cancer as well as in excluding malignant disease. ^[21]

Diagnostic imaging

Ultrasonography is the standard for identifying ovarian pathology. The updated French guidelines indicate that transvaginal pelvic ultrasonography is the first-line modality for evaluating presumed benign ovarian tumors in adult women. ^[22] Transvaginal ultrasonography is limited with regard to its role in assessing masses in neonates, children, and virginal adolescents. Color-coded Doppler ultrasonography improves the diagnostic accuracy of B-mode ultrasonography. Ultrasonography is easy, rapid, and able to provide critical information for the evaluation of an adnexal mass. ^[23] It can help determine whether the mass is ovarian or extraovarian, solid or cystic, simple or complex, and vascular or avascular.

Ultrasonography can be used to evaluate material or fluid contained in a mass, as well as to assess the surface of the ovarian capsule. Color-flow Doppler ultrasonography is useful for distinguishing between benign and potentially malignant lesions. In most cases, computed tomography (CT) and magnetic resonance imaging (MRI) are unnecessary in the evaluation of an adnexal mass.

Ultrasonographic findings suggestive of malignancy include the following:

• Ovarian mass with solid or complex components

• Septations

• Evidence of surface nodularity or papillae

• Increased vascular flow

• Heterogeneous echotexture

Furthermore, serial or follow-up ultrasonograms are helpful in monitoring the progression of an ovarian mass over time. Repeating an ultrasonogram in 6 weeks can help determine whether the mass is enlarging or the dimensions are diminishing.

The presence of pelvic or abdominal ascites or pelvic or abdominal lymphadenopathy on CT or MRI further raises the index of suspicion for ovarian malignancy. The updated French guidelines recommend MRI as the second-line imaging modality for indeterminate masses or lesions larger than 7 cm. ^[22]

Laboratory studies

The cancer antigen 125 (CA-125) test is useful for evaluating the response to treatment of epithelial ovarian malignancies but is perhaps one of the most commonly misordered studies in the evaluation of an ovarian mass. This assay is not recommended for first-line diagnosis in adult women. ^[22] A plethora of medical conditions, many of which afflict reproductive-aged women, can cause an elevated CA-125 level. These include, but are not limited to, pregnancy, endometriosis, fibroids, menstruation, benign ovarian tumors, diverticulosis, liver disease, and pelvic inflammatory disease (PID).

Moreover, in about one half of early-stage ovarian cancers, the CA-125 level is normal, which means that the test has a high false-negative rate if it is used to detect early-stage ovarian cancer. A normal level is usually less than 35 U/mL in a postmenopausal woman. levels higher than 200 U/mL in a premenopausal woman, with or without suggestive radiographic findings, indicate that the patient should be referred for evaluation by an oncologist.

When used purely as a screening tool, the CA-125 test has an unacceptably high false-positive rate. It should be performed judiciously in premenopausal women because of the high likelihood that the level will be elevated in the absence of ovarian pathology.

However, the CA-125 test is useful when used in postmenopausal women with ultrasonographically suspicious ovarian masses. When the CA-125 level exceeds 65 U/mL, the chance that the patient has ovarian cancer is 97%. CA-125 screening does not add useful information for specific diagnosis of benign adnexal tumors (except in the case of endometrioma). An elevated level significantly increases the probability of such a lesion. ^[24]

Alpha-fetoprotein (AFP) is another tumor marker that is elevated in the setting of endodermal sinus tumors, mixed germ cell tumors, immature teratomas, and embryonal carcinomas. The lactate dehydrogenase (LDH) level may be elevated in women with dysgerminomas, whereas the human chorionic gonadotropin (hCG) level may be elevated in women with choriocarcinomas, germ cell tumors, or embryonal cell tumors.

Testosterone levels may be elevated in patients with fibromas and Sertoli-Leydig tumors, and estradiol levels may be elevated in patients with thecomas or dysgerminomas. Often, these patients present with symptoms of rapidly virilizing clinical signs of elevated testosterone, such as male-pattern baldness, voice deepening, clitoromegaly, and increased hirsutism. In the setting of a suspicious ovarian mass, tumor markers should be evaluated, and if the results are abnormal, the patient should be referred for a complete evaluation by a gynecologic oncologist.

According to a 2003 report by Wang et al, circulating follicle-stimulating hormone (FSH) may be a driving force in the field-effect theory for the development of both ovarian neoplasms and their associated peritoneal implants. ^[25] Further investigation is necessary to elucidate the precise roles played by FSH and FSH-releasing factor in the development of epithelial tumors arising in the ovary.

Benign ovarian cysts are common and can appear at various times throughout a woman’s life. This section outlines the different types and varying incidences of benign ovarian lesions occurring in females from specific age groups.

Maternal ovarian cysts during pregnancy

Maternal ovarian cysts during pregnancy are fairly common and arise largely as a result of excessive stimulation of human chorionic gonadotropin (hCG) by the corpus luteum. The corpus luteum itself may then become quite large and undergo ovarian torsion. Additionally, because pregnancy is a time of frequent ultrasonographic evaluation, the other common ovarian cysts seen in the childbearing age group (eg, dermoid cysts, endometriomas, and, occasionally, malignant epithelial tumors) tend to be diagnosed more frequently during pregnancy.

Fetal cysts

In the fetal and neonatal period, both the maternal and fetal ovaries are exposed to excessive stimulation by human chorionic gonadotropin. Other maternal hormone levels are also high, which can lead to disordered folliculogenesis in the fetal ovaries. In addition, the fetal pituitary gland is also producing follicle-stimulating hormone (FSH), which increases the size and number of fetal ovarian follicles. These factors may contribute to the formation of fetal ovarian cysts.

Often diagnosed in the third trimester during routine ultrasound surveillance, these lesions are typically cystic (99%) and can be either simple or complex. The contralateral ovary also may be cystic. Of all fetal cysts, 97% are functional, and the average size is approximately 3.4 cm. Half of these cysts spontaneously resolve, and of the remainder, 25-40% undergo torsion.

The differential diagnosis of an adnexal mass detected in utero includes neoplastic lesions (eg, cystic teratomas, cystadenomas, granuloblastomas); mesenteric cysts; and gastrointestinal, genitourinary, or enteric duplication. In the antenatal period, a conservative approach is recommended because many spontaneously resolve. Although antenatal aspiration is an option, it has not shown any significant benefit and is not the standard of care.

Ovarian lesions in childhood

Childhood is a time of busy activity for the ovaries, a fact that may be underrecognized by both gynecologists and pediatricians. Histologically, the ovarian stroma is growing, causing the ovaries to enlarge. When cysts manifest, they are usually small and simple. The incidence of simple cysts increases with age, and most are caused by a failure of the follicle to undergo involution. Not surprisingly, in this age group, most cysts are diagnosed incidentally after radiographic studies. When smaller than 5 cm, these lesions may be followed conservatively.

Intervention should be considered for cysts larger than 5 cm, lesions demonstrating solid components, those accompanied by pain, those associated with systemic endocrinologic signs, and those with complex components or internal septations. When ovarian neoplasms are encountered in girls of this age group, they fall into the germ cell, epithelial cell, and stromal/sex chord familial classification. The vast majority of ovarian lesions of childhood are of the germ cell variety, but only about 8% of ovarian tumors of childhood are malignant.

The most common germ cell tumor of this age group (and also the most common benign tumor) is the benign cystic teratoma (see Benign Solid Ovarian Tumors). These lesions (also known as dermoid cysts) have a characteristic radiographic appearance. Commonly described as complex, with an enhancing rim and often with visible calcifications (teeth), these cysts are unilateral in greater than 90% of children. Although surgery is not always necessary, ovarian cystectomy with preservation of the ovary is the standard of care.

Ovarian lesions in adolescence

With the activation of the hypothalamic-pituitary-ovarian axis that accompanies menarche, an increase occurs in circulating gonadotropin, estrogen, and progesterone levels. The axis of an adolescent may remain immature for some time after menarche; this results in frequent anovulatory cycles and ovulatory defects.

Of the numerous benign ovarian lesions seen in girls of this age group, the functional cyst, the corpus luteum cyst, and the hemorrhagic cyst are the most common. Other ovarian concerns such as ruptured cysts and ovarian torsion are also discussed.

Follicular cysts are the most common cystic structures found in healthy ovaries; corpus luteum cysts are less prevalent than follicular cysts (see Dysfunctional Ovarian Cysts). These corpus luteal cysts or other hemorrhagic cysts may be seen in any reproductive-aged woman. Radiographically, such cysts may have a clear region of homogenous debris (blood) at the gravity-dependent portion of the cyst.

In a patient with signs or symptoms of hemodynamic instability, acute peritonitis, or a high suspicion of ovarian torsion, surgical management is indicated. This can be performed via laparoscopic means in most cases. In most cases, however, no treatment is necessary because most of these cysts spontaneously resolve.

Fibroma

The most common benign solid tumor of the ovary is the fibroma (see Benign Solid Ovarian Tumors). Fibromas are derived from connective tissue and arise from the solid ovarian cortical stroma. Histologically, spindle cells are seen. Ultrasonographically, these tumors appear hypoechoic with attenuation of the ultrasound beam.

On magnetic resonance imaging (MRI), fibromas demonstrate low-signal intensity on T2-weighted images relative to the myometrium, secondary to their mostly fibrous composition. On computed tomography (CT), ovarian fibromas appear as well-defined, solid masses with mild heterogeneity.

These tumors may undergo calcification and degeneration. More than 90% are unilateral, and approximately 10-15% are found in association with ascites. Fewer than 1% undergo malignant transformation to fibrosarcomas. About 1% of cases are associated with Meigs syndrome, characterized by ovarian fibroma, ascites, and pleural effusion.

Tubo-ovarian abscess

Tubo-ovarian abscesses (TOAs) are an infectious component of the benign lesions seen in females of reproductive age (see Tubo-ovarian Abscesses). TOAs are present in 14-38% of patients hospitalized with pelvic inflammatory disease (PID).

On imaging studies, TOAs may appear as complex, large, and often bilateral masses, with heterogeneous components on both ultrasonography and CT. ^[26] Often, the ovarian outline lacks definition, and the periovarian tissue appears thickened. Pyosalpinges may reveal increased echoes within the purulent tubular fluid, and fluid may also be present in the cul-de-sac.

Patients usually report abdominal and pelvic pain; may have nausea, vomiting, and diarrhea; and are often febrile. Physical examination reveals bilateral tender adnexal masses and diffuse peritoneal signs. Treatment includes intravenous (IV) broad-spectrum and anaerobic antibiotic coverage until symptoms resolve. The dimension of a TOA may be monitored as an indicator of improvement. If symptoms do not improve with IV therapy, drainage via interventional radiology catheter placement may be attempted. Drained fluid should be sent for culture.

Bilateral salpingo-oophorectomy, with or without hysterectomy, is a last resort and should only be undertaken acutely in the presence of severe sepsis. Infected tissue is extremely friable, and surgery can be challenging in the acute setting. If the woman is done with childbearing and she has chronic pelvic pain attributable to her history of TOAs, then bilateral salpingo-oophorectomy, with or without hysterectomy, can be performed after a cooling-off period—that is, after appropriate antibiotic therapy has been completed (usually 4-6 weeks).

Polycystic ovary syndrome

The normal adult ovary measures 1 cm in thickness, 2 cm in width, and 3 cm in length, and it usually weighs 5-8 g. In females with polycystic ovary syndrome (PCOS), the ovaries are usually bilaterally enlarged, contain multiple follicles, and demonstrate increased stromal echogenicity. Because PCOS is thought to affect approximately 5 million women of reproductive age in the United States, its existence should be familiar to any practitioner who treats women.

PCOS is a diagnostic entity that encompasses radiographic findings, clinical presentation, and endocrinologic derangement. ^[27] One or more abnormalities may be present, and these may be different at various times during a woman’s life, because the syndrome typically evolves over time. PCOS is associated with features of hyperandrogenicity, insulin resistance, and an increased risk of developing metabolic syndrome in the future. In fact, many experts call PCOS metabolic syndrome XX because the 2 syndromes have so many features in common.

The diagnosis of PCOS has been simplified from the previously tedious method. Currently, 2 of the following 3 criteria are required to establish the diagnosis of PCOS:

• Polycystic ovaries (multiple small cysts, often around the periphery of the ovary—the classic “string of pearls” appearance)

• Signs of androgen excess (eg, acne, hirsutism, temporal balding, male pattern hair loss, or clitoromegaly)

• Menstrual irregularities (oligomenorrhea or polymenorrhea)

Note that a diagnosis of PCOS does not require multiple ovarian cysts or polycystic ovaries.

Ultrasonographic findings suggestive of PCOS commonly include the following:

• Ovarian enlargement

• Increased follicle count

• Stromal echogenicity

The ovaries are usually bilaterally enlarged and spherical rather than ovoid in shape. However, 30% of patients with PCOS may show no increase in ovarian volume. Typically, multiple small (< 1 cm) follicles are present, and no dominant follicle is observed. These follicles are usually arranged along the periphery of the ovarian parenchyma, in a “string of pearls” configuration. The ovaries may have increased echogenicity in relation to the myometrium.

Many women with PCOS struggle with infertility secondary to anovulation or oligo-ovulation. Fortunately, most women with PCOS respond favorably to oral ovulation induction medications (clomiphene citrate ^[28] ), with or without progestin regulation of menses. If clomiphene citrate alone does not achieve ovulation, oral hypoglycemics may be used in conjunction with clomiphene citrate to achieve pregnancy.

Endometriomas

With the high prevalence of endometriosis currently observed in women of childbearing age, it is not surprising that endometriomas are commonly encountered in clinical practice. An estimated 1-10% of reproductive-age women may have endometriosis to some degree.

The primary pathologic definition of endometriosis requires the presence of endometrial glandular tissue outside the cavity of the uterus. Histologically, endometrial glands, stroma, or hemosiderin pigment must be detected in these lesions. When this tissue invades the ovaries, endometriomas frequently form. These are cystic, blood-filled spaces that contain “chocolate” blood (ie, old blood).

On pelvic ultrasonography, endometriomas may appear multilocular and quite large and may appear solid or cystic (simple or complex). Sonograms typically show a cystic mass with diffuse low-level echoes. On MRI, their appearance is variable, depending on the quantity of blood present in the cyst. Most endometriomas, however, show multiple high-signal intensity on T1-weighted images and very low-signal intensity on T2-weighted images.

The differential diagnosis of endometriomas also includes hemorrhagic cysts, TOAs, and ovarian malignancies.