Ovarian Cyst

Definition/diagnostic criteria

Ovarian cysts are fluid-filled sacs that develop in or on the ovaries. They are common and often asymptomatic. Ovarian cysts are classified into two main types: functional cysts and pathological cysts. Functional cysts, such as follicular cysts and corpus luteum cysts, are related to the menstrual cycle and typically resolve spontaneously. Pathological cysts include dermoid cysts, endometriomas, and cystadenomas, which may require further evaluation and treatment.

Epidemiology

Ovarian cysts are prevalent among women of reproductive age. Approximately 10% of women will undergo surgery for an ovarian cyst at some point in their lives. Functional cysts are most common during the reproductive years, whereas pathological cysts can occur at any age. Postmenopausal women are at a higher risk for malignant cysts, although the overall incidence of ovarian cancer is relatively low.

Diagnosis

Clinical features: Many ovarian cysts are asymptomatic and discovered incidentally during pelvic examinations or imaging for other reasons. When symptoms do occur, they may include:

• Pelvic pain or discomfort, which may be sharp or dull
• Bloating or abdominal distension
• Pain during intercourse
• Menstrual irregularities
• Urinary symptoms due to pressure on the bladder

Investigations and typical abnormalities: Initial evaluation includes a detailed history and physical examination, focusing on the abdomen and pelvis. Key investigations include:

• Transvaginal ultrasound (TVUS): The first-line imaging modality for evaluating ovarian cysts. It provides detailed images of the ovaries and helps characterise cysts based on size, structure (simple or complex), and other features (e.g., septations, solid areas).
• CA-125 blood test: Although not specific, CA-125 levels can be elevated in ovarian cancer and help in assessing the risk of malignancy, particularly in postmenopausal women.
• MRI or CT scan: May be used for further characterisation if ultrasound findings are inconclusive or if malignancy is suspected.

Treatment

Treatment strategies depend on the type, size, and symptoms of the cyst, as well as the patient’s age and reproductive status.

• Watchful waiting: For asymptomatic, simple cysts, particularly those <5 cm in premenopausal women, watchful waiting with repeat ultrasound in 6-12 weeks is often appropriate.
• Medical management: Hormonal contraceptives may be used to suppress ovulation and prevent the formation of new functional cysts, but they do not shrink existing cysts.
• Surgical management: Indicated for cysts that are symptomatic, persist or grow, have suspicious features on imaging, or occur in postmenopausal women. Options include cystectomy (removal of the cyst) or oophorectomy (removal of the ovary). Laparoscopic surgery is preferred for its minimally invasive nature.

Prognosis

The prognosis for ovarian cysts is generally favourable, especially for functional cysts, which often resolve spontaneously. Pathological cysts may require surgical intervention but are usually benign. The risk of malignancy increases with age, particularly after menopause. Regular follow-up and monitoring are crucial to managing potential complications such as torsion, rupture, and malignancy. Early detection and appropriate management of malignant cysts are essential for improving outcomes.