AUTHOR AND EDITOR INFORMATION

Section 1 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

INTRODUCTION

Section 2 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

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

Section 3 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

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.

DIFFERENTIALS

Section 4 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Other Problems to be Considered

The primary goal of the emergency clinician is to rule out acutely life-threatening etiologies for a patient's constellation of symptoms. Ovarian cysts are very common and, therefore, may be an incidental finding noted in the workup of a symptomatic patient. Thus, all patients who appear to have a benign gynecologic condition surmised in the emergency department should have OB/GYN follow-up within an appropriate time frame to ensure that a more serious pathologic process has not been overlooked or misdiagnosed. 

WORKUP

Section 5 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Lab Studies

No laboratory test is diagnostic for ovarian cysts.

• Serum or urine pregnancy testing is the most important test to obtain in any woman of childbearing age. It is needed to alert the clinician to the differential of obstetric emergencies (eg, ectopic pregnancy).
• CBC with differential
• • The hemoglobin and hematocrit provide the level of anemia in the circulation. They may be normal or mildly decreased with acute blood loss.
  • The WBC count can be normal or mildly elevated with an uncomplicated cyst, dysmenorrhea, or early in the course of more significant pathology.
• Coagulation studies should include prothrombin time (PT), activated partial thromboplastin time (aPTT), and international normalized ratio (INR), which can elicit any underlying bleeding disorder.
• A type and screen must be sent on all pregnant patients with abdominal pain and/or vaginal bleeding. Consider Rhesus (Rh) isoimmunization in Rh-negative pregnant mothers with vaginal bleeding.
• A urinalysis can detect pyuria and/or hematuria that may be present if the urinary system becomes infected from an adjacent ovarian process. This may be seen in an inflamed or leaking cyst or ruptured tubo-ovarian abscess.
• Cultures of the blood, urine, and cervix should be obtained from patients with concomitant fever and/or peritoneal symptoms.
• Cancer antigen-125 (CA-125) is a tumor-associated antigen used to detect the nature of an ovarian cyst. This test is of limited utility in the ED because the results cannot be obtained in less than 24 hours. It is most useful in conjunction with ultrasonography in the postmenopausal patient to screen for relapses in treated ovarian cancer or to assess the response to current treatment regimens.

Imaging Studies

• Ultrasonography
  
  
  • Ultrasonography is the primary imaging tool for a patient thought to have an ovarian cyst. It is most helpful when transvaginal and transabdominal modalities are used together. Transabdominal ultrasonography requires the patient to have a full bladder, as opposed to transvaginal ultrasonography. Ultrasonography is safe in pregnancy.
  • Ultrasonography enables the ED physician to exclude other urgent diagnoses that may have similar presentations to ovarian cysts, such as ovarian torsion, tubo-ovarian abscess, ectopic pregnancy, and appendicitis.
  • It assesses cystic size, structure, and complexity (whether it is a simple cyst or a cyst with complex features, such as multi-septate layers or an associated mass). Cystic, unilocular, unilateral masses less than 10 cm in diameter with regular borders are likely benign. Malignant ovarian cysts are associated with irregular borders, a size larger than 10 cm in diameter, papillations, solid areas, thick septa (>2 mm), ascites, and matted bowel.
  • Color flow addition to the Doppler study may aid in the diagnosis of an ovarian cyst or of an ovarian torsion, with which decreased blood flow to the ovary may be noted.
  • Ultrasonography also proves to be a very good tool to follow cysts over time to ensure adequate and timely resolution of cystic changes.
  • Cystic postmenopausal ovarian changes visualized by ultrasonography should prompt a search for ovarian cancer.
• CT scan, although less accurate than ultrasonography for helping define ovarian cysts, can help narrow the differential diagnosis of intra-abdominal processes when the etiology of lower abdominal pain is unclear.
• Plain film abdominal radiography is of limited value in the diagnosis of ovarian cysts.
• MRI
  
  
  • MRI is more sensitive but less specific than ultrasonography in distinguishing malignant ovarian lesions from benign ovarian lesions.
  • It can be safely used during pregnancy to further evaluate adnexal masses after ultrasonography.
  • The advantages of MRI include the capacity to develop 3-dimensional planar images, delineate tissue planes, and characterize tissue composition.

Procedures

• Culdocentesis is a procedure used to look for intraperitoneal fluid that is largely of historical interest due to its complications (bowel perforation, abscess rupture, trauma to a pelvic kidney). Its use has largely been replaced by ultrasonography and CT.
• Laparoscopy/laparotomy
   
  • Laparoscopy offers the advantage of decreased morbidity, improved postoperative recovery, and decreased cost compared with laparotomy.
  • Bilateral oophorectomy and often hysterectomy are performed in postmenopausal women even in the case of benign pathology. Because of the higher risk of malignancy in this age group, laparotomy is more commonly performed.

TREATMENT

Section 6 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Prehospital Care

• Assess airway, breathing, and circulation.
• 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 those patients with signs of shock.
• Obtain appropriate laboratory workup and studies to aid diagnosis and involve obstetrics and gynecologic physicians in consultation when appropriate.

Consultations

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

MEDICATION

Section 7 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Drug Category: Analgesic, Narcotic

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

Drug Category: 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.

FOLLOW-UP

Section 8 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Further Outpatient Care

• Serial ultrasonography may be considered to access adequate cystic resolution with observation periods alone. It is recommended at 8 weeks or at the conclusion of 2 menstrual cycles.
• A gynecologic follow-up examination is indicated to rule out any underlying malignancies or infertility, even in seemingly benign cysts.
• Follow-up is indicated on any cultures that have been sent and may indicate a subacute pelvic inflammatory infection.

In/Out Patient Meds

• Oral contraceptive pills
• • Regular oral contraceptive usage is associated with a reduced incidence of functional ovarian cysts.
  • However, oral contraceptives are of no benefit in hastening resolution of already existent cysts that occur spontaneously or of those that develop after ovulation induction. Watchful waiting over several cycles is just as effective.
  • If a cyst persists, it may be pathological rather than physiological and may warrant surgical management.
  • If used within 15 years, oral contraceptives also reduce the risk of epithelial ovarian cystadenocarcinoma.
• Hormonal replacement therapy (HRT): Few articles have addressed the issue of HRT on ovarian cysts and the results are conflicting.

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:
  
  
  • Back-up 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

• Adnexal torsion has a predilection to the right side and is seen most commonly in cysts larger than 4 cm. It is more common in a cystic ovary accompanied by a tumor, with benign processes outnumbering malignant ones. Benign dermoid cysts are the most common associated growth.
• Ovarian necrosis can be the sequela of the complete or partial twisting of the ovarian pedicle seen with torsion.
• Hemorrhage, with the right side again being more common, can lead to shock. It is postulated that the rigid rectosigmoid on the left provides cushioning from trauma and twisting. The relatively lax ileocecal region on the right is not as efficient at such prevention as the left. In patients with a hemorrhagic ovarian cyst, look for an ectopic pregnancy because the coexistence of both entities is increased. 
• Malignant change can occur in a small percentage of endometriomas. However, the potential of a benign ovarian cyst becoming malignant has not been proven. 

Prognosis

• The prognosis is variable, depending on the cyst etiology, the patient's age, and the occurrence of complications.
• Most cysts in women of childbearing age resolve spontaneously.
• If complicated by ovarian torsion, the prognosis depends on the time to surgical resolution. Tissue may remain viable if salvaged within 6 hours of the onset of symptoms.
• If an ovarian cyst is caused by cancer, the prognosis depends on the disease stage at the time of discovery. 

Patient Education

• For excellent patient education resources, visit eMedicine's Women's Health Center and Cancer and Tumors Center. Also, see eMedicine's patient education articles Ovarian Cysts and Ovarian Cancer.

MISCELLANEOUS

Section 9 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Medical/Legal 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

The etiology of ovarian masses is reflective of the patient's age. Cysts are most common during infancy and adolescence, which are hormonally active periods of development.

• Fetal/neonatal
  
  
  • At birth, 98% of newborn girls have small ovarian cysts as noted on ultrasonography, with 20% being smaller than 9 mm in diameter.
  • Larger cysts, which may occupy the entire fetal abdomen, are at increased risk of torsion or a mass effect causing gastrointestinal obstruction, maternal polyhydramnios, or pulmonary hypoplasia.
  • Most neonatal cysts are asymptomatic and identified because of a palpable mass.
  • Unlike in older children, malignancy is essentially nonexistent in the neonatal ovary. Neonatal complex cysts are almost always the result of prenatal hemorrhage into a cyst or perinatal ovarian torsion.
• Children
• • In a child found to have a symptomatic abdominopelvic mass, the ovary is the most common site of origin.
  • Although such masses are infrequent occurrences, the percentage due to malignant tumors is higher than in the neonatal or reproductive age groups. Such tumors may be partially cystic.
  • A single cyst smaller than 1 cm in diameter in the prepubertal girl is considered normal with no further evaluation needed. This determination should be left to the gynecologist and not the emergency physician.
  • Immature teratomas are the most common ovarian neoplasm in children.
• Pregnancy
• • Cysts should be evaluated in pregnant patients the same way as in nonpregnant patients, with ultrasonographic examinations and CA-125 testing.
  • Ultrasonography is the diagnostic method of choice. MRI is preferable to CT scanning, but both should be avoided in the first trimester.
  • The timing of detection of the adnexal mass influences its likely etiology. Cystic adnexal masses smaller than 5 cm in diameter found in the first 16 weeks are usually functional cysts that resolve spontaneously. Those that persist beyond 16 weeks are more likely to be neoplastic.
  • Torsion, cyst rupture, and obstruction of labor usually only occur in large symptomatic masses.
  • During pregnancy, hemorrhagic cysts are accompanied by a higher rate of spontaneous abortion.
  • Surgical intervention for benign adnexal masses in pregnancy is associated with a higher risk of preterm deliveries and low birth weights compared with patients who do not have surgery.
• Postmenopause
• • The postmenopausal ovary continues to produce cysts. In a postmenopausal ultrasonographic ovarian screening population, the occurrence of a simple, unilocular ovarian cyst approaches 20%. Of these, 50-70% will resolve spontaneously.
  • However, as one's age increases, so does the risk of malignancy. 
• Breast cancer
• • An adnexal mass in a breast cancer patient is of particular concern. There is a 2-fold increased risk for development of primary ovarian cancer, and metastatic breast cancer is also a concern.
• Polycystic ovarian syndrome
• • Polycystic ovarian syndrome (PCOS) is a heterogeneous disorder of uncertain etiology present in 6-10% of women of reproductive age, making it the most common endocrine disorder in this population.
  • Features include menstrual irregularity, anovulatory infertility, miscarriages, hirsutism, acne, and alopecia. Patients have elevated levels of androgens, luteinizing hormone (LH), estrogen, and prolactin. Metabolic consequences include obesity, sleep apnea, insulin resistance, lipid abnormalities, and possibly cardiovascular disease and nonalcoholic fatty liver disease.
  • On sonogram, increased ovarian size (>10 cm³), increased stromal echogenicity, and accumulation of small follicular cysts in a "string of pearls" pattern (approximately 12 follicles between 2 mm and 9 mm in size) are observed.

ACKNOWLEDGMENTS

Section 10 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

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

REFERENCES

Section 11 of 11

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

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• Goldstein SR. Postmenopausal adnexal cysts: how clinical management has evolved. Am J Obstet Gynecol. Dec 1996;175(6):1498-501. [Medline].
• Grimes DA, Jones LB, Lopez LM, Schulz KF. Oral contraceptives for functional ovarian cysts. Cochrane Database Syst Rev. Oct 18 2006;(4):CD006134. [Medline].
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• Leiserowitz GS. Managing ovarian masses during pregnancy. Obstet & Gynecol Survey. Jul 2006;61(7):463-70. [Medline].
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• McDonald JM, Modesitt SC. The incidental postmenopausal adnexal mass. Clin Obstet & Gynecol. Sep 2006;49(3):506-16. [Medline].
• Parazzini F, Moroni S, Negri E, La Vecchia C, Dal Pino D, Ricci E. Risk factors for functional ovarian cysts. Epidemiology. Sep 1996;7(5):547-9. [Medline].
• Pomeranz AJ, Sabnis S. Misdiagnosis of ovarian masses in children and adolescents. Ped Emerg Care. Mar 2004;20(3):172-4. [Medline].
• Setji TL, Brown AJ. Polycystic ovary syndrome: diagnosis and treatment. Am J Med. Feb 2007;120(2):128-32. [Medline].
• Simpkins F, Zahurak M, Armstrong D, Grumbine F, Bristow R. Ovarian malignancy in breast cancer patients with an adnexal mass. Obstet & Gynecol. Mar 2005;105(3):507-13. [Medline].

Article Last Updated: Jun 18, 2007