an adnexal mass that is solid, complex, or larger than 8cm in any age group should be treated as possibly malignant (and if larger than 8cm is at risk of complication and should probably be removed anyway).
in prepubertal children and in premenopausal women, a small mass less than 5cm that is cystic on US can be watched with repeat US if the patient is asymptomatic.
an enlarging or persistent mass should be evaluated
any ovarian mass in a post-menopausal woman should be considered potentially malignant and managed surgically
follicular cysts account for 20-50% of ovarian masses in post-menarchal women during the reproductive years
ruptured cysts may present as acute severe pelvic pain worse on movement +/- rebound tenderness. The pain usually decreases over 1-2 days.
torsion of the cyst is more likely in larger cysts and will cause prolonged pain unless it spontaneously untwists. Torsion may also cause bleeding or infarction of the ovary.
those smaller than 6-8cm will usually disappear after 1-2 menstrual cycles, and if still a problem, may shrink or disappear with combined oral contraceptive pill (OCP) Rx.
those larger than 6-8cm should be referred to O&G as suspicion of neoplasm is increased.
corpus luteum cysts:
occur after ovulation (and thus in early pregnancy) and can reach 6-8cm diameter.
occurs in 10-40% of pregnancies and is a benign solid tumour usually 5-10cm and occasionally produces testosterone causing mild maternal masculinisation during pregnancy and has been reported to cause masculinisation in the female fetus.
these regress post-partum leaving no residua.
NB. a solid ovarian tumour discovered during pregnancy should be surgically evaluated because of the possibility of ovarian cancer.
germinal inclusion cysts may occur
theca lutein cysts:
sometimes present in normal pregnancy, but more often accompany trophoblastic disease (30% of these patients have enlarged ovaries)
multiple cysts ranging from 1-15cm causing ovaries to enlarge rapidly and may continue growing for a short time after delivery of the molar pregnancy then return to normal size within 3-4 months.
parovarian cysts:
remnants of wolffian ducts & account for 10% of adnexal masses in reproductive years.
benign cysts are most commonly found in 30-40yr olds but may occur in any age.
have no pedicle and thus not at risk of torsion.
hydatid of Morgagni is a pedunculated cyst of mullerian origin, usually 1-2cm and usually of no concern, however, may reach 10-15cm and cause torsion of the adnexa.
acute salpingitis may cause a pyosalpinx or hydrosalpinx and may progress to a tuboovarian abscess (DDx includes appendiceal rupture and subsequent sequestration or diverticular abscess).
germ cell tumours account for 80% of ovarian neoplasms requiring surgery in adolescents
dermoid cysts - 99% are benign. 10-20% are bilateral.
solid teratomas:
usually malignant; 50% occur before age 20yrs, 98% are unilateral.
rarely hormonally active, although occasional one does produce hCG.
dysgerminomas:
arise from undifferentiated germ cells and are always malignant.
usually occur before 20yrs age & may be bilateral, and may secrete hCG.
choriocarcinoma:
very rare to arise without a pregnancy; highly malignant; secretes hCG.
gonadoblastomas and endodermal sinus tumours
epithelial ovarian tumours:
serous cystadenomas are most frequent in 20-40yr olds
mucinous cystadenomas
most frequent in 30-50yr olds and usually > 15cm at diagnosis and may form tumours weighing more than 45kg. prone to torsion and adhesion formation.
endometrioid tumors:
less common than cystadenomas; most frequent in 30-50yr olds and are usually malignant although with reasonable prognosis. May be cystic and up to 25cm.
usually 5-10cm and generally solid but may undergo cystic degeneration if large.
may produce dub as they can produce excess oestrogen (25% do), and thus can cause endometrial hyperplasia or carcinoma, particularly in woman aged > 40yrs.
if malignant (25% are), late recurrence beyond 5yrs often occurs.
thecoma fibromas
almost never malignant but almost always hormonally active
rarely occur before age 30yrs, and less common after menopause than granulosa cell tumours
luteoma - may produce oestrogen, androgen or be inert, and more likely to become malignant than thecoma fibromas
Sertoli-Leydig cell tumours (formerly called arrhenoblastomas or androblastomas)
very rare; 25% are hormonally active; 3-20% are malignant.
menopausal women
functional cysts should not occur after the menopause
diverticular abscess (left side more common than right side)
ovarian tumours are common in older women
although benign dermoid and epithelial cysts do occur, any ovarian mass in a post-menopausal woman should be considered potentially malignant and managed surgically
cysts < 5cm may be observed with repeat US in 2-3months and if unchanged may be oberved with interval examinations as more than 90% of these are benign.