OVARIAN CYSTS & MASSES AND MANAGEMENT .pptx

Overview, types and management of various ovarian masses and cysts

1. Ovarian cysts & masses Presenter: dr Bwalya Mubanga supervisor: dr mubiana

2. CLASSIFICATION Non-neoplastic conditions i ) Functional cysts : Follicular cysts, Corpus luteum cysts These cysts are confined to the reproductive years and those not using hormonal contraception ii) Pathological cysts : Demoid , cystadenoma and endometriomas B. Neoplastic conditions

3. Ovarian Cysts It is normal for women to develop a small blister-like growth filled with fluid or semisolid tissue either inside the ovary or on its surface. Ovarian cysts are pockets or sacs filled with fluid in an ovary or on its surface The term “cyst” is descriptive, it is not a diagnosis because are many causes for cysts on the ovary . Ovarian cysts are usually small-sized structures that rarely present any symptoms and usually resolve on their own.

4. Types of ovarian cysts FUNCTIONAL CYSTS Most common type develop routinely as part of monthly growth and ovulation during menstrual cycle and disappear in a matter of 2–8 weeks without any treatment. a. Follicular cyst usually start from a follicle, a cyst-like structure that produces egg cells. Normally , a mature follicle, or sac, breaks open to release an egg. After the egg is released, the follicle dissolves and becomes a corpus luteum, which produces oestrogen and progesterone. An ovarian cyst forms when the follicle, or corpus luteum, has a defect that causes it to accumulate liquid and thus form a cyst.

5. b. Corpus luteum cyst C orpus luteum: tissue that remains after ovulation. It produces the hormone progesterone . Fluid can accumulate in the corpus luteum leading to the cyst . In some women, bleeding into the ovary after ovulation results in a hemorrhagic cyst. Sometimes, the follicle may fail to ovulate. The egg remains in the ovary, and the corpus luteum produces progesterone. This type of cyst is called a luteinized unruptured follicle. These types of cysts are also categorized as functional cysts. Both these cysts result from a functional process rather than a disease process and are benign.

6. 2. PATHOLOGICAL CYST menstrual cycle has no involvement results from excessive growth of ovarian cells and can occur both inside or outside the ovaries . Dermoid cysts also known as cystic teratomas , are the most common in women in the reproductive age (below 30 years ). made up of those ovarian cells that are used to form the ova may also contain traces of hair, dermal tissue, fat, teeth, or bone within it. Despite the threatening appearance, these cysts are usually benign but can become quite large and typically require surgical removal.

7. b. Cystadenoma differ from dermoid cysts both in terms of their composition and location. largely benign tumors that develop from the abnormal growth of those ovarian cells that cover the surface epithelium of the ovaries. r elatively bigger than regular teratomas and can grow large enough to obstruct blood flow to the ovaries. On average, cystadenoma tends to be at least 10 cm wide but can expand to a much greater size. These cysts tend to have a smooth outer and inner surface and are usually filled with a translucent and runny substance. Women above the age of 40 are more prone to developing cystadenomas. These cysts require surgical removal.

8. c. Endometriomas C aused by endometriosis, a medical condition where uterine endometrial tissue, tissue similar to the lining of the uterus, grows outside of the uterus. R eferred to as “chocolate cysts” due to the colour of blood found within the cysts. Note : most pathological cysts are noncancerous, but the risk of malignancy is possible and therefore cannot be completely ruled out. Pathological cysts can affect women of all ages, both reproductive and post-menopausal women.

9. RISK FACTORS Hormonal imbalance, or other hormonal issues Pregnancy (a cyst that persists on the ovary even after ovulation) Endometriosis P olycystic ovary syndrome ( PCOS) Severe pelvic infection Smoking Hypothyroidism Previous ovarian cyst Note that having any of these risk factors does not mean that you will develop one

10. Causes Hormonal issues hormonal dysfunction or imbalance in the female body. Women who face fertility problems and taking hormone-based medicines to stimulate ovulation are particularly prone to this type of cyst formation. 2. Pregnancy It is normal for a woman to develop an ovarian cyst soon after conceiving, which serves the purpose of supporting the embryo until the placenta forms. It is also common for childbearing women to retain the ovarian cyst formed during their last phase of ovulation throughout the course of their pregnancy.

11. 3. Endometriosis Ovaries are often affected by this kind of endometrial tissue growth, which results in the formation of cyst-like mass that is prone to bleeding. This brown-colored cyst is known as endometrioma , or chocolate cyst in more general terms. 4 . Pelvic infections Pelvic infection can spread to the ovaries, resulting in the formation of cysts called ovarian abscesses, which are purulent, or pus-filled, cysts. 5 . Polycystic ovary syndrome (PCOS) Common hormonal disorder afflicting up to 20% of women all over the world. Characterized by the development of multiple tiny cysts in and on the ovaries. It is a common cause of female infertility.

12. Signs & Symptoms

13. Diagnosis History and Clinical examination Ultrasound : to determine the exact location and size of the cyst and to see if it is a solid mass or a fluid-containing cyst. CT scan : not good at evaluating cyst, however, good in presence of ascites MRI: to analyze ovarian growth in greater detail. Pregnancy test : to check if the cyst is the outcome of early-stage gestation

14. Hormonal profile : to identify possible hormonal factors that may contribute to the occurrence of ovarian cysts . Blood tests : to evaluate the level of CA 125, a substance which, if found in higher levels, can signal the risk of cancer, especially in post-menopausal women. The CA-125 test can also be increased in benign conditions associated with ovarian cysts (endometriosis and pelvic infections) Biopsy : a sample of the ovarian tissue is tested for the presence of cancer cells.

15. COMPLICATIONS OF OVARIAN CYSTS Malignancy Functional ovarian cysts and benign ovarian tumors do not become cancerous. However , differentiating a cancerous cyst from a functional cyst or benign tumor is difficult in some cases. Physical examination, blood tests, ultrasounds, X-rays, and MRIs are all descriptive, not diagnostic. These tests help estimate the risk of an ovarian cyst being cancer. However, if concerned about cancer, surgical biopsy is the only definitive test to either prove or disprove cancer. Postmenopausal women are more likely to have ovarian cancer as a cause of an ovarian cyst.

16. 2. Ruptured cyst Although development of ovarian cysts should rarely be a cause of concern, sometimes they can grow to a large size and even rupture, leading to pain, internal bleeding, and other discomforts . 3. Ovarian torsion (adnexal torsion ) R are but very dangerous, cause the ovary to twist around its blood supply resulting in pelvic pain, acute hemorrhage, nausea and vomiting, dizziness, lower back pain, and groin pain. Once diagnosed, often by pelvic ultrasound, surgery may allow preservation of the tube and/or ovary. 4. Infertility If the cyst is endometrioma or chocolate cyst, fertility is significantly compromised by the presence of chocolate cysts

17. TREATMENT OF OVARIAN CYSTS Watchful waiting recommended in most cases and then re-examining to check as most of the cysts go away on their own. preferred when one is not showing any symptoms and the diagnostic exam showed a small and simple fluid-filled cyst. However , follow-up pelvic ultrasound is necessary for making sure that the cyst is not changing in size . Medication Some hormonal contraceptives such as COCs might be prescribed to prevent recurrence. However , these pills won’t do anything for shrinking existing cysts .

18. Surgery Usually Laparotomy I f the cyst is large, is growing, causing pain, continues for more than 3 menstrual cycles, and doesn’t look like a functional cyst, surgical removal might be recommended. Ovarian cystectomy where the cyst is removed without the removal of the ovary. In some cases, the affected ovary might be removed and leave the other just as it is. This procedure is called oophorectomy. If a cyst is cancerous, radiation or chemotherapy and total hysterectomy are other options

19. SURGICAL MANAGEMENT Laparoscopy – up to 12cm Laparotomy Cystectomy – if confident not malignant Hysterectomy – if malignant Unilateral oophorectomy Bilateral oophorectomy

20. Premenopausal

21. Post Menopausal

22. Ovarian tumors Risk factors 1. Nulliparity : Higher frequency of carcinoma in unmarried women and in married women with low parity. 2. Family history: 5-10 % of ovarian cancers are familial. Two genes may be altered in susceptible families (i.e., ovarian cancer genes). Mutations in both BRCA1 and BRCA2 increase susceptibility to ovarian cancer. The estimated risk of ovarian cancer in women bearing BRCA1 or BRCA2 is 16% by the age of 70 years. Prolonged use of oral contraceptives reduce the risk of developing ovarian cancer 3. Early Menarche and late menopause 4. Personal history: colon, endometrial, breast cancer

23. Ovarian neoplasms Types Epithelial Stromal Germ cell Metastatic Behaviour Benign / borderline malignancy / malignant

24. Ultrasound criteria: Most likely benign Unilocular Thin walled Smooth walls Echo free contents Unilateral Usually <8cm in diameter

25. Ultrasound criteria for POTENTIALLY MALIGNANT Solid / semicystic Multilocular Thick walled Papillary growths on walls of cysts and tumour Bilateral Ascites

26. Management Principle: surgery followed by chemotherapy Operations Staging laparotomy: for confined disease: TAH BSO omentectomy , nodes and ascites Cytoreduction : for intraperitoneal spread: aim to do same and not leave tumour larger than 1cm behind Interval cytoreduction : apparently inoperable: biopsy and chemotherapy, then surgery

27. References RCOG Pubmed Medscape Medline