Epidemiology & Risk Factors

High prevalence in reproductive-age females.
Functional Cysts: Most common overall; related to ovulation. c
- Follicular cyst: Failure of follicle rupture during ovulation.
- Corpus luteum cyst: Failure of corpus luteum involution post-ovulation.
Benign Neoplasms:
- Mature Cystic Teratoma (Dermoid cyst): Most common benign ovarian mass in young females (15–30 y/o).
- Endometrioma: “Chocolate cyst” secondary to endometriosis.
- Serous/Mucinous Cystadenoma: Benign epithelial tumors.
Risk Factors for Malignancy: Postmenopausal status, BRCA1/BRCA2 mutations, Lynch syndrome, nulliparity, early menarche/late menopause.
Protective Factors: OCPs (suppress ovulation), multiparity, prolonged breastfeeding.

Clinical Features

Uncomplicated/Simple Cysts: Mostly asymptomatic; found incidentally on pelvic exam or imaging.
Symptomatic Cysts:
- Unilateral lower quadrant/pelvic pain (dull, aching).
- Pelvic pressure, fullness, or bloating.
- Dyspareunia or dysmenorrhea (suggestive of endometrioma).
Acute Severe Pain: Indicates cyst rupture or ovarian torsion.
Physical Exam: Unilateral adnexal tenderness or palpable mobile mass.
- Fixed, nodular mass w/ ascites suggests malignancy.

Initial & Best Test: Pelvic Ultrasound (Transvaginal US [TVUS] preferred).
- Simple Cyst: Thin-walled, anechoic, unilocular, smooth margins, no solid components/septa.
- Dermoid Cyst (Teratoma): Hyperechoic mass w/ acoustic shadowing (hair, calcifications/teeth).
- Endometrioma: Homogeneous low-level internal echoes (“ground-glass” appearance).
- Malignant Features: Solid components, thick septations, internal flow on Doppler, loculated/multilocular, associated ascites, size >10 cm.
Key Labs:
- β-hCG: Rule out ectopic pregnancy or gestational trophoblastic disease.
- CA-125: Biomarker elevated in epithelial ovarian cancers. Best diagnostic/prognostic utility in postmenopausal women (low specificity in premenopausal females due to elevation in endometriosis, fibroids, PID).
- CBC: Check for leukocytosis (infection/TOA) or anemia (hemoperitoneum from ruptured cyst).

Ectopic Pregnancy: Differentiated by (+) β-hCG, amenorrhea, vaginal bleeding, empty uterus on TVUS.
Ovarian Torsion: Differentiated by sudden onset severe unilateral pain w/ N/V and decreased/absent Doppler flow on TVUS.
Tubo-Ovarian Abscess (TOA): Differentiated by complex multilocular adnexal mass w/ fever, purulent cervical discharge, and cervical motion tenderness.
Polycystic Ovary Syndrome (PCOS): Differentiated by bilateral “string of pearls” appearance on US, hyperandrogenism, oligomenorrhea, and obesity.
Appendicitis: Differentiated by RLQ pain, migration from periumbilical region, fever, (+) McBurney point tenderness.

Premenopausal Females:
- Simple Cyst <10 cm & Asymptomatic: Observation & Reassurance. Repeat TVUS in 4–12 weeks (most resolve spontaneously within 1–2 menstrual cycles).
- Simple/Complex Cyst >10 cm OR Persistent OR Symptomatic: Surgical evaluation via Laparoscopic Cystectomy (preserves fertility).
Postmenopausal Females:
- Simple Cyst <5 cm w/ Normal CA-125: Serial TVUS and serum CA-125 monitoring every 3–6 months.
- Complex Cyst / Mass >5–10 cm / Elevated CA-125: Urgent Gynecologic Oncology consult for exploratory laparotomy and intraoperative staging.
Ruptured Ovarian Cyst:
- Hemodynamically Stable (Uncomplicated): Observation, oral analgesics, outpatient rest.
- Hemodynamically Unstable (Complicated / Active Hemorrhage): Emergency Laparoscopy for hemostasis.

Ovarian Torsion: Occlusion of ovarian blood supply leading to ischemic necrosis (surgical emergency).
Cyst Rupture & Hemoperitoneum: Can lead to significant internal bleeding and hypovolemic shock.
Malignant Transformation: Risk significantly increased in postmenopausal complex masses.

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