Atlas of pathophysiology, 2 Edition

Part II - Disorders

Genital Diseases

Ovarian Cysts

Ovarian cysts are usually benign sacs that contain fluid or semisolid material. Although these cysts are usually small and produce no symptoms, they may require thorough investigation as possible sites of malignant change. Cysts may be single or multiple (polycystic ovarian disease). Most ovarian cysts are physiologic, or functional; that is, they arise during the normal ovulatory process. Physiologic ovarian cysts include follicular cysts, theca-lutein cysts, which are commonly bilateral and filled with clear, straw-colored liquid, and corpus luteum cysts. Ovarian cysts can develop any time between puberty and menopause, including during pregnancy. The prognosis for benign ovarian cysts is excellent. The presence of a functional ovarian cyst doesn't increase the risk for malignancy.

Clinical Tip

Polycystic ovarian syndrome is a metabolic disorder characterized by multiple ovarian cysts. About 22% of the women in the United States have the disorder, and about 50% to 80% of these women are obese. Among those who seek treatment for infertility, more than 75% have some degree of polycystic ovarian syndrome, usually manifested by anovulation alone.

Causes

·   Granulosa-lutein cysts (occur within the corpus luteum): excessive accumulation of blood during hemorrhagic phase of menstrual cycle

·   Theca-lutein cysts:

§  hydatidiform mole, choriocarcinoma

§  hormone therapy (human chorionic gonadotropin [HCG] or clomiphene citrate)

Pathophysiology

Follicular cysts are generally very small and arise from follicles that either haven't ruptured or have ruptured and resealed before their fluid is reabsorbed. Luteal cysts develop if a mature corpus luteum persists abnormally and continues to secrete progesterone. They consist of blood or fluid that accumulates in the cavity of the corpus luteum and are typically more symptomatic than follicular cysts. When such cysts persist into menopause, they secrete excessive amounts of estrogen in response to the hypersecretion of follicle-stimulating hormone and luteinizing hormone that normally occurs during menopause.

Dermoid cysts are tumors of developmental origin that consist of a fibrous wall lined with stratified epithelium and may contain hair follicles, sweat glands, sebaceous glands, nerve elements, and teeth.

Signs and symptoms

·   Large or multiple cysts:

§  mild pelvic discomfort, low back pain, dyspareunia

§  abnormal uterine bleeding

·   Ovarian cysts with torsion: acute abdominal pain similar to that of appendicitis

·   Granulosa-lutein cysts:

§  in pregnancy: unilateral pelvic discomfort

§  in nonpregnant women: delayed menses, followed by prolonged or irregular bleeding

Diagnostic test results

Ultrasound, laparoscopy, or surgery confirm the presence of ovarian cysts.

Treatment

·   If cyst disappears spontaneously within one to two menstrual cycles—no treatment

·   Persisting cyst indicates excision to rule out malignancy

·   Functional cysts that appear during pregnancy—analgesics

·   Theca-lutein cysts:

§  elimination of hydatidiform mole

§  destruction of choriocarcinoma

§  discontinuation of HCG or clomiphene therapy

·   Persistent or suspicious ovarian cyst:

§  laparoscopy or exploratory laparotomy with possible ovarian cystectomy or oophorectomy

§  if necessary during pregnancy, optimal time is second trimester

·   Ruptured corpus luteum cyst:

§  culdocentesis to drain intraperitoneal fluid

§  surgery for ongoing hemorrhage

P.329

OVARIAN CYSTS

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