Benign Ovarian Tumor – Causes, Symptoms, Diagnosis, Treatment and Ongoing care
- The ovaries are a source of many tumor types (benign and malignant) because of the histologic variety of their constituent cells.
- Benign ovarian tumors create difficulties in differential diagnosis because of the need to identify malignancy and discriminate tumor from cysts, infectious lesions, ectopic pregnancy, and endometriomas.
- Tumors are often clinically silent until well developed; may be solid, cystic, or mixed; and they may be functional (producing sex steroids, as with arrhenoblastomas and gynandroblastomas) or nonfunctional.
- System(s) affected: Endocrine/Metabolic; Reproductive
Because incidence of malignancy increases with age, postmenopausal patients warrant comprehensive evaluation and follow-up.
Malignancy must be ruled out in premenarchal patients. Early neonatal cysts are rare.
- 30% of regularly cycling females
- 50% of women without regular cycles
- Predominant age: Premenarchal girls have a 5–35% risk of cancer in an ovarian tumor, and postmenopausal women have a 30% risk.
- As yet poorly characterized for benign tumors; cigarette smoking increases the relative risk for developing functional ovarian cysts 2-fold.
- Possible contributory factors are early menarche, obesity, infertility, and hypothyroidism.
- Risks for ovarian cancer include age >60 years; early menarche; late menopause; nulliparity; infertility; family history of ovarian, breast, or colon cancer; or a personal history of breast or colon cancer; or BRCA mutation.
- Risk for ovarian cancer is decreased in women who have used OCPs, been pregnant, or breastfed.
- Although oral contraceptives do not appear to increase rates of cyst resorption, they do decrease risk for forming new ovarian cysts.
- A large British cohort of 5,479 women demonstrated that the resection of benign cysts has no impact on future risk for ovarian cancer.
- A case-control study of 299 women found no evidence that ovulation-induction treatment predisposes women to the development of borderline ovarian growths.
- Endometriosis with localized, repeated ovarian hemorrhage
- Physiologic cysts
- Tumorigenesis, with genetics as yet poorly defined
- A careful history is important.
- Usually asymptomatic
- Pain related to torsion, endometriosis, or rupture
- Early satiety
- Increased abdominal girth
- Bowel pressure or bladder pressure sensations
- Menstrual irregularities
- Hirsutism or sexual precocity
- Severe acne
- Deepening of the voice
- Examine lymph nodes for enlargement.
- Chest auscultation can reveal a pleural effusion.
- Abdominal exam may identify ascites, masses, or increased abdominal girth.
- Pelvic exam is recommended.
Diagnostic Tests & Interpretation
Initial lab tests
- Complete blood count for WBCs helpful if pelvic inflammatory disease (PID) suspected
- Pregnancy test
- Serum estrogens and androgens if signs of androgen excess
- Serum tumor markers may be considered but often confuse rather than help to resolve diagnosis; choose carefully:
- CA-125 should not be ordered in a premenopausal patient for screening purposes. If an ovarian tumor in a premenopausal patient is highly suspicious for cancer by US, a CA-125 level greater than 200 u is concerning. In a postmenopausal patient, cancer must be ruled out and a CA-125 >35 u is concerning.
- α-Fetoprotein and human chorionic gonadotropin (hCG) can be ordered for suspected germ call tumor
- Disorders that may alter lab results:
- CA-125: Endometriosis, peritonitis, PID, Meigs syndrome, uterine fibroids, hepatitis, pancreatitis, systemic lupus erythematosus, diverticulitis
- β-hCG: Pregnancy, hydatidiform mole
- α-Fetoprotein: Hepatocellular carcinoma, hepatic cirrhosis, acute or chronic hepatitis
- Transvaginal US is the best means to determine the architecture of an ovarian cyst or mass.
- Transvaginal ultrasonography may differentiate tumors from other pelvic lesions and identify features that place the patient at greater risk for malignancy (e.g., solid component, papillations, multiple septations, ascites, bilaterality, fixed and irregular, rapidly enlarging, accompanied by cul-de-sac nodules).
- Transabdominal US can help identify ascites.
- Color-flow Doppler evaluation also may be helpful. Color flow to the solid component of the tumor is concerning for cancer. Gray scale may be an important method of differential diagnosis of ovarian growths.
- MRI with apparent diffusion coefficient mapping may be useful in the differential diagnosis of cystic masses. MRI can be helpful in better defining masses in women with low risk of ovarian cancer but who have an “indeterminant” mass on US.
- Cystoscopy if hematuria is present in the absence of infection or if IV pyelogram reveals intravesical surface irregularity
- Abdominopelvic CT scan with contrast material, if MRI unavailable
- Barium enema, colonoscopy, or IV pyelogram, as indicated
Exploratory laparoscopy or laparotomy
- Follicular (fluid distension of atretic follicle) and corpus luteum cysts (corpus luteum hematoma). Follicular cysts are the most common ovarian cysts in the premenopausal nonpregnant female.
- Pregnancy luteoma (composed of hyperplastic stromal theca–lutein cells)
- Serous and mucinous cystadenomas and mixed serous/mucinous cystadenomas
- Granulosa cell tumors
- Benign connective tissue tumors (thecomas, fibromas, Brenner tumors)
- Cystic teratoma (dermoid cyst); teratomas are the most common benign neoplasms.
- Germinal inclusion cyst (regarded by some as the precursor for epithelial ovarian cancer)
- Most cysts discovered during pregnancy are corpus luteum or follicular cysts.
- The 2 most commonly encountered tumors during pregnancy are cystadenomas (serous or mucinous) and dermoid cysts.
- Ovarian malignancies
- Uterine leiomyoma
- Appendicular cysts
- Diverticulitis or bowel abscess
- PID with tubo-ovarian abscess
- Distended urinary bladder
- Ectopic pregnancy
- Functional cysts (follicular and corpus luteum cysts)
- Polycystic ovaries
- Ovarian lipoma
Oral contraceptives decrease risk for forming new ovarian cysts. They do not aid in resorption of current ovarian cysts.
NSAIDs or narcotics may be helpful for discomfort.
- In premenopausal patients with cystic lesions <10 cm in diameter, simple observation for 4–6 weeks is acceptable. No evidence suggests that use of a contraceptive pill is more effective than time alone in facilitating ovarian cyst resorption.
- If a large cyst remains unchanged after 4–6 weeks of observation, then surgical exploration is indicated.
- Unilocular ovarian cysts <5 cm in premenopausal patients were not considered suspicious.
- Cystectomy or wedge resection for cyst with benign features
- Surgical removal of tumor to establish diagnosis when:
- Premenopausal cysts >5 cm that persist >12 weeks
- Mass is solid.
- Mass is >10 cm.
- Mass in a premenarchal or postmenopausal female
- Suspicion of torsion or rupture
- Postmenopausal cysts
- Cysts with worrisome features on US (e.g., papillations)
- For masses that are worrisome for cancer, consider referral to a gyn-oncologist for initial surgery.
- Most require only yearly exams.
- Varies by diagnosis
A variety of excellent patient education materials (e.g., “Ovarian Cyst”) can be downloaded from the American Association of Family Physicians and American College of Obstetricians and Gynecologists Internet sites: http://www.aafp.org/afp and http://www.acog.com.
Complications of untreated dermoid and mucinous cysts may include rupture and pseudomyxoma peritonei.
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220 Benign neoplasm of ovary
92260003 benign neoplasm of ovary (disorder)
- Cigarette smoking doubles the relative risk of developing a functional ovarian cyst.
- Transvaginal pelvic ultrasound is the imaging test of choice to initially determine the architecture of an ovarian cyst or mass.
- Malignancy must be ruled out in both premenarchal and postmenopausal patients.
- Do not order CA 125 on premenopausal patients with an ovarian mass unless it is highly suspicious for cancer.