Ruptured Ovarian Cyst – Causes, Symptoms, Diagnosis, Treatment and Ongoing care
- Ovarian cysts are very common in reproductive-age women.
- Occasionally, once a cyst reaches a certain size or following an episode of strenuous activity or sexual intercourse, a cyst may rupture.
- A ruptured ovarian cyst may be asymptomatic or may cause extreme pain due to the presence of irritating fluid or blood in the abdominal cavity.
- A ruptured ovarian cyst may require surgical intervention.
Types of ovarian cysts that may rupture fall into two groups: physiologic and pathologic (1)[C].
- Physiologic or functional cysts form as a result of normal hormonal stimulation of the ovary. Most are asymptomatic and spontaneously resolve in 60–90 days.
- Follicular cysts form when a growing follicle fails to rupture and release an egg.
- Most common type of functional cyst
- Unilateral and filled with serous fluid
- Corpus luteum cysts occur when an egg is released and pregnancy does not occur. The residual structure does not regress and may hemorrhage internally (hemorrhagic cysts).
- Theca-lutein cysts result from excessive stimulation of beta-human chorionic gonadotropin such as in infertility patients, molar pregnancies, or choriocarcinoma.
- Follicular cysts form when a growing follicle fails to rupture and release an egg.
- Pathologic cysts are caused by a process other than normal hormonal stimulation. When followed, these cysts remain stable in size or may grow.
- Endometriomas are cysts or collections of blood clot that form as a result of cycling endometrial tissue on the ovary. Also called “chocolate cysts” due to their appearance.
- Mature cystic teratoma (dermoid) develop from totipotent germ cells.
- Most commonly, they contain mucinous material and hair.
- Up to 14% are bilateral and can grow very large.
- Less than 1% rupture spontaneously but may lead to shock, hemorrage, and acute peritonitis.
- Cystadenomas may have solid or mucinous areas and are usually benign but may have borderline malignant areas. They rarely rupture.
- Other cystic-appearing adnexal structures include paratubal cysts, tubo-ovarian abscess, hydrosalpinx, ectopic pregnancy.
- A ruptured ovarian cyst may be asymptomatic or present as abdominal pain, varying from dull to acute.
- The broad range of presentations can prove to be a diagnostic dilemma for many physicians.
- A general past medical and surgical history should be reviewed.
- Risk factors for gynecologic pain should be elicited:
- Possibility of pregnancy
- Menstrual history with attention to symptoms suggestive of endometriosis or history of cysts
- Sexually transmitted disease history
- Levonorgestrel-containing intrauterine device (up to 12% of users experience ovarian cysts) (2)[B]
- Infertility treatment
- Other causes of acute abdominal pain should also be considered, including gastrointestinal and urologic etiologies.
- Patients with bleeding diathesis or undergoing anticoagulation therapy may experience significant bleeding from hemorrhagic cysts.
- An uncomplicated ruptured ovarian cyst usually produces dull pain on palpation during the abdominal and pelvic exams. Enlargement of one of the adnexa may be present.
- A complicated ovarian cyst rupture may have more of an “acute abdomen” presentation due to the presence of blood or fluid in the abdominal cavity.
Diagnostic Tests & Interpretation
- Serum quantitative beta-human chorionic gonadotropin (b-hcg) to rule out pregnancy
- Complete blood count (CBC) to evaluate for infection and monitor hemodynamic status
- Cervical cultures if pelvic inflammatory disease is suspected
- Urinalysis to evaluate possibility of infection or stones
- Blood type and cross matching if the patient is hemodynamically unstable and surgery is planned
- Transvaginal ultrasound: Most widely used and the gold standard of gynecologic imaging modality due to its cost-effectiveness and availability, and it is well-tolerated (1)[C],(3)[B]
- The presence of intraperitoneal fluid or blood in the absence of other gynecologic pathology is suggestive of a ruptured cyst.
- The ovaries may contain cysts, be slightly edematous, contain areas of hemorrhage, or appear normal.
- An ovarian cyst may be the causative factor in an episode of ovarian torsion. A torsed ovary is diagnosed by no blood flow to the ovary on ultrasound exam.
- A torsed ovary requires immediate surgical intervention.
Follow-Up & Special Considerations
CT scan may be used if the ultrasound is unclear or the diagnosis is uncertain.
- Traditionally, culdocentesis, or aspirating a small amount of peritoneal fluid transvaginally, has been used to diagnose the presence of fluid or hemoperitoneum from a ruptured cyst.
- Culdocentesis can also be used therapeutically as the removal of irritative blood or fluid from the abdominal cavity may relieve pain.
Should include all causes of acute abdominal pain, both gynecologic and nongynecologic, such as:
- Ectopic pregnancy
- Ovarian torsion
- Pelvic inflammatory disease
- Ovarian hyperstimulation syndrome (OHSS)
- Bowel perforation
Pain due to an uncomplicated cyst rupture is usually self-limiting and can be managed on an outpatient basis with pain medication and rest (4)[B].
NSAID medications are the most effective at relieving pain due to peritoneal irritation.
Narcotic pain medications may also be necessary acutely.
For patiets with painful, recurrent ovarian cysts, oral contraceptive pills can be prescribed to suppress ovulation. This may help prevent the formation of new cysts but will not impact cysts that have already formed (5)[A].
Issues for Referral
Referral to a gynecologic oncologist should be made in any postmenopausal female with an adnexal mass that has concerning ultrasound findings, an elevated CA-125, ascites, a nodular, fixed pelvic mass and a family history of breast or ovarian cancer. (1)[C],(3)[B]
If pain from a ruptured cyst is severe and persistent, the patient is unstable, or the diagnosis is uncertain, surgical evaluation is recommended (4)[B].
- Laparoscopy is the better choice over laparotomy because it is less-invasive, better tolerated by patients, and can usually be done on an outpatient basis. (1)[C],(3)[B]
- Surgery includes suction-evacuation of any fluid or blood found in the pelvis as well as achieving hemostasis, if needed, at the site of the cyst.
- If a cyst wall is present, it should be removed.
- In the vast majority of cases, oophorectomy is not necessary.
- Laprascopic excision of the cyst and capsule of endometriomas substantially decreases risk of recurrence (6)[A].
- Most functional cysts resolve spontaneously without treatment and “watchful waiting” with serial transvaginal ultrasounds for 2–3 cycles is appropriate.
- If cysts fail to resolve or develop concerning ultrasound findings (increasing size or complexity, nodules, septations, excrescences), they may be pathologic and surgical evaluation is recommended (5)[A].
- Concern for malignancy: The vast majority of ruptured ovarian cysts are a result of functional cysts in reproductive-age women and the risk of malignancy is very low. See “Issues for Referral” section.
- Ovarian cysts in pregnancy:
- With the widespread use of ultrasonography during pregnancy, up to 4% of pregnant women are found to have adnexal masses, most of which are follicular cysts which spontaneously resolve by 16 weeks’ gestation.
- Less than 2% will spontaneously rupture or torse during pregnancy; however, this can lead to preterm labor and delivery, which may cause poor obstetric outcomes.
- If they are painful, are large (>8 cm), or have ultrasound characteristics that are concerning for malignancy, elective surgical evaluation can be done during the 2nd trimester. (1)[C],(3)[B]
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620.2 Other and unspecified ovarian cyst
95598005 ruptured cyst of ovary (disorder)
- Functional ovarian cysts are very common in reproductive-age women and usually resolve spontaneously in 60–90 days.
- If a cyst does rupture, the pain is usually self-limited and can be treated with oral pain medications on an outpatient basis.
- Surgery may be necessary if pain is extreme or if the patient is unstable. This usually involves laprascopically evacuating irritating fluid and blood from the abdominal cavity, achieving hemostasis, and removing the cyst wall if possible.