1. Management of Ovarian Cysts Gwen Gottlieb MS4 University of Washington School of Medicine January 30 th 2014

2. Case CC: 16 yr old previously healthy F with four days of intermittent RLQ abdominal pain HPI: – Pain started on right, lateral to umbilicus and slowly moved to lower portion of RLQ – Strong, dull, throbbing. Comes and goes – Heat packs and soft pressure help – Walking makes it worse – Afebrile. No vomiting/diarrhea. No dysuria/hematuria – Normal BMs (today). Normal appetite – Never sexually active. LMP 2 weeks ago. No changes in vaginal discharge/odor – Denies drug/alcohol use

3. Case PMH – Hip dysplasia ROS – Otherwise negative PE – Vitals T: 37 P:80 R: 16 BP: 125/83 SpO2: 100% – General: Uncomfortable, but in no acute distress – HEENT: NCAT, PERRL, EOMI – CV: RRR, no M/R/G – R: CTAB – Abd: soft, non-distended, no mass, no organomegaly, normal bowel sounds, no guarding, no rebound. Tender to palpation of RLQ. Obturator sign negative – GU: deferred – Back: non-tender – Musculoskeletal: Moves all extremities, normal ROM/strength

4. Case – Decision Making Differential: – Ovarian torsion – Appendicitis – Other gyn pathology Consults: general surgery Labs – UA: all wnl – CBC + diff: all wnl – Urine hcg: negative Imaging: Pelvic U/S: – 1. No appendicitis. – 2. No ovarian torsion. – 3. Immediately adjacent to the right ovary posterior to the uterus, there is a large cystic lesion with incomplete septation versus tubular redundancy measuring 7.5 x 7.7 x 5.1 cm (155 mL). The patient is focally tender at this lesion. Transverse superior to inferior cine suggests possible tubular extension superiorly (image 34, frame 23, 22, 21...). Please note the deep echoes seen on CINE clips are artifactual reverberation. Fluid within the cyst is otherwise anechoic.

5. Now What? What is this? Does it require surgery? What are the other treatment options? What type of follow-up should this patient have?

6. Differential Ovarian- Torsion Benign- Functional/physiologic cysts - Mature cystic teratoma - PCOS - Endometrioma - Serous and mucinous cystadenoma Malignant- Germ cell tumors - Epithelial tumors - Sex cord stromal tumors - Other (lymphoma, leukemia) Tubal- Paraovarian/paratubal cysts - Hydrosalpinx Infectious- PID - Tubo-ovarian abscess - Pyosalpinx Obstetrical- Ectopic pregnancy - Corpus luteal cysts - Theca lutein cysts - Luteoma Obstructive- Imperforate hymen - Transverse vaginal septum - Noncommunicating uterine horn Gastrointestinal- Appendicitis - Appendiceal abscess - Diverticular abscess Urinary- Adrenal cyst - Renal cyst - Ureteric stone

7. Functional Cysts Most common ovarian cysts in adolescents Two types: – Follicular: failed rupture of follicle – Corpus Luteal: failed involution of corpus luteum Nearly 100% benign U/S: smooth, thin wall, unilocular

8. Functional Cysts Often regress without treatment – Cysts <7cm Follow with serial ultrasounds (2-3 months) If symptomatic or persistent, further investigation is warranted OCPs can suppress further cyst development, but do not encourage regression

9. Hemorrhagic Cysts Develops from a functional cyst (either follicular or corpus luteal) Complex cystic mass on U/S Typically regress in 2-8 weeks Supportive management If ruptures can cause hemoperitoneum Follow-up U/S – <5 cm: none – >5 cm: in 6-12 weeks

10. Paratubal/Paraovarian cysts From remnants of the paramesonephric or Wolffian ducts Asymptomatic, or dull pelvic pain More likely to be neoplastic (but almost always benign) Average size 1 - 8 cm U/S: simple, anechoic, unilocular, round cysts Consider surgical management if >4cm, torsion, failure to regress

11. Hydrosalpinx Typically from PID/endometriosis Blockage of the fallopian tube, causing fluid collection U/S: tubular structure that may show “beads on a string” sign or “waist” sign Treat the underlying cause

12. Endometrioma Rare in adolescents (and would be at an early stage) Unilocular or multilocular complex cysts Within ovaries or extraovarian Follow-up with a 6-12 week U/S to differentiate from a functional cyst Treat with hormonal suppression to limit endometriosis

13. Ovarian torsion Surgical emergency, but rare Can present as a solid, complex, or cystic pelvic mass due to stromal edema Functional cysts can serve as the lead point Symptoms: – Acute pain – Nausea – Vomiting – Pallor – +/- fever Emergent operation – Untwisting procedure – Ovarian cystectomy (if needed) – Adnexa-preserving management

14. Multimodal Management History – sexual activity, contraceptive use Physical – General, abdominal, pelvic, and/or rectal ROS – Constitutional symptoms, signs of virilization, menstrual irregularity, dysmenorrhea Labs – CBC – Pregnancy test Imaging – Ultrasound - preferred – MRI/CT if concern for malignancy

15. Management Algorithm ultrasound Simple cyst Premenarcheal Acute SymptomsNo Symptoms < 4cm Reassure > 4 cm U/S in 2-3 months Observation RegressionPersistance/Growth/Symptoms CONSIDER SURGICAL MANAGEMENT Postmenarcheal Acute Symptoms Complex, solid or >8cm Functional or hemorrhagic cyst yes Consider hormonal suppression no Premenarcheal Karyotype Tumor markers/MRI or CT Postmenarchael

16. Case - Revisited ultrasound Simple cyst Premenarcheal Acute SymptomsNo Symptoms < 4cm Reassure > 4cm U/S in 2-3 months Observation RegressionPersistance/Growth/Symptoms CONSIDER SURGICAL MANAGEMENT Postmenarcheal Acute Symptoms Complex, solid or >8cm Functional or hemorrhagic cyst yes Consider hormonal suppression no Premenarcheal Karyotype Tumor markers/MRI or CT Postmenarchael

17. References Kirkham YA, Kives S. Ovarian cysts in adolescents: medical and surgical management. Adolesc Med State Art Rev. 2012 Apr;23(1):178-91, xii. Ackerman S, Irshad A, Lewis M, Anis M. Ovarian cystic lesions: a current approach to diagnosis and management. Radiol Clin North Am. 2013 Nov;51(6):1067-85. doi: 10.1016/j.rcl.2013.07.010. Review. UpToDate “Ovarian cysts and neoplasms in infants, children, and adolescents” UpToDate “Differential diagnosis of the adnexal mass”