Ovarian cysts
Ovarian cysts: Excerpt from Professional Guide to Diseases (Eighth Edition)
Ovarian cysts are usually nonneoplastic sacs on an ovary that contain fluid or semisolid material. Although these cysts are usually small and produce no symptoms, they generally require thorough investigation as possible sites of malignant change. Common ovarian cysts include follicular cysts, lutein cysts (granulosa-lutein [corpus luteum] and theca-lutein cysts), and polycystic ovarian disease. Ovarian cysts can develop at any time between puberty and menopause, including during pregnancy. Granulosa-lutein cysts occur infrequently, usually during early pregnancy. The prognosis for nonneoplastic ovarian cysts is excellent.
Causes
Follicular cysts are generally very small and arise from follicles that overdistend. 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. (See Follicular cyst.)
Granulosa-lutein cysts, which occur within the corpus luteum, are functional, nonneoplastic enlargements of the ovaries caused by excessive accumulation of blood during the hemorrhagic phase of the menstrual cycle. Theca-lutein cysts are commonly bilateral and filled with clear, straw-colored fluid; they’re often associated with hydatidiform mole, choriocarcinoma, or hormone therapy (with human chorionic gonadotropin [hCG] or clomiphene citrate).
Polycystic ovarian disease is part of the Stein-Leventhal syndrome and stems from endocrine abnormalities.
Signs and symptoms
Small ovarian cysts (such as follicular cysts) usually don’t produce symptoms unless torsion or rupture causes signs of an acute abdomen (abdominal tenderness, distention, and rigidity). Large or multiple cysts may induce mild pelvic discomfort, low back pain, dyspareunia, or abnormal uterine bleeding secondary to a disturbed ovulatory pattern. Ovarian cysts with torsion induce acute abdominal pain similar to that of appendicitis.
Granulosa-lutein cysts that appear early in pregnancy may grow as large as 2" to 2½"(5 to 6 cm) in diameter and produce unilateral pelvic discomfort and, if rupture occurs, massive intraperitoneal hemorrhage. In nonpregnant women, these cysts may cause delayed menses, followed by prolonged or irregular bleeding. Polycystic ovarian disease may also produce secondary amenorrhea, oligomenorrhea, or infertility.
Diagnosis
Generally, characteristic clinical features suggest ovarian cysts.
Confirming diagnosis Visualization of the ovary through ultrasound, computed tomography scan, laparoscopy, or surgery (often for another condition) confirms ovarian cysts.
Extremely elevated hCG titers strongly suggest theca-lutein cysts. Pregnancy, including molar pregnancy, must be ruled out.
In polycystic ovarian disease, physical examination demonstrates bilaterally enlarged polycystic ovaries. Tests reveal slight elevation of urinary 17-ketosteroids and anovulation (shown by basal body temperature graphs and endometrial biopsy). Direct visualization must rule out paraovarian cysts of the broad ligament, salpingitis, endometriosis, and neoplastic cysts.
Treatment
Follicular cysts generally don’t require treatment because they tend to disappear spontaneously within 60 days. However, if they interfere with daily activities, clomiphene citrate by mouth for 5 days or progesterone I.M. (also for 5 days) re-establishes the ovarian hormonal cycle and induces ovulation. Hormonal contraceptives haven’t been proven to accelerate involution of functional cysts (including both types of lutein cysts and follicular cysts).
Treatment for granulosa-lutein cysts that occur during pregnancy is aimed at relieving symptoms because these cysts diminish during the third trimester and rarely require surgery. Theca-lutein cysts disappear spontaneously after elimination of the hydatidiform mole, destruction of choriocarcinoma, or discontinuation of hCG or clomiphene citrate therapy.
Treatment of polycystic ovarian disease may include the administration of such drugs as clomiphene citrate to induce ovulation, medroxyprogesterone acetate for 10 days of every month for the patient who doesn’t want to become pregnant, or low-dose hormonal contraceptives for the patient who needs reliable contraception.
Surgery, in the form of laparoscopy or exploratory laparotomy with possible ovarian cystectomy or oophorectomy, may become necessary if an ovarian cyst is found to be persistent or suspicious.
Special considerations
Thorough patient teaching is a primary consideration. Carefully explain the cyst’s nature, the type of discomfort — if any — the patient is apt to experience, and how long the condition is expected to last.
❑ Preoperatively, watch for signs of cyst rupture, such as increasing abdominal pain, distention, and rigidity. Monitor vital signs for fever, tachypnea, or hypotension, which may indicate peritonitis or intraperitoneal hemorrhage. Administer sedatives, as ordered, to ensure adequate rest before surgery.
❑ Postoperatively, encourage frequent movement in bed and early ambulation, as ordered. Early ambulation prevents pulmonary embolism.
❑ Provide emotional support. Offer appropriate reassurance if the patient fears cancer or infertility.
❑ Before discharge, advise the patient to increase her activities at home gradually — preferably over 4 to 6 weeks. Tell her to abstain from sexual intercourse and not to use tampons and douches during this period.
Pictures
Book Source Details
- Book Title: Professional Guide to Diseases (Eighth Edition)
- Author(s): Springhouse
- Year of Publication: 2005
- Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2005 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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