Ovarian Cyst/Torsion

Basics

Description

  • Ovarian cysts:
    • Generally asymptomatic until complicated by hemorrhage, torsion, rupture, or infection
    • Follicular cysts:
      • Most common
      • Occur from fetal life to menopause
      • Unilocular; diameter 3–8 cm
      • Thin wall predisposes to rupture, which usually causes minimal or no bleeding
      • Rupture during ovulation at midcycle is known as mittelschmerz
    • Corpus luteal cysts:
      • Most significant
      • More common on the right
      • Diameter 3 cm, but usually <10 cm
      • Rapid bleeding from intracystic hemorrhage causes rupture
      • Rupture is most common just before menses due to increased vascularity
      • Can cause severe intraperitoneal bleeding
      • Gradual bleeding into cyst or ovary distends capsule and may cause pain without rupture
  • Adnexal torsion:
    • 5th most prevalent surgical gynecologic emergency
    • Twisting of vascular pedicle of ovary, fallopian tube, or paratubal cyst
    • Causes adnexal ischemia leading to necrosis
    • Can lead to infertility
    • Occlusion of lymphatics and venous drainage leads to rapid enlargement of adnexa
    • Greatest risk with cysts 8–12 cm

Risk Factors

Adnexal torsion:

  • Reproductive-age women
  • Ovarian cysts, especially >5 cm
  • Ovarian hyperstimulation
  • Tumors: Serous cystadenoma most common; teratomas (benign cysts > malignancy)
  • Pelvic surgery: Tubal ligation; hysterectomy
  • Pregnancy
  • History of pelvic inflammatory disease

Pregnancy Considerations

Torsion in pregnancy (10–22% of torsion) usually occurs in the 1st trimester, and in vitro fertilization or ovarian induction are risk factors

Pediatric Considerations

15% of adnexal torsions occur in children (elongated infundibulopelvic ligament premenarchal)

ALERT
  • Anticoagulated patients at increased risk of:
    • Hemorrhagic corpus luteal cyst
    • Significant bleed from ruptured cyst

Etiology

  • Ovarian cyst:
    • Follicular cysts result from nonrupture of mature follicle or failure of atresia of immature follicle
    • Corpus luteal cysts result from unrestrained growth in early pregnancy or from normal intracystic hemorrhage days after ovulation
    • Other cysts:
      • Theca lutein
      • Cystic teratoma
      • Endometrioma (chocolate cyst)
  • Adnexal torsion:
    • Right > left
    • Highest frequency in reproductive women
ALERT

Cysts found in postmenopausal women suggest carcinoma

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