History and exam

Key diagnostic factors

common

presence of risk factors

Pre-menopausal women with a history of early menarche, endometriosis, or treatment for infertility, with polycystic ovary syndrome, on tamoxifen treatment, or pregnant.

Other diagnostic factors

common

pelvic pain

Chronic pelvic pain impacts 16% of women of reproductive age.[11] New-onset pain or a change in pain should prompt further testing. Case series investigating the surgical findings among patients with pelvic pain report ovarian cyst prevalence of 3.0% to 9.5%.[11]

bloating and early satiety

Case control studies have shown significant association of bloating and early satiety with ovarian cancer, particularly with symptom duration <12 months and symptom frequency >12 times per month.[28]

palpable adnexal mass

Bimanual examination provides poor diagnosis of adnexal masses, with a sensitivity of 28%.[29] Mass features consistent with malignancy include irregularity, solid consistency, fixed mobility, nodularity, and presence of ascites.[31]

Risk factors

strong

pre-menopausal age group

The prevalence of ovarian cysts is higher among pre-menopausal women, and the risk of these cysts being malignant is much lower. In women of reproductive age, the cysts are commonly physiological.

However, benign physiological ovarian cysts are not confined to women of reproductive age. In a European cancer screening trial, 21.2% of healthy post-menopausal women demonstrated ovarian cysts.[4] Another study demonstrated an 18% incidence of unilocular, predominantly benign, ovarian cysts among 15,106 women >50 years.[12]

early menarche

Early menarche is associated with development of physiological ovarian cysts.

first trimester of pregnancy

In approximately 1% to 4% of pregnancies, ovarian cysts are diagnosed on routine ultrasonography.[13][14] Increased beta-human chorionic gonadotrophin levels can mimic gonadotrophin action or stimulate the ovaries themselves to form corpus luteum or other functional cysts.[6][13] The majority resolve by 16 weeks.[14]

personal history of infertility or polycystic ovary syndrome

Due to the administration of extrinsic gonadotrophins, patients receiving treatment for infertility are much more likely to develop ovarian cysts.[15]

increased intrinsic or extrinsic gonadotrophins

Luteinising hormone and follicle-stimulating hormone are normally secreted from the pituitary gland in a pulsatile fashion to stimulate ovarian follicle development and ovulation. Excessive production can be triggered by the oestrogen analogue clomifene, resulting in stimulation of the ovaries via blockade of the normal negative feedback by endogenous oestrogen. Exogenous administration of gonadotrophins by infertility specialists can also lead to over-stimulation of the ovaries, resulting in cyst formation. It is unclear whether the cyst forms from a dominant follicle failing to rupture or from an immature follicle failing to undergo atresia.[6] The cyst is most commonly a follicular or corpus luteum cyst.

Theca lutein cysts may develop in response to similar factors. Beta-human chorionic gonadotrophin (beta-hCG) shares an alpha subunit with luteinising hormone and follicle-stimulating hormone, and over-abundance of beta-hCG may result in a similar pathological process to that described above.

Molar pregnancy, a large placenta, and choriocarcinoma may also predispose to ovarian cysts due to elevated serum beta-hCG.[10]

tamoxifen therapy

Tamoxifen treatment in pre-menopausal breast cancer patients is associated with ovarian hyperstimulation and functional cyst formation.[16][17]

personal or family history of endometriosis

The prevalence of endometriosis in the general population is 5% to 15%, but the incidence of endometrioma formation has not clearly been identified. The frequency of endometrioma formation is estimated at 1% to 10%.[20] The presence of stage III to IV endometriosis significantly increases the risk of tubo-ovarian abscess in women aged 20 to 29 years and in those >40 years (relative risk 2.95).[9] The diagnosis of large (>9 cm) endometriomas, especially in women aged ≥45 years, increases risk (8.95 relative risk) of developing ovarian cancer, specifically clear-cell and endometrioid ovarian carcinoma.[20]

weak

smoking

One study found a threefold increased risk of benign mucinous ovarian tumours among women who smoked versus those with no history of smoking.[18] Another study found a significant increased risk of benign serous cystadenoma formation among smokers.[19]

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