Ovarian cyst

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Ovarian cyst
Classification and external resources

Ovarian cyst
ICD-10 N83.0-N83.2
ICD-9 620.0-620.2
DiseasesDB 9433
eMedicine med/1699 emerg/352
MeSH D010048
An ovarian cyst is any collection of fluid, surrounded by a very thin wall, within an ovary. Any ovarian follicle that is
larger than about two centimeters is termed an ovarian cyst. An ovarian cyst can be as small as a pea, or larger than an
orange.
Most ovarian cysts are functional in nature, and harmless (benign).[1] In the US, ovarian cysts are found in nearly all
premenopausal women, and in up to 14.8% of postmenopausal women.[citation needed]
Ovarian cysts affect women of all ages. They occur most often, however, during a woman's childbearing years.
Some ovarian cysts cause problems, such as bleeding and pain. Surgery may be required to remove cysts larger than 5
centimeters in diameter.

Functional cysts
Some, called functional cysts, or simple cysts, are part of the normal process of menstruation. They have nothing to do
with disease, and can be treated. These types of cysts occur during ovulation. If the egg is not released, the ovary can
fill up with fluid. Usually these types of cysts will go away after a few period cycles.
• Follicular cyst of ovary: One type of simple cyst, which is the most common type of ovarian cyst, is the
graafian follicle cyst, or follicular cyst.
• Lutein cysts:
• Corpus luteum cyst: Another is a corpus luteum cyst (which may rupture about the time of
menstruation, and take up to three months to disappear entirely).
• Theca lutein cyst
The term "hemorrhagic cyst" is used to describe cysts where significant quantities of blood have entered.
"hemorrhagic follicular cyst" is classified under N83.0 in ICD-10, and "hemorrhagic corpus luteum cyst" is classified
under N83.1.

[edit] Non-functional cysts

There are several other conditions affecting the ovary that are described as types of cysts, but are not usually grouped
with the functional cysts. (Some of these are more commonly or more properly known by other names.) These
include:
• Dermoid cyst
• Chocolate cyst of ovary: An endometrioma, endometrioid cyst, endometrial cyst, or chocolate cyst is caused
by endometriosis, and formed when a tiny patch of endometrial tissue (the mucous membrane that makes up
the inner layer of the uterine wall) bleeds, sloughs off, becomes transplanted, and grows and enlarges inside
the ovaries.
• A polycystic-appearing ovary is diagnosed based on its enlarged size — usually twice normal —with small
cysts present around the outside of the ovary. It can be found in "normal" women, and in women with
endocrine disorders. An ultrasound is used to view the ovary in diagnosing the condition. Polycystic-
appearing ovary is different from the polycystic ovarian syndrome, which includes other symptoms in
addition to the presence of ovarian cysts.

[edit] Signs and symptoms

Some or all of the following symptoms[2] [3] [4] [5] [6] may be present, though it is possible not to experience any
symptoms:
• Dull aching, or severe, sudden, and sharp pain or discomfort in the lower abdomen (one or both sides), pelvis,
vagina, lower back, or thighs; pain may be constant or intermittent—this is the most common symptom
• Fullness, heaviness, pressure, swelling, or bloating in the abdomen
• Breast tenderness
• Pain during or shortly after beginning or end of menstrual period.
• Irregular periods, or abnormal uterine bleeding or spotting
• Change in frequency or ease of urination (such as inability to fully empty the bladder), or difficulty with
bowel movements due to pressure on adjacent pelvic anatomy
• Weight gain
• Nausea or vomiting
• Fatigue
• Infertility
• Increased level of hair growth
• Increased facial hair or body hair
• Headaches
• Strange pains in ribs, which feel muscular
• Bloating
• Strange nodules that feel like bruises under the layer of skin

An Axial CT demonstrating a large hemorrhagic ovarian cyst. The cyst is delineated by the yellow bars with blood
seen anteriorly.
Ovarian cysts are usually diagnosed by either ultrasound or CT scan.
Treatment
About 95% of ovarian cysts are benign, meaning they are not cancerous.[7]
Treatment for cysts depends on the size of the cyst and symptoms. For small, asymptomatic cysts, the wait and see
approach with regular check-ups will most likely be recommended.
Pain caused by ovarian cysts may be treated with:
• pain relievers, including acetaminophen/paracetamol (Tylenol), nonsteroidal anti-inflammatory drugs such as
ibuprofen (Motrin, Advil), or narcotic pain medicine (by prescription) may help reduce pelvic pain.[8]
NSAIDs usually work best when taken at the first signs of the pain.
• a warm bath, or heating pad, or hot water bottle applied to the lower abdomen near the ovaries can relax tense
muscles and relieve cramping, lessen discomfort, and stimulate circulation and healing in the ovaries.[9] Bags
of ice covered with towels can be used alternately as cold treatments to increase local circulation.[10]
• combined methods of hormonal contraception such as the combined oral contraceptive pill – the hormones in
the pills may regulate the menstrual cycle, prevent the formation of follicles that can turn into cysts, and
possibly shrink an existing cyst. (American College of Obstetricians and Gynecologists, 1999c; Mayo Clinic,
2002e)[8]
Also, limiting strenuous activity may reduce the risk of cyst rupture or torsion.
Cysts that persist beyond two or three menstrual cycles, or occur in post-menopausal women, may indicate more
serious disease and should be investigated through ultrasonography and laparoscopy, especially in cases where family
members have had ovarian cancer. Such cysts may require surgical biopsy. Additionally, a blood test may be taken
before surgery to check for elevated CA-125, a tumor marker, which is often found in increased levels in ovarian
cancer, although it can also be elevated by other conditions resulting in a large number of false positives.[11]
For more serious cases where cysts are large and persisting, doctors may suggest surgery. Some surgeries can be
performed to successfully remove the cyst(s) without hurting the ovaries, while others may require removal of one or
both ovaries.[12][13]

Rt. ovarian simple cyst:

This patient had an early gestation with embryo and intrauterine gestation sac. Sonography of the
adnexal regions also showed a cystic lesion of the right ovary, which was thin walled and showed no
septae or nodules within it, suggestive of a simple cyst (functional) of the right ovary. However, the left
adnexal region showed a thick walled cystic lesion with echogenic walls. This appearance can easily be
due to an ectopic pregnancy. Both ectopic gestations and corpus luteal cysts show similar features
including the presence of "ring of fire" or ring of vessels around the lesion (on Color Doppler imaging).
The left ovary was not seen separate from the left adnexal cyst; also there was no evidence of
significant fluid in the cul de sac; besides, the presence of intrauterine pregnancy lead to the diagnosis
of a left ovarian Corpus Luteal cyst. Ultrasound images are courtesy of Dr. V. Ganesan, MD, India.

Pathophysiology
The median menstrual cycle lasts 28 days, beginning with the first day of menstrual bleeding and
ending just before the subsequent menstrual period. The variable first half of this cycle is termed the
follicular phase and is characterized by increasing follicle-stimulating hormone (FSH) production,
leading to the selection of a dominant follicle that is primed for release from the ovary. In a normally
functioning ovary, simultaneous estrogen production from the dominant follicle leads to a surge of
leuteinizing hormone (LH), resulting in ovulation and release of the dominant follicle from the ovary
and commencing the leuteinizing phase of ovulation.
After ovulation, the follicular remnants form a corpus luteum, which produces progesterone. This, in
turn, supports the released ovum and inhibits FSH and LH production. As luteal degeneration occurs in
the absence of pregnancy, the progesterone levels decline, while the FSH and LH levels begin to rise
before the onset of the next menstrual period.
Different kinds of functional ovarian cysts can form during this cycle. In the follicular phase, follicular
cysts may result from a lack of physiological release of the ovum due to excessive FSH stimulation or
lack of the normal LH surge at mid cycle just before ovulation. Hormonal stimulation causes these
cysts to continue to grow. Follicular cysts are typically larger than 2.5 cm in diameter and manifest as
pelvic discomfort and heaviness. Granulosa cells that line the follicle may also persist, leading to
excess estradiol production, which, in turn, leads to decreased frequency of menstruation and
menorrhagia.1
In the absence of pregnancy, the lifespan of the corpus luteum is 14 days. If the ovum is fertilized, the
corpus luteum continues to secrete progesterone for 5-9 weeks until its eventual dissolution in 14
weeks time, when the cyst undergoes central hemorrhage. Failure of dissolution to occur may result in
a corpus luteal cyst, which is arbitrarily defined as a corpus luteum that grows to 3 cm in diameter. The
cyst can cause dull, unilateral pelvic pain and may be complicated by rupture, which causes acute pain
and possibly massive blood loss.
Theca lutein cysts are caused by luteinization and hypertrophy of the theca interna cell layer in
response to excessive stimulation of beta-human chorionic gonadotropin (bhCG). This type of cyst can
occur in the setting of gestational trophoblastic disease, multiple gestation, or exogenous ovarian
hyperstimulation. These cysts are associated with maternal androgen excess in up to 30% of cases but
usually resolve spontaneously as the bhCG level falls. Theca lutein cysts are usually bilateral and result
in massive ovarian enlargement, a condition termed hyperreactio luteinalis.2

MEDICATION

Paracetamol (INN) (pronounced /ˌpærəˈsiːtəmɒl, ˌpærəˈsɛtəmɒl/) or acetaminophen (/əˌsiːtəˈmɪnɵfɨn/

( listen)) (USAN) is a widely used over-the-counter analgesic (pain reliever) and antipyretic (fever
reducer).
It is commonly used for the relief of headaches, and other minor aches and pains, and is a major
ingredient in numerous cold and flu remedies. In combination with opioid analgesics, paracetamol can
also be used in the management of more severe pain (such as in advanced cancer).[2]
While generally safe for use at recommended doses (1,000 mg per single dose and up to 4,000 mg per
day for adults, up to 2,000 mg per day if drinking alcohol),[3] acute overdoses of paracetamol can
cause potentially fatal liver damage and, in rare individuals, a normal dose can do the same; the risk is
heightened by alcohol consumption. Paracetamol toxicity is the foremost cause of acute liver failure in
the Western world, and accounts for most drug overdoses in the United States, the United Kingdom,
Australia and New Zealand.[4][5][6][7]
Paracetamol is part of the class of drugs known as "aniline analgesics"; it is the only such drug still in
use today.[8] It is the active metabolite of phenacetin, once popular as an analgesic and antipyretic in
its own right, but unlike phenacetin and its combinations, paracetamol is not considered to be
carcinogenic at therapeutic doses.[9] The words acetaminophen (used in the United States, Canada,
Hong Kong, Iran,[10] Colombia and other Latin American countries) and paracetamol (used
elsewhere) both come from chemical names for the compound: para-acetylaminophenol and para-
acetylaminophenol. In some contexts, it is simply abbreviated as APAP, for N-acetyl-para-
aminophenol.
The classification of paracetamol, and the terminology used to refer to it, can cause confusion. It is
often classified as a nonsteroidal anti-inflammatory drug (NSAID), but paracetamol has few anti-
inflammatory effects in many tissues. However, aspirin, paracetamol and other NSAIDs all act by the
same mechanism (inhibition of prostaglandin synthesis) and all show varying levels of analgesic, anti-
inflammatory, antipyretic and antiplatelet actions.[11]

Available formsTylenol Rapid Release tablets (US)

Panadol 500 mg tablets (AU)

Generic 250 mg tablets (NK)

Duiyixiananjifenpian 500 mg tablets (CN)

See also: List of paracetamol brand names
Paracetamol is available in a tablet, capsule, liquid suspension, suppository, intravenous, and
intramuscular form. The common adult dose is 500 mg to 1000 mg. The recommended maximum daily
dose, for adults, is 4000 mg. In recommended doses, paracetamol generally is safe for children and
infants, as well as for adults,[29], although rare cases of acute liver injury have been linked to amounts
lower than 2.5 grams per day.[30]

Brand names[33] Aceta, Actimin, Anacin-3, Apacet, Aspirin Free Anacin, Atasol, Banesin, Ben-u-ron,
Biogesic, Crocin, Dafalgan, Dapa, Dolo, Datril, Extra-Strength, DayQuil, Depon & Depon Maximum,
Feverall, Few Drops, Fibi, Fibi plus, Genapap, Genebs, Lekadol, LemSip, Liquiprin, Lupocet, Milidon,
Neopap, Ny-Quil, Oraphen-PD, Panado, Panadol, Panamax, Paracet, Parol, Panodil, Paratabs, Paralen,
Phenaphen, Plicet, PyongSu Cetamol, Redutemp, Snaplets-FR, Suppap, Tamen, Tapanol, Tempra,
Tylenol, Uphamol, Valorin, Xcel.
Mechanism of action

The main mechanism of action of paracetamol is considered to be the inhibition of cyclooxygenase

(COX), and recent findings suggest that it is highly selective for COX-2.[34] While it has analgesic and
antipyretic properties comparable to those of aspirin or other NSAIDs, its peripheral anti-inflammatory
activity is usually limited by several factors, one of which is high level of peroxides present in
inflammatory lesions. However, in some circumstances even peripheral anti-inflammatory activity
comparable to other NSAIDs can be observed.

Indications

Paracetamol/acetaminophen is used for the relief of fevers, aches and pains associated with many
parts of the body. It has analgesic and antipyretic properties comparable to those of aspirin,
while its anti-inflammatory effects are weaker. It is better tolerated than aspirin in patients where
excessive gastric acid secretion or prolongation of bleeding time may be a concern. Available
without a prescription, it has in recent years increasingly become a common household drug.[49]
Acetaminophen can relieve pain in mild arthritis but has no effect on the underlying inflammation,
redness, and swelling of the joint. It is as effective as the nonsteroidal anti-inflammatory drug
ibuprofen (Motrin, Advil) in relieving the pain of osteoarthritis of the knee. Unless directed by
physician, acetaminophen should not be used for longer than 10 days.