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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.
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]
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
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
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.