Nonneoplastic Ovarian Masses Functional ovarian cysts include follicular cysts, corpus luteum cysts, and theca lutein cysts. All are benign and usually do not cause symptoms or require surgical management. Cigarette and marijuana smoking are associated with an increased risk of functional cysts, although the increased risk may be attenuated in overweight or obese women (198). Oral contraceptive use is associated with a decreased risk of developing ovarian cysts, although low-dose pills may have a smaller benefit, and oral contraceptives do not hasten the resolution of ovarian cysts (199,200). The annual rate of hospitalization for functional ovarian cysts is estimated to be as high as 500 per 100,000 woman-years in the United States, although little is known about the epidemiology of the condition. The most common functional cyst is the follicular cyst, which rarely is larger than 8 cm. A cystic follicle can be defined as a follicular cyst when its diameter is greater than 3 cm. These cysts usually are found incidental to pelvic examination, although they may rupture or torse, causing pain and peritoneal signs. They can resolve in 4 to 8 weeks with expectant management (201).
Corpus luteum cysts are less common than follicular cysts. Corpus luteum cysts may rupture, leading to a hemoperitoneum and requiring surgical management. Patients taking anticoagulant therapy or with bleeding diatheses are at particular risk for hemorrhage and rupture. Rupture of these cysts occurs more often on the right side and may occur during intercourse. Most ruptures occur on cycle days 20 to 26 (202). Unruptured corpus luteum cysts can cause pain, presumably because of bleeding into the enclosed ovarian cyst cavity. They can produce symptoms that can be difficult to discern from adnexal torsion.
Theca lutein cysts are the least common of functional ovarian cysts. They are usually bilateral and occur with pregnancy, including molar pregnancies. They may be associated with multiple gestations, molar pregnancies, choriocarcinoma, diabetes, Rh sensitization, clomiphene citrate use, human menopausal gonadotropin–human chorionic gonadotropin ovulation induction, and the use of GnRH analogues. Theca lutein cysts may be quite large (up to 30 cm), are multicystic, and regress spontaneously (203).
Combination monophasic oral contraceptive therapy is reported to reduce the risk of functional ovarian cysts (204). It appears that, in comparison with previously available higher-dose pills, the effect of cyst suppression with low-dose oral contraceptives is attenuated (205,206).
Ultrasound Exclude nongynecologic problem, e.g., with barium enema ≤8 cm >8–10 cm Ultrasound Complex, solid, and suspicious Progression Cystic PostmenopausalPremenopausal SurgeryObservation ± suppression for 2 months
Figure 14.20 Preoperative evaluation of the patient with an adnexal mass.
The use of triphasic oral contraceptives is not associated with an appreciable increased risk of functional ovarian cysts (207).
Other Benign Masses Women with endometriosis may develop ovarian endometriomas (“chocolate” cysts), which can enlarge to 6 to 8 cm in size. A mass that does not resolve with observation may be an endometrioma (see Chapter 17). Excision is preferable to ablative techniques with regard to resolution of pain, achievement of spontaneous pregnancy, and risk of recurrence (208).