Although enlarged, polycystic ovaries were originally considered the sine qua non of PCOS, and are included among the Rotterdam diagnostic criteria, they are not always present with other features of the syndrome (209). An enlarged ovarian volume is suggested as an alternative diagnostic criterion, although whether the threshold should be 10 cm3 or 7 cm3 is debated (210). The prevalence of PCOS among the general population depends on the diagnostic criteria used. In one study, 257 volunteers were examined with ultrasonography; 22% were found to have polycystic ovaries (211). The finding of generously sized ovaries on examination or polycystic ovaries on ultrasonographic examination should prompt evaluation for the full-blown syndrome, which includes hyperandrogenism, chronic anovulation, and polycystic ovaries (159). Therapy for PCOS is medical and generally not surgical, with lifestyle modification and weight loss playing a potentially important role (212).
Figure 14.21 Mature cystic teratoma (dermoid cyst) of the ovary.
Neoplastic Masses Most benign cystic teratomas (dermoid cysts) occur during the reproductive years, although dermoid cysts have a wider age distribution than other ovarian germ cell tumors; in some case series, up to 25% of dermoids occur in postmenopausal women, and they can occur in newborns (213). Histologically, benign cystic teratomas have an admixture of elements (Fig. 14.21). In one study of ovarian masses that were surgically excised, dermoid cysts represented 62% of all ovarian neoplasms in women younger than 40 years of age (197). Malignant transformation occurs in less than 2% of dermoid cysts in women of all ages; most cases occur in women older than 40 years of age. The risk of torsion with dermoid cysts is approximately 15%, and it occurs more frequently than with ovarian tumors, perhaps because of the high fat content of most dermoid cysts, allowing them to ﬂoat within the abdominal and pelvic cavity. As a result of this fat content, on pelvic examination a dermoid cyst frequently is described as anterior in location. They are bilateral in approximately 10% of cases, although many have advanced the argument against bivalving a normal-appearing contralateral ovary because of the risk of adhesions, which may result in infertility. An ovarian cystectomy is almost always possible, even if it appears that only a small amount of ovarian tissue remains. Preserving a small amount of ovarian cortex in a young patient with a benign lesion is preferable to the loss of the entire ovary (214). Laparoscopic cystectomy often is possible, and intraoperative spill of tumor contents is rarely a cause of complications, although granulomatous peritonitis was reported (215–217). Laparoscopic removal may be associated with a higher risk of recurrence (216).