Polycystic ovarian syndrome involves the development of multiple small cysts in both ovaries due to an elevated ratio of leutenizing hormone to follicle stimulating hormone, typically more than 25 cysts in each ovary, or an ovarian volume of greater than 10 mL.Larger bilateral cysts can develop as a result of fertility treatment due to elevated levels of HCG, as can be seen with the use of clomifene for follicular induction, in extreme cases resulting in a condition known as ovarian hyperstimulation syndrome. Certain malignancies can mimic the effects of clomifene on the ovaries, also due to increased HCG, in particular gestational trophoblastic disease. Ovarian hyperstimulation occurs more often with invasive moles and choriocarcinoma than complete molar pregnancies. Risk of cancer
A widely recognised method of estimating the risk of malignant ovarian cancer based on initial workup is the risk of malignancy index (RMI). It is recommended that women with an RMI score over 200 should be referred to a centre with experience in ovarian cancer surgery.The RMI is calculated as follows:
RMI = ultrasound score × menopausal score × CA-125 level in U/ml.There are two methods to determine the ultrasound score and menopausal score, with the resultant RMI being called RMI 1 and RMI 2, respectively, depending on what method is used:
An RMI 2 of over 200 has been estimated to have a sensitivity of 74 to 80%, a specificity of 89 to 92% and a positive predictive value of around 80% of ovarian cancer. RMI 2 is regarded as more sensitive than RMI 1.
An ovarian cyst is a fluid-filled sac within the ovary. Often they cause no symptoms. Occasionally they may produce bloating, lower abdominal pain, or lower back pain. The majority of cysts are harmless. If the cyst either breaks open or causes twisting of the ovary, it may cause severe pain. This may result in vomiting or feeling faint, and even cause head aches. Most ovarian cysts are related to ovulation, being either follicular cysts or corpus luteum cysts. Other types include cysts due to endometriosis, dermoid cysts, and cystadenomas. Many small cysts occur in both ovaries in polycystic ovary syndrome (PCOS). Pelvic inflammatory disease may also result in cysts. Rarely, cysts may be a form of ovarian cancer. Diagnosis is undertaken by pelvic examination with an ultrasound or other testing used to gather further details.Often, cysts are simply observed over time. If they cause pain, medications such as paracetamol (acetaminophen) or ibuprofen may be used. Hormonal birth control may be used to prevent further cysts in those who are frequently affected. However, evidence does not support birth control as a treatment of current cysts. If they do not go away after several months, get larger, look unusual, or cause pain, they may be removed by surgery.Most women of reproductive age develop small cysts each month. Large cysts that cause problems occur in about 8% of women before menopause. Ovarian cysts are present in about 16% of women after menopause and if present are more likely to be cancer.