Management of non-neoplastic ovarian cysts with sclerotherapy

OBJECTIVE

To evaluate sclerotherapy with alcohol and erythromycin in the management of simple ovarian cysts.

METHODS

Twenty-four simple ovarian cysts were subjected to sclerotherapy with alcohol and erythromycin. All procedures were performed under local anesthesia and in an outpatient setting. Cytological examination was carried out in all cases and two patients were excluded from the study because of suspicious cytological results. The patients were followed up monthly with color Doppler sonography for more than 12 months.

RESULTS

Cyst fluid was serous in 17 cases and dark-chocolate colored in seven cases. The volume of aspirated fluid ranged from 100 to 220 ml. The size of ovarian masses and cyst-wall thickness ranged from 5.5 to 8.5 cm and 1.5 to 5 mm, respectively. Cytological analysis of 15 cysts revealed acellular sediment, seven cysts were compatible with endometrioma, and two were reported as suspicious. During the 12-month follow-up, seven cyst recurrences were detected.

CONCLUSION

Aspiration and sclerotherapy with alcohol and erythromycin are followed by a relatively high recurrence rate when the aspirate is bloody. However, patients with a simple cyst that is painful or liable to torsion could benefit from sclerotherapy. Such patients, who are at low risk for malignancy, are relieved with sclerotherapy while avoiding surgery.

Management of ovarian cysts in women undergoing restorative proctocolectomy for ulcerative colitis

More than half of all patients undergoing restorative proctocolectomy (RP) for ulcerative colitis (UC) are women, yet there is a paucity of information regarding the frequency, management, and outcome of ovarian cysts. A single surgeon's (E.W.F.) experience with female patients (N = 165) who underwent RP for UC at an academic medical center was retrospectively evaluated for postoperative complications and overall outcome. Patients with large ovarian cysts (LOCs), defined as being greater than 5 cm in diameter, were further segregated for subanalysis. All results were analyzed using the Student's t test and Fisher's exact test. Patients were 29.3 +/- 13 years (mean) at the time of RP; 34 patients were less than 16 years old (21%), 113 patients (68%) were between the ages of 17 and 46 years, and 18 patients were over 46 years old (11%). All patients underwent total colectomy, mucosal proctectomy ileal pouch-anal anastomosis, and temporary end ileostomy. The ileostomy was closed 3 months later. Fifty-five of the 165 patients had ovarian cysts (33%) identified at operation, 46 had unilateral cysts, and nine had bilateral cysts. Mean ovarian cyst size was 4.6 +/- 2.7 cm (range <1-13 cm); 14 were LOCs. Patients with cysts <3 cm in diameter at operation were treated by observation with hormonal manipulation. Seventeen patients with cysts 3 to 5 cm in diameter required partial resection of one or both ovaries. Six of 14 patients with LOC underwent unilateral oophorectomy (cyst size range 10-13 cm). Twelve patients presented within 3 years after RP with malfunction of the pouch because of adhesions or minimal and uncontrolled passage of fecal material (soiling), partial obstruction due to LOC compression of the ileoanal pouch (n = 6), or adhesions. When evaluated on the basis of ovarian cyst size those without cysts and those with small cysts were significantly more likely to have children than those with LOC: 54 of 110 patients without cysts (49%), 18 of the 41 with cysts less than 5 cm in diameter (44%), and two of the 14 patients with LOC (14%) have had children (P = 0.047). Ovarian cysts are common in women undergoing RP for UC. Ovarian cysts often complicate postoperative intestinal function and are best treated by cyst resection or oophorectomy at the time of RP or ileostomy closure. Cysts under 3 cm in diameter may often be managed conservatively with few complications. Women with LOC after RP for UC have decreased fertility compared with those without cysts.

Neonatal ovarian cysts

Foetal and neonatal ovarian cysts have previously been considered uncommon. With the development of sonography, however, the detection of cysts has increased. As ovarian cyst formation in the perinatal period is a self-limiting process, treatment options depend on the risk of complications and on the ability to differentiate these benign cysts from other pathology. The history of two neonates with an ovarian cyst detected antenatally with ultrasound techniques is described.

CONCLUSION

It is important that paediatricians have knowledge about the incidence, treatment and prognosis of foetal neonatal ovarian cysts.

[Functional ovarian cysts in girls]

Ovarian masses may result from functional (nonneoplastic) cysts or benign or malignant neoplasms. In 1973, the World Health Organisation classified ovarian neoplasms into nine major categories and 26 subtypes, based on histologic cell type and benign versus malignant state. The literature review concerning functional ovarian cysts in girls has been presented. Functional cysts are not true neoplasms but rather should be considered a variation of a normal physiologic process. Functional cyst include follicular, corpus luteum, and theca-lutein types, all of which are benign and usually self-limited. The incidence of functional cysts in the community is probably even higher than indicated in most series, as percentages are based on referred cases and it is not possible to determine the underlying incidence of nonidentified or asymptomatic cysts. Incidence, etiopathogenesis, clinical symptoms, methods of diagnostics, treatment and results of functional cysts in fetus and newborns, in children and adolescents are discussed.

Asymptomatic postmenopausal simple ovarian cyst

High-resolution transvaginal ultrasound frequently reveals incidental, simple ovarian cysts in asymptomatic postmenopausal women. Traditionally oophorectomy has been recommended for these women. However, evidence is emerging that most postmenopausal simple ovarian cysts are benign, allowing conservative management. Furthermore, many of these cysts will resolve spontaneously. Cancer antigen 125 (CA-125) and color Doppler may help differentiate benign from malignant cysts. When oophorectomy is favored, the laparoscopic approach may be considered, depending on the clinical situation. Nonoperative management of simple ovarian cysts in asymptomatic women is reasonable; regular follow-up with sonography should be performed. Because sonography is an operator-dependent test, it is imperative that the sonographer have expertise in ovarian imaging. Monitoring of CA-125 levels may be useful. Indications for removal during follow-up are increasing size, development of solid components, abnormal Doppler flow, CA-125 elevation, patient desire for removal of the cyst, and noncompliance with sonographic follow-up.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians

LEARNING OBJECTIVES

After completion of this article, the reader will be able to estimate the prevalence of benign simple ovarian cysts in a postmenopausal population of women, to describe the natural history of a simple ovarian cyst, and outline the features consistent with a benign ovarian cyst on ultrasound.

Ovarian cysts in neonates, children and adolescents

PURPOSE OF REVIEW

This review is intended to increase the understanding of normal ovarian physiology in neonates, prepubescent girls and adolescents and to outline management guidelines for ovarian cysts at each age.

RECENT FINDINGS

Ultrasound has increased the level of understanding regarding the development of ovarian cysts. With ultrasound, ovarian cysts are recognized as a consequence of follicular growth and atresia that can be a normal developmental occurrence at all ages. Clinical experience has taught us that ovarian cysts are common, frequently regress without treatment and are seldom associated with malignancy. New management schemes are developing which rely on increased recognition of torsion and prompt intervention to untwist the adnexa and leave it in situ. In addition, new operative techniques are being developed that are less invasive and morbid, as well as being more conservative of ovarian tissue.

SUMMARY

With the understanding of normal ovarian follicular growth in girls prior to full maturity, the normal development of ovarian cysts can be appreciated. Conservative therapies with observation can often replace surgical management. When treatment is necessary, knowledge of less invasive and morbid techniques can improve ovarian preservation rates.

Reproductive performance after ultrasound-guided transvaginal ethanol sclerotherapy for ovarian endometriotic cysts

OBJECTIVE

Ultrasound-guided transvaginal ethanol sclerotherapy (TV-EST) has been widely practised in Japan for ovarian endometriotic cysts. We investigated the possible adverse effects of TV-EST for ovarian endometriotic cysts on reproductive performance.

PATIENTS AND METHODS

We reviewed retrospectively medical records and compared clinical outcomes of 45 subfertile women who underwent TV-EST for ovarian endometriotic cysts (Study group) with those of 65 subfertile women without ovarian endometriotic cysts (Comparison group). Patients were followed up monthly for 24 months. Serum levels of LH, FSH, CA125 and CA19-9 were determined before and after TV-EST.

RESULTS

No complications associated with TV-EST were observed. There were no differences in the numbers of pregnancies (47% (21/45) versus 39% (25/65)), term deliveries (76% (16/21) versus 76% (19/25)), abortions (19% (4/21) versus 24% (6/25)), retrieved oocytes, or quality of embryos between the Study and Comparison groups, respectively. The serum levels of LH and FSH did not increase after TV-EST. The serum levels of CA125 and CA19-9 did not significantly decrease after TV-EST. Ovarian cysts recurred in six (13.3%) of the 45 women 5.2+/-3.9 months after TV-EST.

CONCLUSION

Although only a small number of women were studied, our observational study suggested that TV-EST appeared not to adversely affect reproductive performance in subfertile women with ovarian endometriotic cysts.

17beta-estradiol, progesterone and testosterone concentrations in cystic fluids and response to GnRH treatment after emptying of ovarian cysts in dairy cows

The aim of this study was to determine possible links between steroidogenic activity of single ovarian cysts and response to intramuscular treatment with 20 microg of buserelin (GnRH-analogue) after cyst emptying, in pluriparous Friesian cows bearing a singleton cyst treated not earlier than 55 days post-partum. Progesterone, 17beta-estradiol and testosterone were determined in cystic fluids collected by needle aspiration of the cyst. Of the cows, 75.6% began ovarian cyclicity within 30 days after treatment with a conception rate of 64.7%. In this study it was found that as progesterone concentration in cystic fluids rose, the number of positive responses to the treatment fell.

Ultrasound guided aspiration in pathological adnexal processes

OBJECTIVE

To establish the efficiency of ultrasonographically guided transvaginal adnexal cyst aspiration as a treatment and diagnostic method.

STUDY DESIGN

In 72 patients with an adnexal cystic mass, transvaginal ultrasound guided cyst aspiration was performed. Before the procedure, presence of primary malignant disease was excluded by gynecologic and ultrasound examination. Cyst content was sent for cytological analysis. Cytological findings were staged according to Papanicolaou. Patients were re-examined 3 and 6 months after the ultrasound intervention. Cysts measuring 3 cm or more in diameter were considered to be recurrence of the disease.

RESULTS

Recurrence of the disease appeared in 32 cases (44%) and was more common with larger cysts. Malignant cells were found in one case (1.5%), a recurrent ovarian cancer, previously treated by surgery and chemotherapy.

CONCLUSION

In our study, ultrasound guided aspiration of adnexal cysts was not shown to be an efficient method of treatment because of the high recurrence rate. It may be used in selected patients at high anaesthesiologic risk for surgery as a therapeutic or a diagnostic procedure.

A paraneoplastic syndrome mimicking extrauterine pregnancy

We report on a 30-year-old female patient with a beta-human chorionic gonadotropin (beta-HCG)-producing lung tumour. Abdominal discomfort and vaginal bleeding were the presenting symptoms and, in conjunction with elevated beta-HCG levels, initially led to the diagnosis of extrauterine pregnancy. Bilateral ovarian cysts were detected on further diagnostic workup. Ultimately, a chest X-ray revealed a lung tumour. The paraneoplastic symptoms were completely reversible after resection of the lung lesion, and the ovarian cysts disappeared.

[Management of endometriosis ovarian cysts]

The efficacy of medical treatment as unique treatment for endometrioma is not demonstrated. Operative laparoscopic management is the gold standard for surgical treatment. There is no indication to prescribe preoperatively medical treatment before cystectomy. Post-operative administration of low-dose cyclic oral contraceptive does not significantly affect long-term recurrence rate of endometriosis after surgical treatment. In cases of infertility, management of endometriomas is controversial. Recurrent ovarian surgery is not recommended.

[Ovarian cysts and pregnancy]

FREQUENCY AND HISTOLOGY: In the first trimester of pregnancy, ovarian cysts are often functional without complications. After 16 weeks of gestation, frequency of ovarian cyst is reported between 0.5 and 3.0%. Histological results are identical to those observed in non pregnant women between 15 and 44 years, essentially dermoid cysts and functional cysts. Frequency of ovarian cancer is reported between 1 out of 15,000 and 1 out of 32,000 pregnancies. A surgical intervention is necessary if suspect signs are observed at ultrasonographic examination.

RISK OF COMPLICATIONS

Almost all unilocular cyst with a diameter < 5 cm and persistent in second and third trimester are not associated with complications and are regressive during pregnancy; in this cases, abstention seems warranted. Conclusions are similar for dermoid cysts with diameter < 6 cm and without malignant criteria but there are a few studies on theses topics. No prospective studies are available to assess the risk of cancer or complications for cyst with diameter > 6 cm without malignant criteria.

MANAGEMENT

Evacuation by puncture is not well evaluated and is not recommended during pregnancy. If an intervention is decided, laparoscopy is warranted until 16-17 weeks. After 17 weeks, laparotomy is the most evaluated method.

OBSTETRICAL CONSEQUENCES

They are uncommon and caesarean section is warranted only if a cyst in the pelvis will obstruct labour. During caesarean section, removal of a cyst should be performed.

[Role of echo-guided aspiration of ovarian cysts. Our experience]

BACKGROUND

Ultrasound-guided puncture is a simple and easy to perform procedure. This study was undertaken to verify the role of fine-needle aspiration (FNA) followed by cytological examination as a possible alternative to surgery in case of cystic pelvic masses. Ovarian cysts are conventionally managed by laparoscopy or laparotomy.

METHODS

From January 1993 to December 1997, 224 patients with a proven cystic pelvic mass underwent surgical intervention and have been retrospectively analysed for FNA under sonographic guidance. The sediment aspirated was examined by a cytological method and when possible it was also correlated to a histological test.

RESULTS

Eight patients (34.8%) had been submitted to one needle cyst aspiration before surgical intervention and 15 (65.2%) to more than one aspiration. Patients with an history of only one aspiration were submitted to surgical intervention with urgency statistically more than the group with an history of more than one aspiration. Anatomo-pathologic examination showed a significative relevance of serous and endometriotic cysts.

CONCLUSIONS

We conclude that FNA might be proposed in young women with a unilocular ovarian cyst to avoid a surgical procedure. In all instances the ultrasonographic appearance of the cyst and the characteristics of aspirated fluid are the most important findings.

Clinical management of functional ovarian cysts: a prospective and randomized study

Most ovarian cysts in women of reproductive age are physiological (functional) and patients have been treated for years with oral contraceptives to obtain the resolution of these cysts. Expectant management has been suggested to have the same effectiveness as hormonal treatment but such suggestions come from studies including all kinds of cysts. The objective of the present study was to assess the resolution of functional ovarian cysts, observed after ovulation induction, with expectant management and hormonal treatment and also to determine the period of time necessary for the resolution of the cysts. For this purpose, 53 patients with ovarian cysts, observed by transvaginal ultrasound within the first 5 days of a cycle after ovulation induction, were randomized to have expectant management (group A) or to receive oral contraception (group B) for one cycle. If the cyst persisted, the patient was followed for another cycle, without any treatment. Within the 50 women who completed the trial, a complete resolution of the cysts was observed in 19/25 (76%) and 18/25 (72%) in groups A and B respectively. On the other hand, all the persistent cysts disappeared after a second cycle without any treatment. In conclusion, expectant management is as effective as oral contraceptives for the resolution of functional ovarian cysts induced by ovarian stimulation. However, studies with a larger number of cases are needed to increase the power of the results and to obtain a firm conclusion.

Fetal ovarian cysts: a report of three cases managed by intrauterine aspiration

Small follicular or functional theca-lutein cysts are a common finding in fetal and neonatal ovaries. After delivery, decrease of hormonal stimulation may lead to spontaneous resolution of the cyst. A high rate of complication has been underlined by recent studies, the most common being ovarian torsion with subsequent loss of the ovary. Because torsion may happen with any size of cyst, however large or small, we suggest in utero decompression even in small fetal ovarian cysts (< 5 cm). We report here three cases of such cysts managed by intrauterine aspiration with good outcome and no further need for neonatal surgery. In all cases cytology of the cyst aspirate demonstrated numbers of granulosa cells and fluid biochemistry showed a high amount of estradiol, progesterone, and testosterone that confirmed the etiology as ovarian. Despite the small size of the cysts, no technical difficulties were encountered and no maternal or fetal morbidity occurred. Prenatal management of fetal ovarian cysts remains controversial, however, and our limited experience needs to be assessed on a larger number of cases.

[Back fat thickness and fertility in Brown Swiss cows]

In a total of 94 cows the mean back fat thickness (BFT) on Day 275 of pregnancy and 2 to 3 days after calving (peripartal) as well as between Days 42 and 44 post partum (postpuerperal) has been examined sonographically. Based on their BFT levels all examined cows have been divided into three groups: overconditioned, optimal conditioned and underconditioned cows. Cows which were peripartal overconditioned had more often ovarian cysts (p < 0.05) and were culled more frequently (p < 0.1) because of infertility than peripartal cows which were optimal or underconditioned. Nevertheless, the interval from calving to conception of peripartal cows being in different physical conditions was not significantly different. Postpuerperal cows which were overconditioned had more often ovarian cysts (p < 0.05) and were more frequently (p < 0.05) slaughtered because of infertility than postpuerperal cows which were optimal or underconditioned. Postpuerperal cows which were over- or underconditioned had a significantly longer interval from calving to conception than cows which were optimal conditioned 6 weeks after calving. The correlation coefficient between peripartal and postpuerperal BFT was 0.82 (p < 0.05). The decrease of BFT between the peripartal and postpuerperal timepoint had no significant influence on the frequency of ovarian cysts, the interval from calving to conception and the infertility caused culling rate.

Conservative management versus aspiration of functional ovarian cysts before ovarian stimulation for assisted reproduction

PURPOSE

To compare the efficiency of transvaginal ultrasound-guided functional ovarian cyst aspiration, with conservative management, in the outcome of patients undergoing assisted reproductive technique (ART) (in vitro fertilization or intracytoplasmic sperm injection). These cysts were identified before ovarian stimulation begun and after administration of a midluteal GnRH agonist.

METHODS

Fifty nine patients undergoing ART from January 1, 1997 to February 28, 1999, who developed functional ovarian cysts were included. Aspirations of these cysts (n = 14) versus conservative management (observation) (n = 45) were compared. Total number of ovarian follicles developed, number of oocytes retrieved, estradiol levels on the day of human chorionic gonadotropin, fertilization rate, number of good quality embryos transferred, implantation, and clinical pregnancy rate per cycle were evaluated.

RESULTS

No statistical differences were observed between the two groups in any of the selected parameters.

CONCLUSIONS

Cyst aspiration and conservative management showed similar implantation and pregnancy rates, in patients who develop functional ovarian cysts after pituitary down-regulation following luteal phase gonadotropin-releasing hormone agonist administration. Prospective studies are needed to confirm this trend.

Ovarian cyst formation and congenital absence of the inferior vena cava: case report

Congenital absence of the inferior vena cava (IVC) is a rare condition that presents clinically as recurrent venous thromboses and leg ulcers. We report an association with painful ovarian cysts in a 25 year old woman. The possible pathophysiology and unique management issues posed by this case are presented.

Conservative management of ovarian cystic teratoma during pregnancy and labor

OBJECTIVE

Our goal was to evaluate the adequacy of conservative management during pregnancy and labor in women with an ultrasonographically diagnosed ovarian cystic teratoma.

STUDY DESIGN

Forty-nine women with ultrasonographically diagnosed ovarian cystic teratoma <6 cm were followed for detection of possible complications through pregnancy and labor. Serial ultrasonographic examinations before pregnancy, during pregnancy, and after delivery were performed to detect changes in the size of the cystic teratoma.

RESULTS

In a group of 49 women with dermoid cysts (mean age, 30 years), 68 pregnancies resulted. Of the 68 pregnancies, 4 ended in miscarriages, 1 was electively terminated, and in the remaining 63 pregnancies, a total of 64 healthy infants were delivered. Five patients needed treatment with assisted reproductive techniques. Fifty-five pregnancies ended in normal vaginal deliveries and 8 were delivered by cesarean (cesarean delivery rate of 16%). None of the classical complications attributed to dermoid cysts such as torsion, dystocia, or rupture occurred in the study group. In a follow-up of 56 dermoid cysts throughout pregnancy, cyst size remained unchanged.

CONCLUSIONS

Ovarian dermoid cysts <6 cm are not expected to grow during pregnancy or to cause complications in pregnancy and labor.

[Clinical study on endometrial ovarian cyst treated by integrated laparoscopy and Chinese herbal medicine]

OBJECTIVE

To investigate a new method of integrated laparoscopy with Chinese herbal medicine (CHM) in treating endometrial ovarian cyst.

METHODS

One hundred and fifty-two patients with endometrial ovarian cyst were randomly treated with three therapies: Integrated laparoscopy with CHM (combination group), CHM (TCM group) and Danazol (WM group). To compare the clinical efficacy and side-effects of the three groups and to elucidate the therapeutic mechanism by detecting the serum CA125 reproductive endocrine hormone, plasma PGF1 alpha, PGE2 etc.

RESULTS

The shrinking rate and disappearance rate of the cysts, and markedly effective rate of combination group were obviously higher than those of TCM group and WM group (P < 0.05, P < 0.01). The pregnancy rate of combination group was also higher than that of WM group (P < 0.05). Few side-effects were the most prominent advantage for combination group and TCM group. After treatment, the plasma PGF1 alpha lowered remarkably, serum p.o. increased and CA125 reduced obviously (P < 0.01, P < 0.05).

CONCLUSION

The integrated laparoscopy and CHM combination therapy is a new method in treating endometrial ovarian cyst with significant efficacy, minimal adverse effect and maximal preservation of reproductive function.

Comparison of synchronization of ovulation and induction of estrus as therapeutic strategies for bovine ovarian cysts in the dairy cow

The benefit of using timed-insemination in lactating dairy cows for the treatment of ovarian cysts lies in the fact that cows do not have to be detected in estrus for insemination and achieving pregnancy. We compared the effectiveness of synchronization of ovulation with timed-insemination and induction of estrus with insemination at estrus in the treatment of bovine ovarian cysts in lactating dairy cows. After Day 65 post partum, a total of 368 lactating dairy cows was divided into 3 groups. Cows in Group 1 (n = 209, normal, noncystic) were treated with 100 ug, i.m. GnRH on Day 0; 25 mg, i.m. PGF2 alpha on Day 7; and 100 ug, i.m. GnRH on Day 9 and then were time-inseminated 16 h later. Cows in Group 2 (n = 76, abnormal, cystic) were treated with 100 ug, i.m. GnRH on Day 0; 25 mg, i.m. PGF2 alpha on Day 7; and 100 ug, i.m. GnRH on Day 9 and time-inseminated 16 h later. Cows in Group 3 (n = 83, abnormal, cystic) were treated with 100 ug, i.m. GnRH on Day 0; 25 mg, i.m. PGF2 alpha on Day 7; and inseminated at induced estrus within 7 d after treatment with PGF2 alpha. Day 0 was the day of initiation of the study. Conception and pregnancy rates among groups were compared using logistic regression and adjusted for parity, time of year and days in milk. Conception and pregnancy rates of Group 1 cows (31.5%) were not significantly different from those of Group 2 cows (23.6%). However, the pregnancy rate in normal cows (Group 1) was higher (P < 0.01) than in cystic cows (Groups 2 and 3). Cows in Group 3 had a higher conception rate than cows in Group 2 (51.7% > 23.6%; P < 0.01). However, pregnancy rates for cows in Groups 2 (23.6%) and 3 (18%) were not significantly different. The finding indicated that synchronization of ovulation and timed-insemination resulted in pregnancy rates similar to those of synchronization of estrus and insemination at an induced estrus within 7 d for the treatment of ovarian cysts in lactating dairy cows.