THE IMPORTANCE OF A CORRECT OVARIAN CYST DIAGNOSIS

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Ovarian cysts are a common gynaecological problem; they are lesions with a liquid content that develop in or on the ovary. They are common and can occur at any age. The most common causes of ovarian cysts in childbearing age are due to ovulation, and in most cases they are functional ovarian cysts, i.e. follicular cysts or corpus luteum cysts. Most functional cysts are < 1.5 cm in diameter; a few are larger than 5 cm but can be as large as 10 cm. Functional cysts generally resolve spontaneously within days or weeks, without any treatment other than evolutionary ultrasound monitoring. Ovarian cysts may also represent benign ovarian tumours, differing from malignant tumours that usually present as solid or mixed-component, termed adnexal masses. Benign ovarian tumours usually present a slow growth and rarely undergo malignant transformation. Benign ovarian tumours include teratomas, fairly common dermoid cysts between 20 and 40 years of age that may contain teeth, hair or fat, fibromas, hydrosalpinx or cystadenomas. Most functional cysts and benign tumours are asymptomatic, but in some cases they may cause intermittent or acute dull pelvic pain or, rarely, profound dyspareunia. Other causes of ovarian cysts include polycystic ovary syndrome PCOS, in which an ovary containing small cysts is ultrasound detected, or endomteriosis, a condition that may lead to the development of a type of ovarian cyst called endometrioma, which is characterised by distinctive ultrasound features: thick-walled avascular cystic lesion containing low echogenic material with a ground glass appearance. Transvaginal ultrasound represents the first-line diagnostic gold standard. Ultrasound, referring to the IOTA classification (International Ovarian Tumor Analysis, an international multicentre prospective study that evaluated the use of a number of ultrasound features), attempts to discriminate between benign and malignant lesions in women with adnexal tumours that may require surgery. The classification is based on the search for certain features such as the content of the lesion (anechogenic, ground glass, haemorrhagic, mixed), the presence or absence of papillae or solid parts, the margins of the lesion, the presence or absence of septa, the vascularisation (described as a unit colour score), the morphological classification (unilocular, multilocular, solid) and additional descriptive findings such as the cone of shadow. Sometimes it is necessary to perform a level II diagnostic examination such as MRI to better study the relationships and characteristics of the lesion. Ovarian cysts can cause complications such as rupture, torsion or haemorrhage. Ovarian torsion is defined as partial or complete rotation of the ovarian vascular pedicle causing obstruction of the venous outflow and subsequently of the arterial inflow, causing a major symptom of acute abdomen. Ovarian torsion represents a gynaecological surgical emergency as, if left untreated, it can quickly lead to necrosis of the involved ovary. Ovarian cyst rupture and haemorrhage are essentially events that also occur physiologically during the ovarian cycle, involving the follicle or corpus luteum. The inner theca and corpus luteum are particularly prone to haemorrhage due to their increased vascularisation. As for the treatment of ovarian cysts, they do not always require treatment. In women of childbearing age, ovarian cysts often resolve spontaneously within one or two months without treatment. In menopausal women, on the other hand, they are less likely to resolve. Therefore in childbearing age one opts for watchful waiting with monitoring of symptoms (pain or pelvic pressure) and repeat pelvic ultrasound after about four to six weeks. After menopause, on the other hand, if a cancerous lesion is excluded, the ultrasound appearance and CA125 levels are monitored over time, and if they increase or if the cyst changes size or morphological appearance, the treatment of choice becomes surgery. Surgery may involve simple enucleation or ovariectomy depending on the suspicion, the patient's age and characteristics such as the size of the lesion. Taking into account this range of possibilities and the different procedures that open up when ovarian cysts are found, one deduces the importance of the correct diagnosis in order to then plan the appropriate follow-up. It should also be emphasised that, since ovarian cyst diagnosis occurs at any age, an important scenario is represented by women of childbearing age seeking pregnancy. For instance, when faced with a diagnosis of endometrioma, excision improves spontaneous pregnancy rates in subfertile individuals, but has no impact when advanced reproductive technologies such as in vitro fertilisation are employed. Endometrioma resection has not been shown to improve the results of in vitro fertilisation/intracytoplasmic sperm injection and is therefore not recommended for this indication. The indication remains only in the event of symptoms, to exclude malignancy or if the size and/or position of the endometrioma preclude follicle aspiration. 

REFERENCES

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