A 30-year-old female presents to your office complaining of painful sexual intercourse for the past few weeks. The pain was getting progressively worse until it became unbearable.
Her past medical history is significant for infertility; she has been trying to conceive for the past 3 years without success. She admits to having cramping pain that usually begins a few days prior to and resolves a few days after her period. She denies any sexually transmitted infections or pelvic inflammatory disease.
Physical exam is significant for immobile uterus with nodularity along the uterosacral ligaments and palpable tender right adnexal mass. Ultrasound shows a homogeneous content of the right ovary.
Which of the following is the most likely diagnosis?
Correct Answer A: Endometriosis is a benign condition, the presence of endometrium-like glands and stroma outside the uterus. It is most often found in the ovaries but can also be found in other places, including fallopian tubes, bladder and intestines, uterine wall, and the lining of the pelvis. Patients with endometriosis present with the dys syndrome: dysmenorrhea, dyspareunia (painful intercourse), dyschezia (painful defecation) and dysuria.
Physical exam often reveals tender adnexal mass and firm nodularities along the broad ligament, uterosacral ligament or cul de sac.
The chocolate cyst of endometriosis in the ovary typically appears (on ultrasound) as a cyst containing low-level homogenous internal echoes consistent with old blood.
Endometriosis can cause infertility; in fact 30 % of infertile couples are diagnosed with this condition.
The gold standard for diagnosis of endometriosis remains laparoscopy.
A 35-year-old G0 woman presents with her husband to the infertility clinic for a follow-up visit. The couple has been trying to get pregnant for the past 2 years but has not had any success. A spermogram and a hysterosalpingogram as well as estrogen, progesterone, FSH and LH blood levels were all normal. Her menarche was at the age of 13 years and her cycles have always been regular, occurring every 30 days. The patient’s past medical history is significant for dysmenorrhea of 5 years duration and dyschezia for the last few months. Her last menstrual period was 1 week ago. She is taking no medications except for her daily multivitamins. Vitals are within normal limits. Physical exam reveals a non specific pelvic tenderness, a left adnexal mass and multiple tender nodular masses along the thickened uterosacral ligaments. Heart, lung, and abdominal examinations are unremarkable.
Which of the following is considered the gold standard test for diagnosis of the patient’s condition?
Correct Answer B:
Endometriosis is the presence of endometrial-like tissue outside the uterine cavity, which induces a chronic inflammatory reaction. It can occur in various pelvic sites such as on the ovaries, fallopian tubes, vagina, cervix, or uterosacral ligaments or in the rectovaginal septum. This condition is often associated with pelvic pain and infertility, but it is most often asymptomatic. The classic presentation is the Dys-syndrome: Dysmenorrhea, Dyspareunia, Dyschezia and Dysuria. Although not always done, laparoscopy is the gold standard test to visualize and confirm the diagnosis of endometriosis.
→ Endometrial biopsy (choice A) is the gold standard test for post menopausal bleeding diagnosis.
→ MRI (choice C) gives detailed image of the pelvic area and would be useful but again, not the gold standard.
→ Pelvic ultrasound (choice D) is an excellent test that is usually done for endometriosis and may show the adnexal cyst (chocolate cyst) or endometrial seedings in the Douglas pouch, but it is not the gold standard test.
→ Serum prolactin level (choice E) would the best initial test for suspected prolactinoma.
A G3P2 woman at 8 weeks gestation is found to have an ovarian cyst 6cm in size.
What is the appropriate management at this time?
Cysts (fluid-filled structures) can resolve on their own. Cysts are not that uncommon during pregnancy, affecting about 1 in 1,000 pregnant women. The vast majority of ovarian masses found during pregnancy are benign. Ultrasound can be helpful in determining if a mass is benign or malignant, but it cannot do so with 100 percent certainty. If ultrasound shows that the mass is strictly fluid-filled, without septation or thick walls, it is probably benign.
The problem with large, even benign, cysts during pregnancy is that they may rupture or torse (twist on themselves). Either of these events leads to significant pain for mom and the potential for miscarriage or preterm labor and delivery for the baby. Large (more than 6-8cm) cysts are usually removed surgically if they do not decrease in size spontaneously over the course of a few weeks.
In pregnancy, the best time to operate is in the second trimester, ideally around 14-16 weeks. Occasionally, a cyst may be dealt with via laparoscopy, but very large cysts often require a large, open incision.
A 5 cm right ovarian cyst is found incidentally during the first prenatal examination of an otherwise healthy 22-year-old primigravida at 12 weeks gestation.
The most likely diagnosis is:
Correct Answer E:
An ovarian cyst is an enlargement of the ovary that appears to be filled with fluid. The vast majority of ovarian cysts diagnosed in early pregnancy represent a physiological cyst known as the corpus luteum (cystic or hemorrhagic). This is a normal finding in early pregnancy. The corpus luteum supports the lining of the womb and in turn the pregnancy itself. The corpus luteum does this by producing the pregnancy hormone progesterone which helps nurture the pregnancy. Once the pregnancy gets beyond the 1st trimester, the corpus luteum is no longer needed and therefore this resolves spontaneously, not causing any harm whatsoever to the mother or baby.
Most ovarian cysts diagnosed in early pregnancy do not cause any symptoms. They tend to be an incidental finding and women are unaware of their presence. However, if an ovarian cyst ruptures, twists or if there is bleeding into the middle of the cyst, then lower abdominal pain on the side of the ovarian cyst occurs. Most ovarian cysts diagnosed in early pregnancy do not represent ovarian cancer; in fact the risk of ovarian cancer in pregnancy is extremely rare indeed (1 in 15,000 to 1 in 32,000 pregnancies).
A 24-year-old female presents with abdominal discomfort. Beta-hCG is negative. Pelvic ultrasound shows a 5 cm right ovarian hypoechoic cyst with an uniformly thin, rounded wall.
You would:
The management of ovarian cysts depends on a number of factors, including age of the woman, size of the cyst, type of cyst as determined by ultrasound (simple or complex), level of CA-125 and the presence or not of symptoms.
On a sonogram, simple ovarian cysts have a uniformly thin, rounded wall and a unilocular appearance that is either hypoechoic or anechoic. They usually measure 2.5-15 cm in diameter, and posterior acoustic enhancement (a hyperechoic area) may be visible deep to the fluid-filled cyst. These cysts are unlikely to be cancerous. Complex cysts may have more than 1 compartment (multilocular), thickening of the wall, papulations sticking into the lumen or on the surface, or abnormalities within the cyst contents. Malignant cysts usually fall within this category, as do many benign neoplastic cysts.
If ultrasound identifies that the cyst is simple, a wait-and-see plan ('expectant management') may be appropriate, because many simple ovarian cysts resolve spontaneously. In fact one study of 278 women aged 14 to 81 years with simple cysts found that 44% of cysts resolved with no treatment.
With expectant management, the woman has a repeat ultrasound 6-8 weeks after the simple cyst was first diagnosed. In the past, combined oral contraceptives were often prescribed to pre-menopausal patients during this time, but it is now accepted that these agents only prevent the development of functional cysts and do not suppress them. If the cyst has persisted after the observation period, then the patient is usually referred for surgical evaluation.
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