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eMedicine Specialties > Obstetrics and Gynecology > General Gynecology

Benign Lesions of the Ovaries

Diana Curran, MD, FACOG, Clinical Assistant Professor, Associate Program Director, Department of
Obstetrics and Gynecology, University of Michigan Health Systems
Jennifer L Ashton, MD, Consulting Staff, Department of Obstetrics and Gynecology, Englewood Hospital
Medical Center, All-Women Ob-Gyn Associates, LLC
Updated: Aug 19, 2007

Dysfunctional Ovarian Cysts

Follicle cysts

Follicle cysts of the ovary are the most common cystic structures found in healthy ovaries. These
cysts arise from temporary pathologic variations of a normal physiologic process and are not
neoplastic. The tumors result from either nonrupture of the dominant mature follicle or failure of an
immature follicle to undergo the normal process of atresia. Many follicle cysts lose the ability to
produce estrogen; in other instances, the granulosa cells remain productive, with prolonged secretion
of estrogen. Solitary follicle cysts are common and occur during all stages of life, from the fetal stage
to the postmenopausal period. The cysts are thin walled and unilocular, usually ranging from several
millimeters to 8 cm in diameter (average, 2 cm). Follicle cysts are lined with an inner layer of
granulosa cells and an outer layer of theca interna cells.

Corpus luteum cysts

Corpus luteum cysts are less prevalent than follicular cysts. The cysts mainly result from intracystic
hemorrhage. They are hormonally inactive but may tend to rupture with intraperitoneal bleeding,
especially in patients on anticoagulant therapy.

Generally, no treatment is required, and many of these cysts resolve spontaneously within 6-12
weeks. In every case involving postmenopausal women with a pelvic mass, the cancer antigen 125
(CA-125) level, although imprecise, should be ordered and pelvic ultrasonography should be
performed. Newer markers for ovarian cancer are on the horizon and will hopefully be available in the
near future. If the CA-125 level is elevated and/or the ultrasonographic features of the mass are
suggestive of malignancy, the patient should be referred for evaluation by a gynecologic oncologist.
In premenopausal women with a pelvic mass, generally an ultrasonogram suffices for the initial
evaluation and, often, for follow-up, as well.

In rare situations (eg, torsion, rupture and hemorrhage), operative intervention may be needed to
treat these cystic masses.

Benign Epithelial Neoplastic Cysts of the Ovary

Epithelial cysts

Epithelial cystic tumors account for approximately 60% of all true ovarian neoplasms. One third of all
ovarian tumors are the serous type, and two thirds of these serous tumors are benign. By definition,
serous tumors are characterized by a proliferation of epithelium resembling that which lines the
fallopian tubes. They are virtually all cystic, are most commonly seen in women in their forties and
fifties, and are bilateral in 15-20% of cases. Benign lesions (e.g. mucinous cystadenoma) may be
unilocular or multilocular; have a smooth lining surface; and contain thin, clear, yellow fluid.
Mucinous epithelial tumors account for approximately 10-15% of all epithelial ovarian neoplasms. Of
these tumors, 75% are benign and are found in women aged 30-50 years. Mucinous cysts are
usually smooth walled; true papillae are rare compared with the serous variety. The tumors are
generally multilocular, and the mucus-containing loculi appear blue through the tense capsules.
These tumors can grow quite large, measuring up to 30 cm; patients often present with ovarian
torsion. Mucinous tumors are most common in the third to fifth decades of life and are only rarely
bilateral. The larger-sized varieties are associated with an increased risk of rupture, with resultant
pseudomyxoma peritonei.

For women of childbearing age, simple unilateral oophorectomy via laparoscopy or laparotomy is
adequate provided the contralateral ovary appears grossly normal. In women who desire future
fertility who have stage IA, low-risk ovarian cancer, conservative surgical therapy is appropriate,
provided close follow-up can be maintained. At the completion of childbearing, usually the remaining
ovary and uterus are removed. Total abdominal hysterectomy and bilateral salpingo-oophorectomy
(with or without staging) are reasonable options and are recommended by many authorities for
women of perimenopausal age.

Solid Benign Tumors of the Ovary

Solid epithelial ovarian tumors are almost invariably malignant. Approximately 80% of epithelial
tumors are of the serous type; 10% are mucinous; and 10% are endometrioid, with rarer varieties
including clear cell tumors, Brenner tumors, and undifferentiated ovarian carcinomas. The Brenner
tumor is usually found incidentally at pathologic evaluation and often coincides with a mucinous
cystadenoma or dermoid cyst. They are relatively rare tumors and are most common in the fifth to
sixth decades of life. Brenner tumors may be benign, intermediate, or malignant transitional cell
tumors. These tumors are usually small, firm, and solid, and when confined to the ovary, carry a
good-to-excellent prognosis, depending on the malignancy status.

The common benign solid tumors are fibromas and thecomas. The fibroma is the most common
benign ovarian neoplasm. These tumors occur most commonly in women of postmenopausal age.
They are unilateral tumors, and they are often at least 3 cm in size. Fibromas are connective-tissue
tumors that arise from the ovarian cortical stroma. If the stroma is estrogenic or luteinized, the tumors
are actually thecomas. Solid mature teratomas are a form of tumor that consists of differentiated
tissue from all 3 germ layers.

Benign teratomas (also known as mature teratomas or dermoid cysts) are likely to contain more of
the recognizable organic structures, such as thyroid, bronchial, and central nervous system tissue. In
dermoid cysts, ectodermal structures such as hair, teeth, and skin predominate. In most instances,
simple excision of the solid tumors is adequate therapy, particularly for women of reproductive age.

Laparoscopic treatment of benign cystic teratomas of the ovaries has also been recommended (ie,
laparoscopic ovarian cystectomy). In this procedure, in premenopausal women, the contralateral
ovary is preserved and all attempts are made to excise simply the dermoid cyst itself, thereby leaving
both ovaries in situ. Although the data regarding recurrence risk of dermoid tumors are severely
limited, most clinicians favor ovarian conservation in premenopausal women, if surgically possible. In
menopausal patients, a total hysterectomy and bilateral salpingo-oophorectomy are indicated, thus
obviating the need for future gynecologic surgery.

Tubo-ovarian Abscesses

Tubo-ovarian abscesses (TOAs) are present in 14-38% of patients hospitalized with pelvic
inflammatory disease and are still seen commonly in patients with scant or poor access to routine
gynecologic care. Initial inflammation of the endometrium may spread to the adnexa by the fallopian
tubes, which connect with the endometrial cavity via the interstitial portion and then run laterally in
the free edges of the broad ligament. When some or all of the interstitial portion of the ovaries is in
communication with the inflamed tube, a true TOA develops.

The traditional criteria for the diagnosis of pelvic inflammatory disease include subjective bilateral
abdominal pain per patient report and positive physical examination findings for bilateral adnexal
tenderness to palpation and cervical motion tenderness. Currently, however, these diagnostic criteria
have been expanded to encompass a more diverse range of symptoms and objective findings.
Therefore, other minor criteria include fever, excessive vaginal discharge, menorrhagia, genitourinary
symptoms, or chills. Abnormal laboratory findings may include leukocytosis, elevated erythrocyte
sedimentation rate or C-reactive protein level, and positive findings at endometrial biopsy or
gonorrheal or chlamydial culture. Historically, the criterion standard for diagnosis, although seldom
used in current clinical practice, involved visual identification of purulent material from the fimbriated
ends of the fallopian tubes (salpingitis) noted during diagnostic laparoscopy.

The commonly reported symptoms of TOAs are dyspareunia and rectal discomfort, partial intestinal
obstruction, dysuria, urinary frequency, and sterility. Occasionally, fever with the symptoms of pelvic
peritonitis develops. Pelvic examination findings are characteristic; the uterus is retroverted and
cervical motion produces pain. Lateral to the uterus, enlarged masses adherent to the cul-de-sac
may be felt. The adnexa may be indurated with soft cystic areas. The tumors are often bilateral, and
all pelvic structures are immobilized (ie, "frozen pelvis").

The ultrasonographic findings of pelvic inflammatory disease vary and are related to the stage of the
disease process. A pyosalpinx, or pus-filled fallopian tube, appears as a hyperechoic dilated mass in
the adnexal region, often with low-level echoes. The clear delineation of the tubal contour is often
obscured, and therefore, the ultrasonographic findings simply show a dilated, tortuous structure.
Dilated fallopian tubes appear ultrasonographically as tubular fluid collections. The hydrosalpinx is
generally anechoic, whereas a pyosalpinx may have increased echoes within the fluid. Fluid also
may be present in the cul-de-sac.

Transvaginal scanning is most useful in TOA evaluation. Extension of the inflammation to the ovary
leads to lack of definition of the ovarian outline and thickening of the periovarian tissue. Early in the
course of the disease in most patients (and in patients with infection confined to the uterus), no
abnormalities are identified. Endometritis may be considered likely with the presence of fluid in the
endometrial cavity, uterine enlargement, ill-defined uterine contour, and/or an indistinct central
endometrial echo.

A few entities simulate chronic pelvic inflammation and TOA; these include ectopic pregnancy,
endometriotic cysts, malignant disease, and torsion of an ovarian cyst.

Therapy

Before embarking on a surgical approach, make every effort to treat the local infection with
intravenous antibiotics. If an intrauterine device is in situ, prompt removal of the device and
commencement of high-dose antibiotics is generally recommended. Intravenous antibiotics may be
continued following removal of the device. Antimicrobial therapy should involve drugs that best
penetrate into the abscesses. These drugs are mainly imipenem or Tienam (ie, imipenem and
cilastatin; carbapenem group) and metronidazole.

Other commonly used regimens include triple-antibiotic therapy using ampicillin, gentamicin, and
clindamycin or metronidazole. The therapeutic goal is to provide polymicrobial coverage against
gram-positive, gram-negative, and anaerobic bacteria. No data strongly support the use of one
combination regimen over another. This form of therapy is used as a preliminary step preceding
radical surgery, with the goal of reducing the technical difficulties of surgical extirpation of the pelvic
organs. If the abscess is incompletely removed, recurrence in the form of an inflammatory tumor is
possible.

In patients who do not respond to antibiotic therapy (characterized by persistent pain and fever),
placing a drain or drains into the abscess or abscesses may be helpful. Abdominal exploration is
required acutely only in cases of severe sepsis. Surgical exploration should ideally be delayed until
adequate antibiotic treatment has occurred. In most instances, total abdominal hysterectomy and
bilateral salpingo-oophorectomy are needed. In rare cases and in young women desiring fertility, less
radical surgery could be considered, such as unilateral or bilateral salpingectomy. Such women often
require in vitro fertilization (IVF) to achieve pregnancy.

Endometriosis

Endometriosis is frequently encountered in everyday gynecologic practice. It is currently the most

commonly diagnosed disease in females of childbearing age. Approximately 10-15% of reproductive-
aged women have endometriosis. A family history of first-degree relatives with endometriosis
increases the risk of having endometriosis tenfold. Despite its prevalence, however, endometriosis
remains one of the most enigmatic disorders in gynecology.

Endometriosis is defined histologically by the presence of endometrial tissue in an ectopic location

exclusive of the myometrium. Many etiologic theories have been advanced over the years. Although
each of the proposed mechanisms is possible and each may contribute to some cases of
endometriosis, whether any fully explains the major source of the disease is doubtful. The typical age
at which endometriosis is diagnosed is 25-29 years, however, teenagers can also have
endometriosis. Severe dysmenorrhea and other pelvic pain complaints should be taken seriously in
teenagers. Endometriosis is commonly believed to be frequent in females of childbearing age and
rare in menopausal women.

The most common symptoms of endometriosis are pelvic pain, secondary dysmenorrhea,
dyspareunia, and infertility. Primary dysmenorrhea or dysmenorrhea occurring from the onset of
menses should increase a clinician's suspicion for endometriosis. Clinical symptoms result from
implantation of endometrial tissue on the pelvic organs. Thus, endometriosis may result in bowel-
related symptoms (eg, tenesmus) and urinary tract symptoms. Physical findings associated with
endometriosis are variable and are dependent on the severity and location of the disease. Common
findings include characteristic tender nodularity and tenderness of the obliterated cul-de-sac,
parametrial thickening, and adnexal masses.

Patients with disease that is more advanced present with bilateral endometrial cysts, known as
endometriomas. These typically appear on ultrasonograms as complex ovarian masses with low-
level echoes, consistent with blood. Often they are bilateral, and they can range in size from small to
medium (5-6 cm). Characteristic physical examination findings help confirm the diagnosis of
advanced forms of endometriosis.

Imaging methods in these cases are complementary. Ultrasonic examination may reveal
endometriotic cysts as hypoechoic areas. Commonly, CA-125 levels are elevated but do not exceed
100 U/L.

Laparoscopy remains the optimal diagnostic method for endometriosis. Compared with medical
(hormonal) management or simple palliative treatment, laparoscopic excision or fulguration and/or
laser of implants remains the most effective therapy for this disease. Sending excisional biopsies for
pathology is important. Some gynecologic surgeons also perform laparoscopic uterosacral nerve
ablation (LUNA) procedures at laparoscopy. The LUNA targets Frankenhauser's plexus and has
been shown to be effective for pelvic pain in some patients.

Over the years, a variety of treatment options have been developed to combat endometriosis.
Recommended medical therapies have included gestagens, oral contraceptive pills, nonsteroidal
anti-inflammatory drugs (NSAIDs) and gonadotropin-releasing hormone analogs. Danazol, the
isoxazole derivative of 17-alpha-ethinyl testosterone, was previously used and was effective, but its
use has ceased because of severe androgenic side effects. The goals of surgery are to restore
normal pelvic anatomy, to remove visible endometriotic changes, and to eliminate pelvic pain. Such
surgery is generally considered conservative in nature. The number of recurrences is very high.

Radical treatment is accomplished with abdominal hysterectomy and bilateral salpingo-

oophorectomy. Approximately 90% of women with pain associated with endometriosis will experience
relief of their chronic pelvic pain. After definitive surgery, consider adjuvant therapy. In
premenopausal women with severe endometriosis, most adjuvant therapy is readily accomplished
with gonadotropin-releasing hormone analog (Depo-Lupron) for suppression, with progesterone or
estrogen add-back to protect skeletal health and help ameliorate the iatrogenic menopausal
symptoms. In patients with less severe disease, continuous oral contraceptives can be used for
ovarian suppression, with good clinical results and few adverse effects.

For women in whom a hysterectomy and bilateral salpingo-oophorectomy did not accomplish pain
relief, a presacral neurectomy can be effective.

Diagnosis of Benign Lesions of the Ovary

Diagnostic imaging

Ultrasonography is the criterion standard for identifying ovarian pathology; however, transvaginal
ultrasonography is limited in its role for assessing masses in neonates, children, and virginal
adolescents. Color-coded Doppler ultrasonography improves the diagnostic accuracy of B-mode
ultrasonography. Ultrasonography is easy, rapid, and able to provide critical information for the
evaluation of an adnexal mass. It can help determine whether the mass is ovarian or extraovarian,
solid or cystic, simple or complex, and vascular or avascular.

Ultrasonography can be used to evaluate material or fluid contained in a mass and it can be used to
assess the surface of the ovarian capsule. Color-flow Doppler is useful for distinguishing between
benign and potentially malignant lesions. In most cases, CT scanning and MRI are unnecessary in
the evaluation of an adnexal mass. Ultrasound findings suggestive of malignancy include an ovarian
mass with solid or complex components, septations, evidence of surface nodularity or papillae,
increased vascular flow, or heterogeneous echotexture. Furthermore, serial or follow-up
ultrasonograms are helpful in monitoring the progression of an ovarian mass over time. Repeating an
ultrasonogram in 6 weeks can delineate if the mass is enlarging or if the dimensions are diminishing.
The presence of pelvic or abdominal ascites and/or pelvic or abdominal lymphadenopathy on CT
scans or MRIs further raises the index of suspicion for ovarian malignancy.

Laboratory studies

Perhaps one of the most commonly misordered tests in the evaluation of an ovarian mass is the CA-
125 test. It is useful for evaluating the response to treatment for epithelial ovarian malignancies. The
CA-125 level may be elevated as a result of a plethora of medical conditions, many of which afflict
reproductive-aged women. These include, but are not limited to, pregnancy, endometriosis, fibroids,
menstruation, benign ovarian tumors, diverticulosis, liver disease, and pelvic inflammatory disease.
Moreover, in half the early-stage ovarian cancers, the CA-125 level is normal, which means the test
has a high false-negative rate if it is used to detect early-stage ovarian cancer. A normal level is
usually less than 35 U/mL in a postmenopausal woman. Levels greater than 200 U/mL in a
premenopausal woman with or without suggestive radiographic findings should be referred for
evaluation by an oncologist.

When used purely as a screening tool, the CA-125 test has an unacceptably high false-positive rate.
It should be performed judiciously in premenopausal women because of the high likelihood that the
level will be elevated in the absence of ovarian pathology. The CA-125 test is useful, however, when
used in postmenopausal women with ultrasonographically suspicious ovarian masses. When the
level is greater than 65 U/mL, the chance that the patient has ovarian cancer is 97%.

Alpha-fetoprotein is another tumor marker that is elevated in the setting of endodermal sinus tumors,
mixed germ cell tumors, immature teratomas, and embryonal carcinomas. The lactate
dehydrogenase level may be elevated in women with dysgerminomas, while the human chorionic
gonadotropin level may be elevated in women with choriocarcinomas, germ cell tumors, or
embryonal cell tumors.

Testosterone levels may be elevated in patients with fibromas and Sertoli-Leydig tumors, and
estradiol levels may be elevated in patients with thecomas or dysgerminomas. Often, these patients
present with symptoms of rapidly virilizing clinical signs of elevated testosterone, such as male-
pattern baldness, voice-deepening, clitoromegaly, and increased hirsutism. In the setting of a
suspicious ovarian mass, tumor markers should be evaluated, and, if the results are abnormal, the
patient should be referred for a complete evaluation by a gynecologic oncologist.

According to Wang et al in 2003, circulating follicle-stimulating hormone (FSH) may be a driving force
in the field-effect theory for the development of both ovarian neoplasms and their associated
peritoneal implants. The precise role of FSH and/or FSH-releasing factor in the development of
epithelial tumors arising in the ovary needs further investigation.

Ovarian Lesions in Childhood

Benign ovarian cysts are common and can appear at various times throughout a woman's life, and
this section outlines the different types of benign ovarian lesions with respect to age groups and
respective incidence.

Maternal ovarian cysts diagnosed during pregnancy

Maternal ovarian cysts during pregnancy are fairly common and arise largely as a result of excessive
human chorionic gonadotropin stimulation by the corpus luteum. The corpus luteum itself, then, may
become quite large and undergo ovarian torsion. Additionally, because pregnancy is a time of
frequent ultrasonographic evaluation, the other common ovarian cysts seen in the childbearing age
group (eg, dermoid cysts, endometriomas, and, occasionally, the malignant epithelial tumors) tend to
be diagnosed more frequently during pregnancy.

Fetal cysts

In the fetal and neonatal period, both the maternal and fetal ovaries are exposed to excessive
stimulation by human chorionic gonadotropin. Other maternal hormone levels are also high, which
can lead to disordered folliculogenesis in the fetal ovaries. In addition, the fetal pituitary gland is also
producing FSH, which increases the size and number of fetal ovarian follicles. These factors may
contribute to the formation of fetal ovarian cysts. Often diagnosed in the third trimester during routine
ultrasound surveillance, these lesions are typically cystic (99%) and can be either simple or complex.
The contralateral ovary also may be cystic. Of all fetal cysts, 97% are functional, and the average
size is approximately 3.4 cm. Half of these cysts spontaneously resolve, and of the remainder, 25-
40% undergo torsion.

The differential diagnosis of an adnexal mass detected in utero includes neoplastic lesions (eg, cystic
teratomas, cystadenomas, granuloblastomas); mesenteric cysts; or gastrointestinal, genitourinary, or
enteric duplication. In the antenatal period, a conservative approach is recommended because many
spontaneously resolve. Although antenatal aspiration is an option, this has not shown any significant
benefit and is not the standard of care.

Ovarian lesions in childhood

Childhood is a time of busy activity for the ovaries, a fact that may be underrecognized by both
gynecologists and pediatricians. Histologically, the ovarian stroma is growing, causing the ovaries to
enlarge. When cysts manifest, they are usually small and simple. The incidence of simple cysts
increases with age, and most are caused by a failure of the follicle to undergo involution. Not
surprisingly, in this age group, most cysts are diagnosed incidentally after radiographic studies. When
smaller than 5 cm, these lesions may be followed conservatively.

Intervention should be considered for cysts larger than 5 cm, lesions that demonstrate solid
components, those that are accompanied by pain, those that are associated with systemic
endocrinologic signs, or those with complex components or internal septations. When ovarian
neoplasms are encountered in girls of this age group, they fall into the germ cell, epithelial cell, and
stromal/sex chord familial classification. The vast majority of ovarian lesions of childhood are of the
germ cell variety, but only roughly 8% of ovarian tumors of childhood are malignant.

The most common germ cell tumor of this age group, which is also the most common benign tumor,
is the benign cystic teratoma. Also known as the dermoid cyst, these lesions have a characteristic
radiographic appearance. Commonly described as complex, with an enhancing rim, and often with
visible calcifications (teeth), these cysts are unilateral in greater than 90% of children. Although
surgery is not always necessary, ovarian cystectomy with preservation of the ovary is the standard of
care.

Ovarian lesions in adolescence

With the activation of the hypothalamic-pituitary-ovarian axis that accompanies menarche, an

increase occurs in circulating gonadotropin, estrogen, and progesterone levels. The axis of an
adolescent may remain immature for some time following menarche, which results in frequent
anovulatory cycles and ovulatory defects. Of the numerous benign ovarian lesions seen in girls of
this age group, the functional cyst, the corpus luteum cyst, and the hemorrhagic cyst are the most
common. Other ovarian concerns such as ruptured cysts and ovarian torsion are also discussed.

Follicular cysts are the most common cystic structures found in healthy ovaries. These cysts arise
from a temporary pathologic variation of a normal physiologic process. They result from either
nonrupture of the dominant mature follicle or from failure of an immature follicle to undergo atresia.
Solitary follicle cysts are common and occur during all stages of life. These lesions typically have thin
walls, are unilocular, and range from 2.5-8 cm in diameter. Usually, dimensions less than 2.5 cm are
classified as follicles, and, therefore, these are not of clinical significance.

Corpus luteum cysts are less prevalent than follicular cysts. These commonly arise as a result of
intracystic hemorrhage and may be seen in the second half of the menstrual cycle. Of note, these
corpus luteal cysts or other hemorrhagic cysts may be seen in any reproductive-aged woman.
Radiographically, these cysts may have a clear region of homogenous debris (blood) at the gravity-
dependent portion of the cyst. These lesions are hormonally inactive but may be prone to rupture,
with subsequent intraperitoneal bleeding. In a patient with signs or symptoms of hemodynamic
instability, acute peritonitis, or a high suspicion of ovarian torsion, surgical management is indicated.
This can be performed via laparoscopic means in most cases. In most cases, however, no treatment
is necessary because most of these cysts spontaneously resolve.

Ovarian Lesions in Reproductive-Aged Females

Fibroma

The most common benign solid tumor of the ovary is the fibroma. Fibromas are derived from
connective tissue and arise from the solid ovarian cortical stroma. Histologically, spindle cells are
seen. Ultrasonographically, these tumors appear hypoechoic with attenuation of the ultrasound
beam. On MRIs, they demonstrate low-signal intensity on T2-weighted images relative to the
myometrium secondary to its mostly fibrous composition. On CT scans, ovarian fibromas appear as
well-defined, solid masses with mild heterogeneity.

These tumors may undergo calcification and degeneration. Greater than 90% are unilateral, and
approximately 10-15% are found in association with ascites. Less than 1% undergo malignant
transformation to fibrosarcomas. One percent of cases are associated with Meigs syndrome,
characterized by ovarian fibroma, ascites, and pleural effusion.

Tubo-ovarian abscess

TOAs are an infectious component of the benign lesions seen in females of this age group. TOAs are
present in 14-38% of patients hospitalized with pelvic inflammatory disease. Initial inflammation and
infection of the endometrium may spread to the adnexa by the fallopian tubes. When some or all of
the interstitial portion of the ovaries is in communication with the inflamed tube, a true TOA develops.
On imaging studies, TOAs may appear as complex, large, and often bilateral masses, with
heterogeneous components on both ultrasound images and CT scans. Often, the ovarian outline
lacks definition and the periovarian tissue appears thickened. Pyosalpinges may reveal increased
echoes within the purulent tubular fluid, and fluid may also be present in the cul-de-sac.

Patients usually report abdominal and pelvic pain; may have nausea, vomiting, and diarrhea; and are
often febrile. Physical examination reveals bilateral tender adnexal masses and diffuse peritoneal
signs. Treatment includes intravenous broad-spectrum and anaerobic antibiotic coverage until
symptoms resolve. The dimension of a TOA may be monitored as an indicator of improvement. If
symptoms do not improve with intravenous therapy, an attempt at drainage via interventional
radiology catheter placement can be helpful. Culture of the drained fluid should be sent.

Bilateral salpingo-oophorectomy with or without hysterectomy is a last resort and should only be
undertaken acutely in the presence of severe sepsis. Infected tissue is extremely friable and surgery
can be challenging in the acute setting. If the woman is done with childbearing and she has chronic
pelvic pain attributable to her history of TOAs, then bilateral salpingo-oophorectomy with or without
hysterectomy can be performed after a "cooling off" period, that is, after appropriate antibiotic therapy
has been completed (usually 4-6 wk).

Polycystic ovarian syndrome

The normal adult ovary measures 1 cm in thickness, 2 cm in width, and 3 cm in length. Each normal
ovary usually weighs 5-8 g. In females with polycystic ovarian syndrome (PCOS), the ovaries are
usually bilaterally enlarged, contain multiple follicles, and demonstrate increased stromal
echogenicity. Because PCOS is thought to affect approximately 5 million reproductive-aged women
in the United States, its existence should be familiar to any practitioner who treats women.
PCOS is a diagnostic entity that encompasses radiographic findings, clinical presentation, and
endocrinologic derangement. One or more abnormalities may be present, and these may be different
at various times during a woman's life; this is typically a syndrome that undergoes evolution. It is
relevant because of the associated features of hyperandrogenicity, insulin resistance, and an
increased risk of developing metabolic syndrome in the future. In fact, many experts call PCOS
metabolic syndrome XX because they share so many common features.

The diagnosis of PCOS has been simplified from the previously tedious method. Currently, 2 of 3
criteria are required to diagnosis PCOS. The 3 criteria are (1) polycystic ovaries (multiple small cysts,
often around the periphery of the ovary, the classic "string of pearls" appearance), (2) signs of
androgen excess (acne, hirsutism, temporal balding, male pattern hair loss, clitoromegaly, etc), and
(3) menstrual irregularities (oligomenorrhea or polymenorrhea). Note that a diagnosis of PCOS does
not require multiple ovarian cysts or polycystic ovaries.

Ultrasonographic findings suggestive of PCOS commonly include ovary enlargement, increased

follicle count, and stromal echogenicity. The ovaries are usually bilaterally enlarged and spherical in
shape, rather than ovoid. However, of patients with PCOS, 30% may show no increase in ovarian
volume. Typically, multiple small (

Many women with PCOS struggle with infertility secondary to anovulation or oligo-ovulation.
Fortunately, most women with PCOS respond favorably to oral ovulation induction medications
(clomiphene citrate) with or without progestin regulation of menses. If clomiphene citrate does not
achieve ovulation alone, oral hypoglycemics are used in conjunction with clomiphene
citrate successfully to achieve pregnancy.

Endometriomas

With the high prevalence of endometriosis observed today in women of childbearing age, the fact
that endometriomas are encountered in common practice is not surprising. An estimated 1-10% of
reproductive-aged women may have endometriosis to some degree. The primary pathologic
definition of endometriosis requires the presence of endometrial glandular tissue outside the cavity of
the uterus. Histologically, endometrial glands, stroma, or hemosiderin pigment must be detected in
these lesions. When this tissue invades the ovaries, frequently an endometrioma may form. These
are cystic, blood-filled spaces that contain "chocolate" blood (ie, old blood).

On pelvic ultrasonography, these masses may appear multilocular and quite large. On MRIs, their
appearance is variable, depending on the quantity of blood present in the cyst. Most, however, show
multiple, high-signal intensity on T1-weighted images and very low-signal intensity on T2-weighted
images. On ultrasonographic images, a cystic mass is evident with diffuse low-level echoes. These
lesions may appear solid or cystic (simple or complex). The differential diagnosis of endometriomas
also includes hemorrhagic cysts, TOAs, and ovarian malignancies.

References

1. Adamyan LV, Fanchenko ND, Alexeyeva ML, et al. Hormonal and immunologic methods in
the diagnosis and treatment of patients with benign ovarian tumors and endometriotic
cysts. Int J Fertil. Mar-Apr 1993;38(2):92-8. [Medline].

2. Benjapibal M, Boriboonhirunsarn D, Suphanit I, Sangkarat S. Benign cystic teratoma of the

ovary: a review of 608 patients. J Med Assoc Thai. Sep 2000;83(9):1016-20. [Medline].

3. Chow SN, Chen M. Tuboovarian abscess mimicking malignancy: report of two cases. J
Formos Med Assoc. Oct 2000;99(10):779-82. [Medline].
4. Dai J, Wu H, Li J. [CT diagnosis of fibrothecoma and fibroma of the ovary]. Zhonghua Zhong
Liu Za Zhi. Nov 2000;22(6):504-6. [Medline].

5. Daly S, Outwater E. Endometrioma/Endometriosis. eMedicine journal [serial online]. 2004.

Available at: http://www.emedicine.com/radio/topic250.htm. [Full Text].

6. Drake J. Diagnosis and management of the adnexal mass. Am Fam Physician. May
15 1998;57(10):2471-6, 2479-80. [Medline].

7. George JP. Laparoscopic Management of Tubo-Ovarian Abscess. J Am Assoc Gynecol

Laparosc. Aug 1994;1(4, Part 2):S12. [Medline].

8. Georgilis K. Conservative management of PID. Ann N Y Acad Sci. 2000;900:309-

15. [Medline].

9. Hermanns B, Faridi A, Rath W, Füzesi L, Schröder W. Differential diagnosis, prognostic

factors, and clinical treatment of proliferative Brenner tumor of the ovary. Ultrastruct
Pathol. May-Jun 2000;24(3):191-6. [Medline].

10.Obwegeser R, Stumpflen I, Deutinger J, Bernaschek G. [Echographic evaluation of the

integrity of adnexa tumors]. Geburtshilfe Frauenheilkd. Feb 1993;53(2):108-14. [Medline].

11.Pascual MA, Tresserra F, Lopez-Marin L, et al. Role of color Doppler ultrasonography in the
diagnosis of endometriotic cyst. J Ultrasound Med. Oct 2000;19(10):695-9. [Medline].

12.Schmidt E, Nehra P. Tubo-ovarian abscess: a study of 17 patients. Am Fam

Physician. Apr 1988;37(4):181-5. [Medline].

13.Scurry J, Whitehead J, Healey M. Classification of ovarian endometriotic cysts. Int J

Gynecol Pathol. Apr 2001;20(2):147-54. [Medline].

14.Vercellini P, De Giorgi O, Pisacreta A, et al. Surgical management of

endometriosis. Baillieres Best Pract Res Clin Obstet Gynaecol. Jun 2000;14(3):501-
23. [Medline].

15.Wang J, Lin L, Parkash V, et al. Quantitative analysis of follicle-stimulating hormone receptor

in ovarian epithelial tumors: A novel approach to explain the field effect of ovarian cancer
development in secondary mullerian systems. Int J Cancer. Jan 20 2003;103(3):328-
34. [Medline].

16.Wiser F, Cohen M, Gaeddert A, Yu J, Burks-Wicks C, Berga SL, et al. Evolution of medical

treatment for endometriosis: back to the roots?. Hum Reprod Update. June 2007;[Medline].

17.Juang CM, YEN MS, Horng HC, Cheng CY, YU HC, Change CM. Treatment of primary deep
dyspareunia with laparoscopic uterosacral nerve ablation procedure: a pilot study. J Chin
Med Assoc. March 2006;69:110-4. [Medline].

18.Latthe PM, Proctor ML, Farquhar CM, Johnson N, Khan KS. Surgical interuuption of pelvic
nerve pathways in dysmenorrhea: a systematic review of effectiveness. Acta Obstet
Gynecol Scand. 2007;86(1):4-15. [Medline].
 19.Bahamondes L, Petta CA, Fernandes A, Monteiro I. Use of the levonorgestrel-releasing
intrauterine system in women with endometriosis, chronic pelvic pain and
dysmenorrhea. Contraception. June 2007;75(6 Suppl):S134-9. [Medline].

20.Tanir HM, Hassa H, Ozalp S, Kaya M, Oge T. Pelvic abscess in intrauterine device
users. Eur J Contracept Reprod Health Care. March 2005;10(1):15-8. [Medline].

21.Meirik O. Intrauterine devices-upper and lower genital tract infections. Contraception. June
2007;75(6 Suppl):S41-7. [Medline].

22.McNeeley SG, Hendrix SL, Massoni MM, Kmak DC, Ransom SB. Medically sound, cost-
effective treatment for pelvic inflammatory disease and tuboovarian abscess. Am J Obstet
Gynecol. June 1998;178(6):1272-8. [Medline].

23.Hiller N, Sella T, Lev-Sagi a, Fields S, Lieberman S. Computed Tomographic features of

tuboovarian abscess. J Reprod Med. March 2005;50(3):203-8. [Medline].

24.Legro RS, Barnhart HX, Schlaff WD, Carr BR, Diamond MP, Carson SA. Clomiphene,
metformin, or both for infertility in the polycystic ovary syndrome. N Engl J Med. Feb
8 2007;356(6):551-66. [Medline].

25.Ehrmann DA. Polycystic ovary syndrome. N Engl J Med. Mar 24 2005;352(12):1223-

36. [Medline].

Keywords

benign lesions of the ovaries, ovarian cystic tumors, ovarian solid benign tumors, pelvic inflammatory
disease, PID, ovarian dysfunctional cysts, endometriotic cysts, benign ovarian cysts, dysmenorrhea,
dyspareunia, endometriosis, Brenner tumors, fibromas, thecomas, teratomas, tubo-ovarian abscess,
salpingo-oophorectomy, salpingooophorectomy hysterectomy

Contributor Information and Disclosures

Author

Diana Curran, MD, FACOG, Clinical Assistant Professor, Associate Program Director, Department of
Obstetrics and Gynecology, University of Michigan Health Systems
Diana Curran, MD, FACOG is a member of the following medical societies: American College of
Obstetricians and Gynecologists, American Medical Association, Central Association of Obstetricians
and Gynecologists, and Nebraska Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

Jennifer L Ashton, MD, Consulting Staff, Department of Obstetrics and Gynecology, Englewood
Hospital Medical Center, All-Women Ob-Gyn Associates, LLC
Disclosure: Nothing to disclose.

Medical Editor

Suzanne R Trupin, MD, Clinical Professor of Obstetrics and Gynecology, University of Illinois
College of Medicine-Champaign; CEO and Owner, Women's Health Practice; CEO and Owner, Hada
Cosmetic Medicine and Midwest Surgical Center
Suzanne R Trupin, MD is a member of the following medical societies: American Association of
Gynecologic Laparoscopists, American College of Obstetricians and Gynecologists, American
Institute of Ultrasound in Medicine, American Medical Association, Association of Reproductive
Health Professionals, International Society for Clinical Densitometry, and North American Menopause
Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine

Disclosure: Nothing to disclose.

CME Editor

Frederick B Gaupp, MD, Consulting Staff, Department of Family Practice, Hancock Medical Center
Frederick B Gaupp, MD is a member of the following medical societies: American Academy of Family
Physicians
Disclosure: Nothing to disclose.

Chief Editor

Carl V Smith, MD, The Distinguished Chris J and Marie A Olson Chair of Obstetrics and Gynecology,
Professor, Department of Obstetrics and Gynecology, University of Nebraska Medical Center
Carl V Smith, MD is a member of the following medical societies: American College of Obstetricians
and Gynecologists, American Institute of Ultrasound in Medicine, American Medical Association,
Arkansas Medical Society, Association of Professors of Gynecology and Obstetrics, Central
Association of Obstetricians and Gynecologists, Council of University Chairs of Obstetrics and
Gynecology, Nebraska Medical Association, and Society for Maternal-Fetal Medicine
Disclosure: Nothing to disclose.

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