What is the pathophysiology of ovarian cysts?

From the Guidelines

Ovarian cysts develop through several pathophysiological mechanisms, primarily involving disruptions in normal ovarian function, hormonal regulation, or abnormal cell growth, with the most common variety being functional cysts that typically resolve spontaneously within 1-3 menstrual cycles without treatment. The pathophysiology of ovarian cysts can be understood by categorizing them into different types, including functional cysts, endometriomas, dermoid cysts, cystadenomas, and those associated with polycystic ovary syndrome.

• Functional cysts form during normal ovarian function when either a follicle fails to rupture during ovulation (follicular cysts) or when the corpus luteum doesn't dissolve properly after ovulation (corpus luteum cysts) 1.
• Pathological cysts, such as endometriomas, form when endometrial tissue implants on the ovary and bleeds during menstruation, creating chocolate-colored fluid collections.
• Dermoid cysts (teratomas) arise from germ cells that abnormally develop into various tissue types.
• Cystadenomas develop from ovarian surface epithelium and can become quite large.
• Polycystic ovary syndrome involves multiple small follicular cysts resulting from hormonal imbalances, particularly elevated androgens and insulin resistance, which prevent normal follicular maturation and ovulation.

The management and risk stratification of ovarian cysts have been standardized through systems like the O-RADS US risk stratification and management system, which categorizes lesions based on their risk of malignancy and provides guidelines for management 1. The O-RADS system emphasizes the importance of a standardized lexicon and risk stratification to guide clinical management, ensuring that patients receive appropriate care based on the risk category of their ovarian cyst. This approach helps in minimizing unnecessary interventions for benign lesions while ensuring timely and appropriate management for potentially malignant ones.

Key points in the management of ovarian cysts include:

• Simple cysts up to 10 cm in diameter are likely to be benign and may be safely monitored using repeat imaging without surgical intervention, even in postmenopausal patients 1.
• The risk of malignancy in simple cysts is very low, with studies suggesting a risk of less than 1% in premenopausal women and slightly higher in postmenopausal women 1.
• Classic benign lesions such as endometriomas, hemorrhagic cysts, and dermoids have characteristic appearances on ultrasound and can often be managed conservatively with follow-up imaging 1.

Overall, understanding the pathophysiology and applying a standardized approach to the management of ovarian cysts can improve patient outcomes by reducing unnecessary interventions and ensuring timely diagnosis and treatment of potentially malignant lesions.

From the Research

Pathophysiology of Ovarian Cysts

The pathophysiology of ovarian cysts involves various factors and can be complex. Here are some key points to consider:

• Ovarian cysts can be defined as follicular structures that persist for an extended period in the absence of a corpus luteum 2.
• The development of ovarian cysts is often associated with hormonal imbalances, particularly with the hypothalamus and pituitary gland's responsiveness to luteinizing hormone (LH) and estradiol 2.
• In some cases, ovarian cysts can be caused by genetic predisposition, and treatments may only be temporary solutions 2.
• The risk of malignancy in cystic ovarian tumors is generally low, especially for unilocular cysts < 10 cm in diameter in asymptomatic postmenopausal women or women > 50 years of age 3.
• However, complex ovarian cysts with wall abnormalities or solid areas are associated with a significant risk for malignancy 3.

Types of Ovarian Cysts

There are different types of ovarian cysts, including:

• Follicular cysts, which are the most common type of ovarian cyst 4, 5.
• Serous cystadenomas, which are benign tumors that can occur in the ovary 5.
• Mucinous cystadenomas, which are also benign tumors that can occur in the ovary 5.
• Necrotic ovarian cysts, which can occur due to torsion or other complications 4.

Complications of Ovarian Cysts

Ovarian cysts can be associated with various complications, including:

• Torsion, which can cause severe abdominal pain and require surgical intervention 4, 6.
• Rupture, which can cause bleeding and require emergency surgery.
• Malignancy, which can occur in some cases, especially with complex ovarian cysts 3.

Diagnosis and Treatment

The diagnosis of ovarian cysts typically involves ultrasonography and other imaging modalities. Treatment options depend on the size, type, and complexity of the cyst, as well as the patient's symptoms and overall health. In some cases, surgical intervention may be necessary to remove the cyst or to treat complications such as torsion 4, 5, 6.