What are the diagnostic and treatment options for enlarged ovaries?

Diagnostic and Treatment Options for Enlarged Ovaries

Transvaginal ultrasound combined with transabdominal ultrasound is the gold standard for evaluating enlarged ovaries, with specific imaging features guiding diagnosis and management decisions. 1

Diagnostic Approach

Initial Imaging

• Transvaginal ultrasound (TVUS) with color Doppler is the first-line imaging modality for evaluating enlarged ovaries 1
• Combine with transabdominal ultrasound for optimal visualization of adnexal structures, especially for larger masses 1

Key Ultrasound Features to Identify

1. Simple cysts:

   • Anechoic, thin-walled, no internal echoes
   • Benign in 98.7% of premenopausal women 1
   • Can be safely followed without intervention, even in postmenopausal women 2

2. Complex cysts:

   • Hemorrhagic cysts: Spiderweb-appearing or retracting clot with peripheral vascularity
   • Endometriomas: Low-level internal echoes, mural echogenic foci
   • Teratomas: Echogenic attenuating component or small horizontal interfaces 1

3. Suspicious features suggesting malignancy:

   • Thick or irregular septations
   • Mural nodules
   • Solid or papillary components
   • Diameter >5 cm 3
   • Presence of ascites 3

4. Polycystic ovary morphology:

   • Follicle number per ovary (FNPO) is the gold standard marker for PCOS diagnosis
   • Ovarian volume (OV) is a robust alternative when follicle counting is difficult 3
   • Enlarged ovaries with multiple peripherally located cysts may indicate hyperreactio luteinalis 3

Serum Markers

• CA-125: Useful for evaluating suspicious masses, especially in postmenopausal women

  • Specificity of 98.5% for women over 50 years
  • Lower specificity (94.5%) for women under 50 3
  • Progressive elevation over time is concerning for malignancy 3

• Other markers for specific conditions:

  • Inhibin: Useful for granulosa cell tumors 3
  • hCG, AFP, and LDH: Important for young patients with suspected germ cell tumors 3

Advanced Imaging

When ultrasound is inconclusive:

• MRI: Indicated as a problem-solving examination 1
• CT: Useful for diagnosis and treatment planning of advanced disease or when retroperitoneal pathology is suspected 3, 4
• PET/CT: Not recommended for primary detection due to high false-positive rates 3

Common Causes of Enlarged Ovaries

Benign Causes

1. Functional cysts:

   • Follicular cysts
   • Corpus luteum cysts
   • Theca lutein cysts
   • Hemorrhagic cysts 3, 1

2. Endometriomas 3, 1

3. Benign neoplasms:

   • Mature cystic teratomas (dermoid cysts)
   • Serous or mucinous cystadenomas
   • Fibromas/thecomas 3, 2

4. Polycystic ovary syndrome (PCOS):

   • Characterized by enlarged ovaries with multiple small follicles 3, 5

5. Massive ovarian edema:

   • Can be associated with venous and lymphatic obstruction 4

Malignant Causes

1. Primary ovarian malignancies:

   • Epithelial ovarian carcinoma
   • Germ cell tumors
   • Sex cord-stromal tumors 3

2. Metastatic disease:

   • From gastrointestinal tract, breast, or lymphoma 4

Management Options

Conservative Management

1. Observation for:

   • Simple cysts <10 cm
   • Asymptomatic functional cysts
   • Simple cysts in postmenopausal women 2

2. Follow-up protocol for simple cysts:

   • Annual transvaginal ultrasound for three years
   • Annual CA-125 tests for five years 2

Medical Management

1. Hormonal therapy for PCOS:
   • Combined hormonal contraceptives
   • Progestins
   • Insulin-sensitizing agents for associated metabolic disorders 5

Surgical Management

1. Indications for surgery:

   • Suspicious features on imaging
   • Symptomatic cysts (pain, pressure symptoms)
   • Cysts >10 cm
   • Persistent cysts after observation
   • Ovarian torsion 3, 1

2. Surgical approaches:

   • Conservative surgery: Cystectomy or unilateral salpingo-oophorectomy for benign disease or early-stage malignancy in young patients desiring fertility preservation 3

   • Comprehensive staging surgery for suspected malignancy:

     • Total hysterectomy, bilateral salpingo-oophorectomy
     • Omentectomy
     • Peritoneal biopsies
     • Lymph node assessment 3

Special Considerations

Ovarian Torsion

• Surgical intervention should be performed promptly when suspected
• Laparoscopic approach preferred when feasible
• Detorsion preferred to preserve ovarian function 1

Pregnancy

• Most common histologic types during pregnancy: dermoid cysts (25-40%), corpus luteum cysts (13-17%), and serous cystadenomas (5-16%) 3
• Hyperreactio luteinalis characterized by enlarged ovaries with many peripheral thin-walled cysts 3

Retroperitoneal Pathology

• Large retroperitoneal tumors (like lymphoma) can cause bilateral ovarian enlargement through venous and lymphatic obstruction 4
• CT imaging warranted when bilateral ovarian enlargement is unexplained 4

Common Pitfalls to Avoid

1. Misdiagnosing mucinous ovarian tumors:

   • Carefully evaluate upper and lower gastrointestinal tract to rule out metastatic disease 3

2. Relying solely on Doppler flow:

   • Normal blood flow does not exclude torsion 1

3. Delaying surgical intervention for suspected torsion:

   • Can lead to ovarian necrosis 1

4. Overlooking non-ovarian causes of pelvic masses:

   • Paratubal cysts, pedunculated fibroids, and retroperitoneal masses can mimic ovarian pathology 3, 4

5. Inadequate follow-up of simple cysts:

   • Even in postmenopausal women, simple cysts require appropriate monitoring 2