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Sonography of the Ovary: Benign vs. Malignant

Introduction

Because of the improved resolution with transvaginal sonography, ovarian cysts and/or masses can be delineated with greater confidence than with the transabdominal approach. In addition, detailed tissue characterization is possible and artifacts can be readily excluded. However, the limited field of view with transvaginal sonography permits adequate visualization of only the true pelvis. Transabdominal sonography is still required to gain to overall assessment of large pelvic masses.

The greatest amount of information will be obtained from transvaginal sonography if it is considered an extension of the routine pelvic examination. During real-time scanning, simultaneous pressure with the transvaginal transducer and on the patient’s abdomen with the examiner’s free hand will optimize visualization of adnexal structures that may be beyond the normal field of view. Pelvic manipulation will also provide information on whether a particular ovarian mass is fixed in the pelvis or mobile. An ultrasound examination not only determines the size of an ovarian mass, but it can also evaluate its architectural pattern, thereby correlating sonomorphology with macroscopic pathologic features of a tumor.

Pre-test Probability

The risk of malignancy once an ovarian mass is detected varies based upon specific historical information. In the general population, the lifetime risk of ovarian cancer is 1.8%¹. The risk of malignancy increases 12-fold from 20-29 to 60-69 years of age². An ovarian mass in a premenopausal girl or a post-menopausal woman is abnormal. In the reproductive age group, an ovarian mass may be malignant, but it is more likely benign.

A family history of ovarian, breast, or colon cancer would increase the patient’s pre-test probability of having a malignancy.

The lifetime risk of ovarian cancer based on family history alone ranges from 6.7% for one first degree relative with disease to 40% for women with an hereditary syndrome³.

The use of oral contraceptives for greater than 5 years reduces the lifetime risk of ovarian cancer for the general population from 1.6% to 0.8%⁴. Tubal ligation may also reduce the risk of epithelial ovarian cancer⁵.

Serum CA-125 in a patient with a pelvic mass may provide additional important information with respect to the likelihood of malignancy. In the postmenopausal age group with a pelvic mass, an elevated CA-125 has a positive predictive value ³ 70% for malignancy⁶. The increased false positive rate in the premenopause, significantly reduces the applicability of this test. By using the initial level and the rate of increase over time, the specificity of a CA-125 value increases without affecting sensitivity⁵.

There are 35 sub-types of ovarian tumors. The variability in the macroscopic characteristics of benign and malignant lesions prevents a precise pathologic diagnosis from a detailed sonographic description in every case. There are few ovarian tumors that have characteristic sonomorphologic findings.

Benign Cystic Teratomas

Benign cystic teratomas or dermoids are the most common ovarian neoplasm in the reproductive age group (Fig. 1). Because of their characteristic findings, Sassone et al⁷ correctly diagnosed 23/24 benign cystic teratomas. The diffuse echogenicity of some benign cystic teratomas makes even large tumors (> 6 cm) sometimes difficult to visualize sonographically⁸. A combined pelvic and transvaginal ultrasound examination will improve the accuracy of detecting these masses.

Figure 1 – The echogenic focus (between markers) and speckled
debris within the cyst are characteristic of a benign cystic teratoma

The growth rate of benign cystic teratomas in the premenopause is 1.8 mm per year and practically zero in the postmenopause. Because of the know complications of torsion and malignant transformation in larger dermoids, tumors > 6 cm and those with a growth rate > 2 cm per year should be removed⁹.

When vascular flow is detected within the central solid component of a presumed dermoid, a struma ovarii containing thyroid tissue should be suspected. Benign cystic teratomas are generally avascular¹⁰.

A sonographic scoring system utilizing morphology and Doppler has a 99. 02% sensitivity and 99.75% specificity for detecting benign cystic teratomas¹¹.

Endometriomas

Endometriomas may have several sonomorphologic appearances ranging from an anechoic cyst, a diffusely echogenic cyst to a mass with multiple septations and debris. In general, 95% of endometriomas have diffuse low-level echoes (Fig. 2). Small hyperechoic wall foci in a mass with low-level echoes is also highly suggestive for an endometrioma. These foci are highly echogenic and should not be confused with papillary excrescences. Patel and co-workers¹² have speculated that these echogenic foci within the wall of an endometrioma are secondary to cell breakdown. A final feature of some endometriomas is the presence of septations without nodularity.

Figure 2 – Cyst containing homogeneous debris consistent with an
endometrioma

Acoustic streaming is the movement of fluid within a cyst due to the transfer of energy within the Doppler box to the particles within a cyst. The size of a cyst and its distance from the ultrasound transducer, as well as the viscosity of a cyst determine whether acoustic streaming will be present. Because of their viscosity, endometriomas will only occasionally have acoustic streaming¹³.

Ovarian Crescent Sign

The presence of normal ovarian tissue adjacent to an adnexal mass has been described as the ovarian crescent sign (Fig. 3). In one study of 100 women with adnexal masses, the absence of an ovarian crescent sign had a sensitivity of 96% and a specificity of 76% for the diagnosis of ovarian carcinoma. However, this sign cannot differentiate between benign and borderline tumors. In addition, it is more difficult to document in the postmenopausal age group¹⁴. Additional studies involving a sufficient number of stage I ovarian cancers will be required to truly test the reliability of this sign.

Figure 3 – Crescent sign. There is normal ovarian tissue adjacent to
a benign cystic teratoma (between markers)

Specific sonographic parameters have been evaluated in an attempt to reliably distinguish between benign and malignant ovarian tumors. The addition of color Doppler (see below) helps to decrease the false positive rate of a morphologic evaluation of an ovarian mass. The most important sonographic criteria utilized to distinguish benign from malignant lesions are discussed in the following paragraphs.

Ovarian Volume or Size

The risk of malignancy increases with tumor size, regardless of morphology^15,16. However, the incorporation of tumor size does not improve the accuracy of the morphologic criteria outlined below and is, therefore, not included in most of the more recent studies of ovarian masses¹⁷. Ovarian lesions³ 10 cm are difficult to assess morphologically, do not decrease in size with observation and should, therefore, be removed. For ovarian masses less than 5 cm, sonomorphology and Doppler assessment are most efficacious. With masses between 5 cm and 10 cm determining a course of action should be individualized. The patient’s age, history, symptoms, adequacy of the ultrasound examination, and possibly observational over 6 to 8 weeks should be considered.

Simple Thin Walled Cysts

The risk of malignancy generally increases with patient age and the size of a simple cyst. Because of the limited number of patients in any single study, the prevalence of ovarian malignancy for a specific size simple cyst varies (Fig. 4). Osmers et al¹⁸ reported an overall risk of malignancy and of tumors of low-malignant potential of 0.3% and 0.5%, respectively for simple ovarian cysts. It must be emphasized that there were only two malignancies and three tumors of low malignant potential in this study. As a result, the prevalence given may have a wide confidence interval. Ekerhovd et al¹⁹ found that 3/413 simple cysts (0.7%) were borderline or malignant in premenopausal women; 4/247 cysts (1.6%) were borderline or malignant in postmenopausal women. There were no borderline or malignant ovarian tumors with a cyst size < 7.5 cm. There appears to be a general consensus that the likelihood of a malignancy with a simple ovarian cyst of < 4 cm is remote. As a cyst increases in size, the risk of missing a papillary excrescence that would increase the risk of malignancy by 3 to 6-fold also increases. Hence, the presence or absence of papillary excrescences may explain the differences noted in the above reports.

Figure 4 – 4.4 x 3.4 cm clear ovarian cyst

Modesitt and co-workers²⁰ screened 15,106 asymptomatic women over the age of 50; 18% had a unilocular ovarian cyst and 1.2% had a mean diameter > 6 cm to 10 cm. There were no cases of ovarian carcinoma in the latter study. The risk of malignancy in this study was, therefore, < 0.1% with a 95% confidence interval.

Sixty-nine percent of cystic ovarian tumors in the premenopause resolve within 3 months. The size of an ovarian follicle is between 15 and 25 mm (Fig. 5). However, even between 30 and 40 mm, 68.2% of simple cysts were found to be functional¹¹.

Figure 5 – 1.56 cm dominant follicle

Loculated Cyst

The loculation of an ovarian cyst increases the risk of malignancy (Fig. 6)^21,22. The presence of papillary excrescences can help to differentiate a mucinous cyst adenoma from a mucinous cyst adenocarcinoma²³. As the number of mucinous tumors increases in a series, the sensitivity and specificity for the detection of malignancy decreases¹⁷.

Figure 6 – Multiloculated ovarian cyst

Solid Adnexal Masses

When a solid adnexal mass is detected sonographically, a pedunculated leiomyoma must be excluded²⁴. Color Doppler can be utilized in an attempt to find the stalk between the uterus and the adnexal mass. A partial list of solid ovarian tumors (Fig. 7) is outlined in Table I. An ovarian fibrothecoma has a homogeneous echo pattern and marked posterior acoustic shadowing without any internal calcifications. A diffusely hypoechoic ovarian mass without posterior echo enhancement suggests a thecoma²⁵. Ovarian steroid cell tumors have a different echogenicity from the surrounding ovary²⁶. While the majority of granulosa cell tumors (Fig. 8) have cystic components, some are isoechoic to the uterus²⁷. Brenner tumors are also solid, hypoechoic and with good through transmission of sound. They are architecturally similar to fibromas/thecomas²⁴. Dysgerminomas are malignant germ cell tumors; sonographically, they are solid and multiloculated. Color Doppler reveals vascular flow along the septations of dysgerminomas²⁸.

Figure 7 – Solid ovarian tumor

Figure 8 – Central vascular flow is present within this granulosa cell
tumor

Papillary Excrescences

Papillary excrescences are localized overgrowths of the epithelial lining of a cyst (Fig. 9). The more papillary excrescences, the greater the likelihood of malignancy²⁹. Papillary excrescences that do not protrude³ 3 mm into the cyst cavity are not strongly associated with malignancy^15,30. Papillary excrescences must be distinguished from focal punctate calcifications in an otherwise normal appearing ovary (Fig. 10). The latter areas have been found to represent superficial inclusion cysts and associated psammomatous calcifications³¹. When tumors were evaluated macroscopically at the time of surgery, papillary excrescences was the finding most frequently associated with malignancy³².

Figure 9 – Ovarian malignancy containing two papillary excrescences
(arrows)

Figure 10 – Echogenic foci (arrow) on the periphery of the ovary

Focal Solid Areas

Focal solid areas within an ovarian cyst are much larger and, therefore, sonographically distinct from papillary excrescences. Focal solid areas also increase the likelihood of malignancy (Fig. 11)^{7,15,18,22,33}.

Figure 11 – Solid component within an ovarian malignancy with
internal vascular flow

Tincture of Time

If there are not any obvious stigmata of malignancy and the size of the lesion does not mandate surgery, a follow up ultrasound examination in 6-8 weeks will reduce the false positive rate of sonomorphology. Occasionally, hemorrhagic ovarian cysts (Fig. 12) will have a complex appearance that almost completely resolves in the interval between examinations. From 76%³⁴ to 94%³⁵ of functional ovarian cysts in women of reproductive age resolve in 5 to 10 weeks. Even in postmenopausal women 29% of simple ovarian cysts will disappear³⁶.

Figure 12 – 7.3 x 5.0 cm cyst with a dependent “ground-glass”
component consistent with a hemorrhagic cyst

Presence or Absence of Cul-de-sac Fluid

Transvaginal sonography will consistently detect 8 ml of cul-de-sac fluid. A post-menopausal patient has between 1.2 ± 1.9 ml³⁷ and 5.5 ± 7.8 ml³⁸ of cul-de-sac fluid. Hence, a moderate amount of cul-de-sac fluid in a post-menopausal patient should increase the index of suspicion for an ovarian malignancy or liver disease. Unfortunately, this sign is usually only present with advanced ovarian carcinoma³⁹.

Color Doppler

Color Doppler has been used in attempt to reduce the false positive rate of ovarian morphology. Although the initial reports were quite promising, subsequent studies have had conflicting results. The utilization of color Doppler has evolved from the quantitative to the qualitative. Hence, rather than utilizing a specific RI or PI cut-off for benign and malignant^40,41, the presence or absence of vascular flow into specific regions of a mass are evaluated. In the latter instance, central vascular flow within the mass, flow within a papillary excrescence or flow along septations (Fig. 13) would be considered indicators of malignancy, while peripheral flow is more indicative of a benign process^42,43. Hence, with a unilocular cyst, Doppler flow would not improve the diagnostic accuracy of morphology. It has not yet been determined if three-dimensional power Doppler will further improve the accuracy of the qualitative assessment of ovarian masses⁴².

Figure 13 – Vascular flow on a dividing septation in an ovarian malignancy

Conclusions

Ultrasound is most reliable predicting that an ovarian lesion is benign; it is less accurate in detecting malignancy^44,45. The data presented indicates that sonographic morphology can provide a significant amount of information concerning the risk of malignancy of an ovarian tumor. The most consistent sonographic signs of malignancy appears to be the presence of papillary excrescences > 3 mm along the internal wall of an ovarian mass^32,46 and the presence of a solid component²¹. From a morphologic standpoint, benign cystic teratomas produce the most false positive diagnoses of malignancy. By excluding benign cystic teratomas from evaluation based upon their distinct morphology, all of the scoring systems that attempt to distinguish benign from malignant ovarian masses are improved²². Pattern recognition of the specific criteria outlined above has been shown to be as effective as the multiple scoring systems that have been proposed¹⁵. The ability of ovarian morphology to distinguish between a benign and malignant ovarian mass ranges between 65% and 94%¹⁷.

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Ultrasound – ultrasound in the presence of ovarian cysts

Ultrasound in gynecology is used to diagnose diseases of the female reproductive organs. This is a fairly common, completely safe, highly informative and easy method. An ovarian cyst on ultrasound is visualized as a cavity formation.

Ultrasound of the pelvic organs

Ultrasound of the pelvic organs is used in the diagnosis of various gynecological diseases, urgent conditions, for monitoring treatment and as a screening study. The method has no contraindications. It does not require preparation. Ultrasound of the pelvic organs, on which the ovarian cyst is visualized, is performed transabdominally or transrectally. Since transabdominal ultrasound is performed with a full bladder, the patient is advised to drink one liter of fluid an hour before the procedure.

For echography, devices with sectoral transabdominal and vaginal sensors are used. The frequency of the first of them is in the range from 3.5 to 5 MHz, and the second – from 5 to 7.5 MHz. Transabdominal sensors look at women with a full bladder. Before using the vaginal sensor, it is processed according to a special technique, and then a sound-conducting gel is applied to the scanning surface, after which a condom is put on. If a woman is of reproductive age, then an ultrasound for an ovarian cyst is best performed either at the end of menstruation, or one or three days before the start.

Doppler ultrasound determines the following parameters:

• number of vascularization zones;
• Mosaic flow present or absent;
• pulsation index;
• resistance index;
• maximum systolic blood flow velocity.

Interpretation of ultrasound results is based on analysis of internal echostructure of the lesion, echogenicity, sound conduction, and contour evaluation. After the study is completed, the doctor gives a conclusion about the structure of the formation (solid, cystic or solid cystic), and also makes a conclusion about the nosological affiliation. Dopplerography is often used in the differential diagnosis of malignant and benign and ovarian neoplasms.

Normal ovarian ultrasound

In women of reproductive age, the ovaries are about four centimeters long, three centimeters wide, and two centimeters thick. Transvaginal scanning of the ovarian parenchyma shows multiple follicles with a diameter of 0.3 to 0.6 cm. In the middle of the menstrual cycle, a dominant follicle with a diameter ranging from 1.8 cm to 2.4 cm can be seen.

After after ovulation occurs, a corpus luteum appears in the parenchyma of a healthy ovary. It is a formation of a round shape, having an anechoic or heterogeneous structure and thick walls. Its diameter is two centimeters, by the beginning of the next cycle it gradually decreases in size. If a woman is in menopause, then her follicular apparatus disappears and the size of the ovaries gradually decreases.

Ultrasound can also detect an ovarian cyst in polycystic ovary syndrome. The disease has the following echographic features:

• the uterus is reduced due to its thickness;
• the size of the ovaries is increased;
• no dominant follicle or corpus luteum;
• , the number of follicles, which are located diffusely, is increased, and there are practically no differences in their diameter.

In order to facilitate ultrasound diagnosis of diseases of the reproductive organs, including ovarian cysts, it is proposed to calculate the ovarian-uterine index. It is the ratio of the average volume of the ovaries to the thickness of the uterus. In the case when the ovarian index is higher than 3.5, then this is evidence of polycystic ovaries. If it is less than the threshold value, then according to ultrasound, there is no ovarian cyst.

Ovarian cyst on ultrasound

In most cases, ultrasound reveals functional ovarian cysts, which include follicular cyst and corpus luteum cyst. On ultrasound, the follicular ovarian cyst has a round or egg-like shape. Its inner surface is smooth, and the wall is rather thin. Its thickness is about one millimeter. The internal content of the cyst is homogeneous, has an anechoic structure. Its diameter can be different – from three to ten centimeters. A follicular ovarian cyst ceases to be visible on ultrasound three months after it occurs.

Cysts of the corpus luteum form after ovulation. They are rounded, the wall can have a thickness of two to six millimeters. The size of the corpus luteum cyst can be different – from three to seven centimeters. Their content in most cases is anechoic, has a cobweb-like or mesh structure. They may contain partitions of irregular shape and various sizes. In the formation cavity hyperechoic inclusions, which are represented by blood clots. On ultrasound, ovarian corpus luteum cysts become invisible within three weeks.

In almost one hundred percent of cases, blood flow is determined in the ovarian corpus luteum cyst by ultrasound. However, in the presence of a corpus luteum cyst, low values ​​of the resistance index can be determined, which are combined with a high maximum systolic blood flow velocity.

In hyperstimulated ovary syndrome and in case of hydatidiform mole, a thecalutein ovarian cyst occurs. On ultrasound, they can be visible from one or both sides and are multi-chamber formations, the diameter of which can be in the range of 4-8 centimeters. The stack of such a cyst is thin, about one millimeter. Its contents are anechoic, homogeneous. After the elimination of the pathological process, the cyst gradually disappears. After the patient’s pathological focus is eliminated, the teculutein cysts are not visible on ultrasound, as they regress.

Endometrioid ovarian cysts appear round or oval on ultrasound. They are in most cases located behind the uterus. The size of the endometrioid cyst can be different – from one to eight centimeters. Their wall thickness can vary from two to six millimeters. Its internal contents are filled with a highly echogenic or medium echogenic suspension, which does not move during the percussion of this formation. The presence of a double wall contour is considered one of the main ultrasound signs of an endometriotic cyst. In eighty percent of cases, blood flow is recorded in the wall of the endometrioid ovarian cyst on ultrasound.

Paraovarian ovarian cyst is formed in embryogenesis, but begins to increase during puberty. It reaches its maximum development by puberty. A paraovarian ovarian cyst on ultrasound has dimensions from three to twelve centimeters in diameter. Sometimes huge paraovarian cysts are revealed. Their walls are thin, about one centimeter. The content has a homogeneous structure, it is anechoic. In the contents of the paraovarian ovarian cyst, ultrasound often reveals a delicate fine suspension, which shifts when tapped on the formation. The only reliable echographic sign of a paraovarian cyst is the presence of a separate ovary.

Teratomas are two to twelve centimeters in diameter. Their internal structure is very diverse. So, for example, on ultrasound, this ovarian cyst may contain only one hyperechoic component, which is fat. In other cases, various sizes are visualized, either a cystic dense hyperechoic component, or a dense component that gives a shadow due to the presence of bone rudiments in the cavity. Sometimes on ultrasound, this ovarian cyst has multiple small-streaked inclusions, and also, in the presence of hair, thin elongated hyperechoic structures. The blood flow in the presence of teratoma is not determined.

Of the pathological ovarian cysts, cystadenomas are the most common. They can be serous and mucinous. The latter are divided into papillary and smooth-walled. Smaller smooth-walled cystadenomas are mostly round, while larger ones are oval. The size of such formations can vary widely. Their diameter is from three to fifteen centimeters, and the wall thickness is not more than one millimeter.

Cystadenomas contain contents in the cavity, which in most cases are homogeneous, have an anechoic structure. Sometimes on ultrasound, such an ovarian cyst contains a low-echoic suspension that is displaced by percussion. In twenty percent of cases, partitions are determined inside the formation. Papillary serous cystadenomas are mostly round in shape. Their diameter is from three to twelve centimeters, and the walls can be from one to two millimeters thick. On ultrasound, the papillary ovarian cyst has one chamber. In their cavity, a medium-echoic suspension is predominantly determined, which is displaced during palpation. The main echographic sign of cystadenomas is the presence of growths on the inner surface, the diameter of which is in the range of 0. 3–1 cm. They are round in shape and have a spongy texture.

Small mucinous cystadenomas are generally round, while larger ones may be oval. In most cases, they have a diameter that can vary from four to twenty centimeters. These cysts in some cases can occupy the entire abdominal cavity. These tumors have a pathognomonic echoscopic sign – a finely dispersed, medium-echoic, non-displaceable suspension, but multiple thin irregularly shaped septa.

Echoscopic diagnosis of ovarian masses

In addition to their cysts, fibroma is also referred to as tumor-like formations of the ovaries. This is a tumor of the stroma of the ovaries and the sex cord and stroma of the ovary. Fibroids have different localization. Their shape is round or oval. The size of the neoplasm can vary – they can have a diameter of several millimeters or huge sizes. In the latter case, the mass formation occupies almost the entire abdominal cavity. On ultrasound, ovarian fibromas have low sound conductivity and an anechoic internal structure. In the parenchyma of the tumor, an ovarian cyst can be detected on ultrasound at the site of tumor necrosis. In the presence of fibroids in ten percent of cases, the blood flow is determined, there is no mosaic.

Tumors of ovarian stroma and sex cord also include tecoma. In half of the cases, the tumor produces estrogens. Thecomas are mainly located on the side of the uterus. They have different sizes – from three to fifteen centimeters. The surface of the techome is predominantly smooth, the internal structure is homogeneous. Tumors have an average or increased echogenicity. On ultrasound, ovarian cysts in the thecoma cavity are extremely rare. Neoplasms have an average or increased sound conductivity. In the presence of thecoma during echoscopy, blood flow is recorded in almost all cases. In forty percent of cases there is a mosaic.

Granulosa cell tumors are clinically manifested by hyperestrogenism. They are most often located on the side of the uterus. The size of the formation can be different – from three to five centimeters. Small tumors are solid. They have medium or low echogenicity. At the same time, tumors of medium size have an average echogenicity. They have superior sound transmission. Echoscopy can often identify small liquid inclusions that have clear, even contours. In tumors with a diameter of more than nine centimeters, cystic inclusions are often detected, which are large. Many of them, due to the huge number of thin partitions, have a spongy structure.

Androblastomas are classified as sex cord and stromal tumors of the ovary. These tumors are masculinizing. On scans, tumors are mainly defined as round or oval formations located on the side or above the fundus of the uterus. The average diameter of an androster is ten centimeters. Their echogenicity is different, sound conductivity is increased. In thirty percent of cases, these tumors have a solid structure.

Masculinizing ovarian tumors include androsteromas. Their parenchyma is heterogeneous due to cystic formations with increased echogenicity. In the presence of androblastoma, arterial blood flow is ascertained in one hundred percent of observations.

Ultrasound of the pelvic organs reveals not only an ovarian cyst, but also other neoplasms of the uterine appendages. Many of them contain cystic inclusions. This research method is non-invasive and comfortable.

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classification, risk factors, diagnosis and treatment

Usually women are faced with such a conclusion after ultrasound of the pelvic organs. And it makes a lot of people nervous. However, ovarian cysts are different and not always, contrary to popular belief, they must be removed surgically.

Let’s understand what a cyst is. The word “kystis” in Greek means “bubble”. It is the “bubble” of the ovarian cyst that is the cyst formation in the ovary, the cavity of which can be filled with fluid, blood, mucus and various tissues.

Classification

In women of childbearing age, ovarian cysts are common, and most of them are benign neoplasms, among which functional, endometrioid cysts, dermoid cysts (mature teratomas) and serous cystadenomas predominate.

Functional cysts (follicular cyst, corpus luteum cyst) are formed from the natural structures of the ovary – the follicle and corpus luteum. Follicular cysts are the result of the fact that, for various reasons, ovulation does not occur, an unruptured follicle remains in the ovary for some time and may even increase in size. Corpus luteum cysts are the result of excess fluid accumulation in the corpus luteum that forms after ovulation. Functional cysts exist for a short time (up to 2-3 months), most often disappear on their own and do not require any treatment. At the same time, a woman is recommended sexual rest, restriction of physical activity and exposure to high temperatures (baths, saunas, etc.). In order to monitor the condition of the ovarian cyst, ultrasound of the pelvic organs is performed on the 2nd-5th day of the menstrual cycle.

Endometrioid cysts (endometriomas) are caused by endometriosis of the ovary. Monthly small bleeding from the focus of endometriosis leads to the formation of a cavity in the ovary filled with blood, which thickens over time, darkens and becomes similar in consistency and color to liquid chocolate. Therefore, such cysts are also called “chocolate”. In 0.8% of cases, endometriomas become malignant (degenerate into malignant ones). The tactics of treating endometrioid cysts is determined individually depending on its size, the age of the woman, reproductive plans, etc. Therapy may be limited to the appointment of hormonal drugs, but more often such cysts are removed surgically.

Dermoid ovarian cysts appear as a result of a violation of the course of the embryonic period, when cells of the integumentary epithelium enter the ovary of the unborn child. Therefore, such cysts contain adipose tissue, teeth, hair, bones. The dermoid cyst usually does not reach large sizes, grows slowly, about 2% degenerate into cancer. The treatment of such cysts is surgical.

Serous cystadenomas are neoplasms of a benign nature, with elastic dense walls containing a clear serous fluid. The walls of the cyst are dense, the inner surface of the capsule is smooth. The neoplasm is painless and quite mobile, according to external signs it resembles a follicular cyst. There are also papillary serous cystadenomas, which are characterized by the presence of papillary growths on the inner surface of the capsule. Such cysts can be borderline and in most cases degenerate into malignant tumors, so serous cystadenomas are always surgically removed.

Factors contributing to the formation of ovarian cysts

• hormonal disorders;

• artificial termination of pregnancy;

• inflammation of the female genital organs;

• sexually transmitted infections;

• premature puberty;

• operations on the pelvic organs in the past;

• heredity.

Ovarian cyst diagnostics

• Complaints about irregular menstruation, pain in the lower abdomen. In this case, quite often the ovarian cyst is asymptomatic.

• During a gynecological examination, pain in the lower abdomen and an increase in the ovaries are revealed.

• Ultrasound examination of the pelvic organs is the most informative method, as it allows not only to determine the presence of a cyst, but also to observe its development, assess its size and structure.

• With the help of a blood test for oncomarkers (biological substances produced by cancer cells): Ca-125, HE4 with the calculation of the RMI index and the ROMA index, a malignant ovarian tumor (cancer) can be suspected.

• With the help of magnetic resonance imaging of the pelvic organs with contrasting, the location, size and structure of the cyst are clarified.

Treatment of ovarian cysts

As mentioned above, the choice of cyst treatment depends on the type of cyst and is determined by the doctor.

In order to determine whether the cyst is functional or not, a woman is recommended to undergo an ultrasound of the pelvic organs in dynamics on the 2nd-5th day of the menstrual cycle for 1-3 months. If necessary, hormonal preparations are prescribed during the observation period. Positive dynamics (disappearance of formation in the ovary or its decrease in size) indicates the absence of a tumor in the ovary.