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Benign Ovarian Tumours

Ovarian tumours can be divided into three main groups:

Functional
Benign
Malignant

In relative frequency, functional cysts account for about 24% of all ovarian cysts, benign cysts 70% and malignant
6% (see separate article Ovarian Cancer). See also separate article Ovarian Tumours and Fibroids in
Pregnancy.

Benign epithelial neoplastic cysts (60% of benign ovarian tumours)

Serous cystadenoma:
Develop papillary growths which may be so prolific that the cyst appears solid.
They are most common in women aged between 40-50 years.
About 15-25% are bilateral and about 20-25% are malignant.

Mucinous cystadenoma:
The most common large ovarian tumours which may become enormous.
They are filled with mucinous material and rupture may cause pseudomyxoma peritonei.
They may be multilocular.
They are most common in the 20-40 age group. About 5-10% are bilateral and around 5%
will be malignant.

Benign neoplastic cystic tumours of germ cell origin

Benign cystic teratoma; rarely malignant.
They arise from primitive germ cells.
A benign mature teratoma (dermoid cyst) may contain well-differentiated tissue - eg, hair, and teeth.
20% are bilateral.
They are most common in young women.
Poorly differentiated, malignant teratomas are rare.

Benign neoplastic solid tumours

Fibroma (less than 1% are malignant); small, solid benign fibrous tissue tumours. They are associated
with Meigs' syndrome and ascites.
Thecoma (less than 1% are malignant).
Adenofibroma.
Brenner's tumour:
Rare ovarian tumours displaying benign, borderline or proliferative, and malignant variants.
Over 95% are benign and more than 90% are unilateral.
They may be associated with mucinous cystadenoma and cystic teratoma.

Epidemiology
Benign ovarian tumours occur in 30% of females with regular menses (eg, luteal cysts as incidental
findings on pelvic scans) and 50% of females with irregular menses.
Predominantly they occur in premenopausal women; they may also occur perinatally.
Benign ovarian tumours are uncommon in premenarchal and postmenopausal women.
The likelihood of malignancy in women of childbearing age is low and a large proportion of cysts are of
functional origin, tending to resolve over time. [1]
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Benign neoplastic cystic tumours of germ cell origin are most common in young women. They
account for 15-20% of all ovarian neoplasms.

Risk factors
Obesity.
Tamoxifen therapy has been associated with an increase in persistent ovarian cysts.
Early menarche.
Infertility.
Dermoid cysts can run in families.

Presentation
Asymptomatic - chance finding (eg, on bimanual examination or ultrasound).
Dull ache or pain in the lower abdomen, low back pain.
Torsion or rupture may lead to severe abdominal pain and fever.
Dyspareunia.
Swollen abdomen, with palpable mass arising out of the pelvis, which is dull to percussion and does
not disappear if the bladder is emptied.
Pressure effects - eg, on the bladder, causing urinary frequency, or on venous return, causing
varicose veins and leg oedema.
Torsion, infarction or haemorrhage:
Cause severe pain.
Torsion may be intermittent, presenting with intermittent episodes of severe pain.
Ovarian torsion is a complication for persistent masses in pregnancy. [2]

Rupture:
Rupture of a large cyst may cause peritonitis and shock.
Rupture of mucinous cystadenomas may disseminate cells which continue to secrete
mucin and cause death by binding up the viscera (pseudomyxoma peritonei).

Ascites - suggests malignancy or Meigs' syndrome.

Endocrine - hormone-secreting tumours may cause virilisation, menstrual irregularities or
postmenopausal bleeding. This is uncommon though.

Differential diagnosis
Non-neoplastic functional cysts - eg, follicle cyst, corpus luteum cyst, theca lutein cyst.
Any other cause of pelvic pain.
Polycystic ovary syndrome.
Endometrioma.
Ovarian malignant tumour.
Bowel - colonic tumour, appendicitis/appendix mass, diverticulitis.
Gynaecological - pelvic inflammatory disease, tubo-ovarian abscess, uterine tumour (eg, fibroids),
ectopic pregnancy, para-ovarian cyst.
Pelvic malignancies - eg, retroperitoneal tumours, small intestine tumours and mesothelial tumours.

Investigations
It is important that some types of adnexal cysts (such as endometrioma, mature cystic teratoma, and
paraovarian cysts) are diagnosed correctly as these may affect patients’ fertility, may be associated with
significant pelvic disease or put the patient at risk for ovarian torsion. [3]

Pregnancy test (uterine or ectopic pregnancy).

FBC - infection, haemorrhage.
Urinalysis - if there are urinary symptoms.
Ultrasound - a pelvic ultrasound is the single most effective way of evaluating an ovarian mass.
Transvaginal ultrasonography is preferable due to its increased sensitivity over transabdominal
ultrasound.
CT or MRI scan - usually required only if ultrasound results are not definitive or if intra-abdominal
pathology is suspected.
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A recent meta-analysis found that the sensitivity and specificity of MRI for correct detection of
malignancy may reach 92% and 88%, respectively. [4]
Diagnostic laparoscopy may be performed in some cases.
Fine-needle aspiration and cytology may be used to confirm the impression that a cyst is benign.
Cancer antigen 125 (CA 125):
CA 125 does not need to be done in premenopausal women who have had an ultrasound
diagnosis of a simple ovarian cyst made.
CA 125 is unreliable in differentiating benign from malignant ovarian masses in
premenopausal women because of the increased rate of false positives and reduced
specificity.
Diverticulitis, endometriosis, liver cirrhosis, uterine fibroids, menstruation, pregnancy,
benign ovarian neoplasms and other malignancies (pancreatic, bladder, breast, liver, lung)
can all result in an elevated CA 125 levels. [5]
CA 125 is primarily a marker for epithelial ovarian carcinoma and is only raised in 50% of
early-stage disease.
When serum CA 125 levels are raised, serial monitoring of CA 125 may be helpful, as
rapidly rising levels are more likely to be associated with malignancy than high levels which
remain static.
If serum CA 125 assay is more than 200 units/mL, discussion with a gynaecological
oncologist is recommended [6] .
The main use of CA 125 is in assessing response over time to treatment for malignancy.

Lactate dehydrogenase (LDH), alpha-fetoprotein (AFP) and human chorionic gonadotrophin (hCG)
should be measured in all women under the age of 40 with a complex ovarian mass because of the
possibility of germ cell tumours.

NB: although pelvic ultrasound is highly sensitive in detecting adnexal masses, its specificity in detecting
malignancy is lower. [1]

Risk of Malignancy Index (RMI)

There are different risk of malignancy scores which can be used to assess an ovarian mass. [7]
The RMI I is the most effective for women with suspected ovarian cancer. This is also recommended
by the National Institute for Health and Care Excellence (NICE) guideline on ovarian cancer. [8] It should
not be used for premenopausal women though.
RMI I combines three pre-surgical features: serum CA 125 (CA 125); menopausal status (M); and
ultrasound score (U).
The RMI is a product of the ultrasound scan score, the menopausal status and the serum CA 125
level (IU/mL) as follows:
RMI = U x M x CA 125.
The ultrasound result is scored 1 point for each of the following characteristics: multilocular
cysts, solid areas, metastases, ascites and bilateral lesions. U = 0 (for an ultrasound score
of 0), U = 1 (for an ultrasound score of 1), U = 3 (for an ultrasound score of 2-5).
The menopausal status is scored as 1 = premenopausal and 3 = postmenopausal.
Serum CA 125 is measured in IU/mL.

Recommendations are that those women suspected of having ovarian cancer who have an RIM score
greater than 200 should have a CT of the abdomen and pelvis performed in secondary care. [9]

Management
Many patients with simple ovarian cysts based on ultrasound findings do not require treatment.

Expectant management
Women with small (less than 50 mm in diameter) simple ovarian cysts generally do not require follow-
up, as these cysts are very likely to be physiological and almost always resolve within three menstrual
cycles. [6]
Women with simple ovarian cysts of 50-70 mm in diameter should have yearly ultrasound follow-up
and those with larger simple cysts should be considered for either further imaging (MRI) or surgical
intervention. [10]
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Even in postmenopausal women, as many as 80% of incidental adnexal masses will resolve over a
period of several months. For those that are persistent, unchanged, less than 10 cm, and with normal
CA 125 values, the likelihood of an invasive cancer is sufficiently low that observation should usually
be offered. [11]
However, ovarian cysts that persist or increase in size are unlikely to be functional and may need
surgical management.

Oral contraceptives
The oral contraceptive pill is not recommended, as its use has not been shown to promote the
resolution of functional ovarian cysts. [12] Watchful waiting for two or three cycles is appropriate and if
cysts persist then surgical management is often indicated.

Surgery
If conservative measures fail or criteria for surgery are met, surgical therapy for benign ovarian
tumours is generally very effective and provides a cure with minimal effect on reproductive capacity.
Persistent simple ovarian cysts larger than 5-10 cm, especially if symptomatic, and complex ovarian
cysts should be considered for surgical removal.
In children and younger women (wishing to preserve maximum fertility), cystectomy may be preferable
to oophorectomy. [13]
Laparoscopic surgery for benign ovarian tumours is usually preferable to open surgery.
Although most adnexal masses are benign in pregnancy, when surgical management is chosen,
laparoscopy can be safely performed. [2]
Ovarian torsion:
Usually initially treated by laparoscopy with uncoiling of the affected ovary and possible
oophoropexy.
Salpingo-oophorectomy may be indicated if there is severe vascular compromise,
peritonitis or tissue necrosis.

Immediate surgical intervention is indicated for a haemorrhagic cyst.

Laparoscopy will need to be upgraded to laparotomy when malignancies are discovered.
Pseudomyxoma peritonei is treated by surgical debulking.

Complications
Torsion of an ovarian cyst can occur.
Haemorrhage is more common for tumours of the right ovary.
Rupture of an ovarian cyst can occur.
Infertility can occur as a result of ovarian tumours or their treatment. However, the role of cysts in
infertility is controversial and the effects of surgical treatment are often more harmful than the cyst
itself to the ovarian reserve. Surgery does not seem to improve pregnancy rates. [14]

Prognosis
This is variable and depends on the type and size of tumour, associated complications and the
patient's age.
Most small ovarian cysts in premenopausal women will resolve spontaneously.
Ovarian torsion: if operated within six hours of onset of symptoms, tissue will usually remain viable.
Prognosis of surgically removed cysts ultimately depends on the histology.

Further reading & references

The Management of Ovarian Cysts in Postmenopausal Women; Royal College of Obstetricians and Gynaecologists
(2016)

1. Smorgick N, Maymon R; Assessment of adnexal masses using ultrasound: a practical review. Int J Womens Health. 2014
Sep 23;6:857-63. doi: 10.2147/IJWH.S47075. eCollection 2014.
2. Goh W, Bohrer J, Zalud I; Management of the adnexal mass in pregnancy. Curr Opin Obstet Gynecol. 2014 Apr;26(2):49-53.
doi: 10.1097/GCO.0000000000000048.
3. Patel MD; Pitfalls in the sonographic evaluation of adnexal masses. Ultrasound Q. 2012 Mar;28(1):29-40. doi:
10.1097/RUQ.0b013e31823c22a4.
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4. Dodge JE, Covens AL, Lacchetti C, et al; Preoperative identification of a suspicious adnexal mass: a systematic review and
meta-analysis. Gynecol Oncol. 2012 Jul;126(1):157-66. doi: 10.1016/j.ygyno.2012.03.048. Epub 2012 Apr 6.
5. Cohen JG, White M, CruzA, et al; In 2014, can we do better than CA125 in the early detection of ovarian cancer? World J
Biol Chem. 2014 Aug 26;5(3):286-300. doi: 10.4331/wjbc.v5.i3.286.
6. Management of Suspected Ovarian Masses in Premenopausal Women; Royal College of Obstetricians and
Gynaecologists (December 2011)
7. Obeidat BR, Amarin ZO, Latimer JA, et al; Risk of malignancy index in the preoperative evaluation of pelvic masses. Int J
Gynaecol Obstet. 2004 Jun;85(3):255-8.
8. Ovarian cancer - the recognition and initial management of ovarian cancer; NICE Clinical Guideline (April 2011)
9. Management of epithelial ovarian cancer; Scottish Intercollegiate Guidelines Network - SIGN (Nov 2013)
10. Levine D, Brown DL, Andreotti RF, et al; Management of asymptomatic ovarian and other adnexal cysts imaged at US:
Society Radiology. 2010 Sep;256(3):943-54. Epub 2010 May 26.
11. Solnik MJ, Alexander C; Ovarian incidentaloma. Best Pract Res Clin Endocrinol Metab. 2012 Feb;26(1):105-16. doi:
10.1016/j.beem.2011.07.002.
12. Grimes DA, Jones LB, Lopez LM, et al; Oral contraceptives for functional ovarian cysts. Cochrane Database Syst Rev. 2014
Apr 29;4:CD006134. doi: 10.1002/14651858.CD006134.pub5.
13. Hernon M, McKenna J, Busby G, et al; The histology and management of ovarian cysts found in children and adolescents
BJOG. 2010 Jan;117(2):181-4.
14. Legendre G, Catala L, Moriniere C, et al; Relationship between ovarian cysts and infertility: what surgery and when? Fertil
Steril. 2014 Mar;101(3):608-14. doi: 10.1016/j.fertnstert.2014.01.021.

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical
conditions. EMIS has used all reasonable care in compiling the information but makes no warranty as to its
accuracy. Consult a doctor or other healthcare professional for diagnosis and treatment of medical conditions.
For details see our conditions.

Original Author: Current Version: Peer Reviewer:

Dr Colin Tidy Dr Louise Newson Dr Helen Huins
Document ID: Last Checked: Next Review:
1855 (v23) 14/01/2015 13/01/2020

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