Ruptured Ovarian Cyst

Ruptured Ovarian Cyst

Definition: An ovarian cyst is a sac filled
with liquid or semi liquid material arising
in an ovary
Types:
1. Polycystic Ovarian Syndrome (PCOS)
2. Endometrial Cysts (Chocolate cyst)
3. Functional Cysts (commonest)
Follicular cysts
Theca lutein cysts
Corpus luteum cysts

Functional cyst
Ovarian cysts arise during normal process of

ovulation and are related to temporary hormonal

disorder.
Characteristic: Usually asymptomatic
Usually 6-8cm in diameter.
Unilocular and contain clear fluid.
Spontaneous regression with correction of
hormone.
Mittelschmerz : rupture of follicular cyst every
cycle resulting in pelvic pain.
Non physiologic cysts: cystadenomas, mature
cystic teratomas

Follicular cyst

Corpus luteum
cyst

Theca lutein cysts

- Commonest in - Corpus luteum - Usually bilateral

- Caused by high
reproductive age become cystic
- Result from
and fail to
hCG secreted in
growth of follicle regress
cases of GTN or
- Progesterone
that does not
induced
rupture.
and estrogen
ovulation.
- Usually
continue results - Regress after
asymptomatic
in prolonged
gonadotropin
menses and
level falls.
heavy bleeding
- Usually resolve
spontaneously

Clinical features
Signs
Acute Abdominal pain
Rebound tenderness due to peritoneal irritation
Abdomen is distended (with decrease bowel sound)
Palpable mass
Symptoms
Sudden onset of pain
Generalized abdominal pain
Dizziness or syncope (hemoperitoneum)

Investigation
Urine pregnancy test:
to exclude ectopic
pregnancy
Ultrasonography: look
for hemoperitoneum
C-reactive Protein:
Raised in ovarian
torsion
Urinalysis: to rule out
urinary tract infection

Management
Expectant management - In many cases you can
wait and re-examined to see if the cyst goes
away on its own within a few months.
COCPs - to reduce the chance of new cysts
developing in future menstrual cycles and help
resolution as well.
Surgery- removal of a cyst if it is large, does not
look like a functional cyst, is growing, or persists
through two or three menstrual cycles. Cysts that
cause pain or other symptoms may be removed

ENDOMETRIOSIS

Endometrios
is
- Presence of ectopic
benign endometrial
tissue outside the
endometrial cavity
- Proliferative oestrogen
dependent disease
- Common sites:
- Ovaries
- Pouch of Douglas
- Pelvic Peritoneum
- Uterosacral ligament
- Rectovaginal
- Sigmoid Colon

Etiology
Sampsons implantation theory:
Retrograde reflux of menstrual endometrial
glands & tissue thru fallopian tubes
implantation on surrounding peritoneal
structures.
Meyers coelomic metaplasia theory:
Peritoneal cells transform into endometrial
cells.
Metastatic theory:
Endometrial tissues "travels" through the
body via vascular or lymphatic channels
eaches distant sites Implants and grows,

Characteristic
Ectopic endometrial tissue responds to
cyclical ovarian hormones.
Blood oozing during menstruation causes
local adhesions in the pelvis.
Local inflammatory reaction and healing
leads to fibrosis.
End result are pelvic pain & infertility.
Malignancy is extremely rare, though
endometrial tissues are highly
proliferative.

Risk Factors
Age: all ages but most typically it occurs
in women ages 25 - 40.
Family History
Nulliparity or delayed childbearing
Menstrual History: shorter than normal
cycle, heavier periods, and longer
periods. Begun menstruating at a
younger than average age.
Uterine/genital tract outflow
abnormalities

Clinical features
Symptoms
Dysmenorrhea
Dyspareunia
Infertility
Painful Defaecation
Pelvic Heaviness

Signs
Visible lesions on cervix
or vagina
Tender nodules at culde-sac,
uterosacralligaments or
rectovaginalseptum
Pain with uterine
movement
Tender adnexalmasses
(endometriomas)
Fixation (retroversion)
of uterus

Classification
Minimal: Small spots of endometriosis
seen at laparoscopy, but no clinical
symptoms
Mild: Scattered fresh superficial lesions.
No scarring or retraction. No adnexal
adhesions
Moderate: Ovaries are involved, with
more scarring & retraction. They contain
endometriomas not more than 2 cm in
size. There is minimal peritubal and
periovarian adhesions. Endometriotic

 Revised
Classification
System by
ASM (1996)

Investigations
Laparoscopy (Gold standard)
Powder burn- puckered black
spots, red vascular, bluish,
blackish cyst, chocolate cyst, &
dense adhesion with yellow
brown peritoneal fluid.
Allows diagnosis and treatment
Transvaginal ultrasound
Detect gross endometriosis
involving ovaries
MRI: detect lesion >5mm,
particularly in deep tissues

Management
MEDICAL
TREATMENT

NONHORMONA
L

NSAIDS

COX-2
Inhibitor

HORMONA
L

COCP

PROGESTIN
S

DANAZO GNRH
AGONIST
L

GESTRINON

Aim: To induce a pseudo-pregnancy or pseudo-menopausal

state (for 4-6 months), longer for contraception
purposes & relief dysmenorrhea.

 NSAIDs (mild disease)

- Helps in reducing the severity of dysmenorrhea and
pelvic pain
- For symptom control only
- Codeine/opiates should be avoided
- T. Mefenamic Acid 500 mg TDS 3-5 days during menses
(oral)

COC
Diagnostic and therapeutic purposes
Must check the risk factors for the suitability first.
Taken continuously 6 months period
If symptomatic relied with continuous use of COC
should be continued up to several years or longer

Progestogens
- Use of levonorgestrel intrauterine system shows
effectiveness (long term therapy effect)

 GnRH-Analogs
- Relieve severity and symptoms of
endometriosis
- Induce pseudomenopause
- Long term use (>6months) lead to
osteoporosis therefore HRT is administered
along with GnRH analogues
- Cessation of therapy rapid recurrence of
symptoms
- S/C Zoladex 3.75 mg every month (3-6
mths) (Goserelin acetate)

Treatment
Surgical therapy
Conservative
Aim for removal and destruction of
all endometrial implants using
diathermy, laser vaporization or
excision.
Recurrent risk is 30%

Radical surgery
Severe symptoms, complete family
Total abdominal hysterectomy and
bilateral salphingo-oophorectomy
(TAHBSO)

Prognosis
Patients with endometriosis are often difficult to
treat
Known to be recurrent disorder
About 5-20% of patients have symptoms again
within 5 years.
Patients treated only medically, without surgery,
can have higher recurrence rates.
A second examination is recommended 3-4
months after the first laparoscopy if symptoms
continue or in cases of severe Endometriosis when
recurrence of the disease or the formation of
adhesions is anticipated.
Tx designed according to age, symptoms, extent
of disease and desire for future childbearing.
Do go for regular follow- up!!

A D E N O M YO S
IS

Definition
Ingrowth of endometrial glands and storm
directly into the myometrium.
Usually affects the body of uterus, rarely
seen in cervix.
Most commonly seen in multiparous women
diagnosed in late 30s or early 40s.
Pelvic endometrium coexist in 40% of
patient.

Symptoms
1/3 are asymptomatic.
Menorrhagia (50%) - Increased uterine
cavity with endometrial hyperplasia &
inadequate uterine contraction.
Dysmenorrhea (30%) - Depends on the
depth of adenomyotic foci into
myometrium.
Dyspareunia - Enlarged and boggy
uterus
Infertility

Investigation
TVUS: hypoechoic, irregular, cystic
spaces predominantly involving the
posterior uterine wall; an enlarged
uterus with a widened posterior wall;
an eccentric endometrial cavity; and
decreased uterine echogenicity
MRI: definitive investigation of choice
as it provides excellent images of
myometrium, endometrium and areas
of adenomyosis.

Treatment
Medical Tx: Aim to relieve pain and minimise
bleeding.
Mefenamic acid (NSAID) to reduce pain.
Levonorgestrel releasing IUS - Improve
menorrhagia and dysmenorrhea.
GnPH agonist, Danazol IUD
Surgical Tx:
Conservative: Adenomyomectomy, endometrial
ablation, uterine artery embolisation.
Hysterectomy - Definitive treatment opt for
older women who have completed family.