Ovarian Cyst, Ruptured

Basics

  • Ovarian cysts are frequent in reproductive-aged women.
  • Patients with a symptomatic ruptured cyst usually complain of acute onset unilateral lower abdominal pain.
  • Rupture can be caused by sexual intercourse, luteal phase, exercise, trauma, or pregnancy, or it can be idiopathic.
  • Evaluation of the patient should include exclusion of other emergent causes: ectopic pregnancy, ovarian torsion, and nongynecologic sources of acute unilateral lower abdominal pain.
  • Once the diagnosis of a ruptured cyst is confirmed, most patients can be managed conservatively as outpatients with adequate pain control. Surgical intervention is rarely indicated.

Description

Most ovarian cysts are benign physiologic follicles created by the ovary at the time of ovulation. Ovarian cysts can cause symptoms when they become enlarged and exert a mass effect on surrounding structures, or when they rupture and the cyst contents irritate the peritoneum or nearby pelvic organs.

Epidemiology

  • The actual incidence of ovarian cysts is difficult to calculate as many ruptured cysts are asymptomatic or found incidentally.
  • Ovarian cysts can be seen on transvaginal ultrasounds in nearly all premenopausal women and in up to 18% of postmenopausal women. The vast majority of these cysts are benign or functional.
  • About 13% of ovarian masses in reproductive-aged women are malignant, as opposed to 45% in postmenopausal women. About 70% of ovarian malignancies are diagnosed at a late stage.
  • Ruptured ovarian cysts most commonly affect the right ovary, 63%.

Incidence
About 7% of women worldwide experience a symptomatic cyst during their lifetime.

Prevalence
During pregnancy, prevalence varies from 1 to 5.3%; of those, just 0.63% are symptomatic and 1% are malignant.

Etiology and Pathophysiology

Normal ovulation occurs when a follicle matures and ruptures, releasing an oocyte, leaving a corpus luteum, which subsequently involutes. If the follicle fails to rupture and continues to grow, a follicular cyst is formed. If a corpus luteum fails to involute and continues to grow, then a corpus luteum cyst occurs. These are the most common cysts. Both types are physiologic (termed “functional”) without malignant potential. Other cyst types include endometriomas (filled with menstrual blood), dermoid cysts that contains mature tissue of ectodermal, mesodermal, and/or endodermal origin, and ovarian malignancy originating from any of the structures of the ovary.

Risk Factors

Medications or conditions associated with increased ovulation and/or increased risk of cyst rupture.

  • Ovulation induction agents (i.e., clomiphene [Clomid], aromatase inhibitors, GnRH agonists)
  • Tamoxifen increases the risk of ovarian cysts in reproductive-aged women.
  • Polycystic ovarian syndrome (PCOS) (common), fibrous dysplasia/McCune-Albright syndrome (rare)
  • Ovarian endometriosis

General Prevention

Ovulation suppression with combined hormonal contraceptives is the mainstay therapy for prevention of recurrent ovarian cyst.

Commonly Associated Conditions

  • Endometriomas located on or adjacent to the ovaries are found in 20–55% of women with endometriosis.
  • PCOS

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