ADOLESCENT GYNECOLOGY

ADOLESCENT
GYNECOLOGY
Ovarian Cysts
in the Adolescent
Wendy L. Jackson, MD
The evaluation and treatment of an ovarian
cyst are among the most common reasons
an adolescent patient seeks care from a
gynecologic clinician. Whether the cyst is
found on routine examination or incidentally on an imaging study, it may provoke
anxiety for the patient. Initial care begins
with reassuring the patient and her family
that the most conservative management
approach will be provided.
Wendy L. Jackson, MD, is an Instructor of Obstetrics and
Gynecology, University of Kentucky, Lexington.
The differential diagnosis of FOCUSPOINT
ovarian cysts in the postmenarchal adolescent is quite
extensive (Table). Despite the
vastness of the differential, the
most common type of lesion in It is controversial
this population is a functional whether laparotomy
cyst. It represents 45% of adnex- or laparoscopy is the
al pathology in children and
adults.4 This category is made up best approach for
of follicular cysts and corpus ovarian cystectomy
luteum cysts, both of which may of dermoid cysts.
vary in size. Follicular cysts
develop in the earlier part of the
menstrual cycle.5 When ovulation does not occur and follicular growth continues, the result
is ovarian cyst formation. If ovulation does occur
but the corpus luteum persists with continued
bleeding, a corpus luteum cyst develops.
Commonly included in the differential for
ovarian cysts in the adolescent is the mature cystic teratoma, or dermoid cyst. It is the most common ovarian neoplasm in adolescents. This type
of cyst comprises representative tissues from all
3 germ layers: ectoderm, endoderm, and mesoderm. Therefore, the contents may include adipose, hair, sebaceous material, cartilage, teeth,
and other calcifications. This type of benign cyst
occurs in varying sizes and is bilateral in fewer
than 10% of cases. The treatment is surgical intervention. It is controversial whether laparotomy
or laparoscopy is the best approach for ovarian
cystectomy of dermoid cysts. There is concern
regarding possible spillage with subsequent
chemical peritonitis, adhesion development,
and future fertility issues when the laparoscopic
approach is taken. Regardless of the approach or
the size, cystectomy should be performed with
preservation of the remaining ovarian tissue.
History of an abrupt onset of lower abdominal
pain, nausea, vomiting, and a low-grade temperature in the setting of an acute abdomen is
worrisome for adnexal torsion. Patients with
Follow The Female Patient on
P
atients with ovarian cysts may present
complaining of menstrual irregularities,
pelvic pain, urinary frequency, constipation, or pelvic heaviness.1 In the setting of
torsion or a ruptured cyst, the presentation may
include nausea, vomiting, rebound, or guarding.
Sometimes patients may present completely
asymptomatically, with the cyst being an incidental finding.
EVALUATION
The initial evaluation begins with taking a thorough history, including a menstrual and sexual
history. The physical examination should include a pelvic and/or rectal exam. Preliminary
testing involves obtaining a pregnancy test, sexually transmitted disease screening, and a complete blood count with differential.2 Care should
be taken to order the most appropriate imaging
study. For evaluating ovarian cysts, ultrasound
is the study of choice.3 Whether the scan is performed transabdominally or transvaginally, it
provides excellent imaging of pelvic structures.
In addition, it is the least invasive and most costeffective method when considering the need for
follow-up studies.
and
The Female Patient | VOL 35 MAY 2010 31
ADOLESCENTGYNECOLOGY
Ovarian Cysts in the Adolescent
regions, septations, papillary projections, and a
decreased resistance index on Doppler ultrasound. When malignancy is being considered,
a CT scan may provide additional information
in regard to other organ system involvement.
Tumor markers for lactate dehydrogenase,
human chorionic gonadotropin, CA-125,
α-fetoprotein, carcinoembryonic antigen, inhibin, and Müllerian inhibiting substance
should be obtained prior to treatment.
TABLE. Differential Diagnosis of Ovarian Cysts
• Adnexal torsion
• Neoplasms (benign)
• Ectopic pregnancy
• Obstructive anomalies
• Endometriomas
• Paratubal cysts
• Follicular cysts
• Periappendiceal abscesses
• Hemorrhagic cysts
• Peritoneal cysts
• Hydrosalpinx
• Pregnancy
• Leiomyomas
• Pyosalpinx
• Malignancy
• Tubo-ovarian abscesses
TREATMENT
ovarian cysts may be at increased risk of torsion
secondary to the size of the lesion. High clinical
suspicion for torsion warrants surgical intervention. The most common approach is via
laparoscopy. Treatment includes detorsion
with subsequent ovarian cystectomy. Some authors recommend oophoropexy if there is ovarian torsion in the absence of a cyst.
Despite the low rate of malignancy in this particular age-group, it should nonetheless always
be considered. One study quotes an ovarian malignancy rate of 4.4% between the ages of 15 and
21.5 These lesions would appear to have solid
Other considerations for cystic lesions in the adolescent include pregnancy, endometriomas (rare
in adolescents), tubo-ovarian abscesses, hemorrhagic cysts, neoplasms (benign), ectopic pregnancy, paratubal cysts, hydrosalpinx, pyosalpinx,
leiomyomas, obstructive anomalies, peritoneal
cysts, and periappendiceal abscesses.1,2
Preservation of ovarian tissue in the adolescent population is critical in regard to future
fertility. Thus, the management of ovarian cysts
begins with taking the most conservative
approach. Characteristics of the cyst and symptoms of the patient are evaluated initially (Figure). If the cyst appears simple or complex but
not worrisome for malignancy, it can be fol-
Ovarian cysts on ultrasound
Symptomatic
Surgical
intervention
Asymptomatic
>10 cm
Surgical
intervention
≥5 but <10 cm
Observation
Surgical
intervention
Repeat ultrasound
2-3 cycles
If persists, enlarges, or
symptomatic, then surgery
FIGURE. Algorithm for Ovarian Cyst Management.
32 The Female Patient | VOL 35 MAY 2010
All articles are available online at www.femalepatient.com.
Jackson
lowed with a repeat ultrasound after 2 to 3
menstrual cycles.2 According to Shapiro and
colleagues, ovarian cysts have a 70% spontaneous resolution rate.3 If the cyst is larger than
5 cm on repeat ultrasound, Spinelli et al recommend surgical intervention, although they
mention that this cutoff is sometimes considered controversial.4 Yet others mention laparoscopy for cysts larger than 6 cm or the option
of observation for those up to 10 cm.1 To date,
no clear surgical guidelines for the pediatric/
adolescent patient have been established; thus,
the management has been extrapolated from
the adult management guidelines.3 The major
difference to consider is the focus on preservation of fertility in the adolescent.
Historically, oral contraceptive (OC) pills have
been initiated while waiting for the repeat ultrasound. This was done to potentially suppress
ovarian cyst formation secondary to gonadotropin suppression. OC pills may prevent the development of additional cysts, but the current
literature shows minimal efficacy in the resolution of the existing cyst.1 Whether patients are
taking OC pills or not, functional
FOCUSPOINT
cysts have usually regressed by
the time the follow-up image is
performed. If at the time of repeat
OC pills may
scan there is persistence, enlargement, or concern for malignancy, prevent the developor the patient has become symp- ment of additional
tomatic, surgical intervention cysts, but the current
should be arranged.1,4
Laparoscopy with ovarian cys- literature shows minitectomy is the preferred surgical mal efficacy in the
method to treat adolescents for resolution of the
benign-appearing ovarian cysts.
The endoscopic bag is commonly existing cyst.
used to prevent spillage of cyst
contents. The laparoscopic surgical approach is preferred because
it is an outpatient, cosmetically
more appealing approach that provides a shorter
recovery, decreased intraoperative blood loss,
and decreased postoperative pain.2,3 However, in
the event that the cyst is suspicious for malignancy, the best approach may be via laparotomy, unless a laparoscopically skilled gyneco-
In this issue…
How Drug
Delivery and
Pharmacokinetics
Impact Estrogen
Therapy
Supported by Teva Women’s Health, Inc.
Follow The Female Patient on
and
The Female Patient | VOL 35 MAY 2010 33
ADOLESCENTGYNECOLOGY
Ovarian Cysts in the Adolescent
FOCUSPOINT
logic oncologist is available for
management.
Cystectomy, as opposed to aspiration, allows ovarian specimens to be sent to pathology for
The most conservaconfirmation of diagnosis. An
tive management
additional benefit to cystectomy
is the decreased rate of recuris the best approach
rence.1 If aspiration is performed,
for the adolescent
then fluid should be evaluated
patient with ovarian
by pathology. There are 2 approaches to aspiration: laparocysts.
scopic or ultrasound-guided. Intraoperatively, the focus is on
limiting manipulation and destruction of ovarian tissue to prevent adhesions that could affect
future fertility. The same explanation supports why disruption of incidentally
found small ovarian follicles is discouraged.1
CONCLUSION
The most conservative management is the best
approach for the adolescent patient with ovarian
Coding for Ovarian Cysts in the Adolescent
There are many symptoms referred to in this article. It is helpful
to list 3 or 4 different symptoms on the insurance form, as
this would indicate a higher degree of difficulty in establishing
a diagnosis, or a higher level of complexity in your medical
decision making.
626.4Irregular menstrual cycle
Irregular: bleeding NOS, menstruation, periods
625.9Unspecified symptom associated with genital organs
(pelvic pain)
788.41Urinary frequency
564.00Constipation
787.01Nausea and vomiting
620.0Follicular cyst of ovary, Cyst of graafian follicle
620.1Corpus luteum cyst or hematoma
Corpus luteum hemorrhage or rupture, Lutein cyst
620.2Other and unspecified ovarian cyst
Cyst of ovary: corpus albicans, retention, serous,
theca-lutein
220Benign neoplasm of ovary (mature cystic teratoma or
dermoid cyst)
620.5Torsion of ovary, ovarian pedicle, or fallopian tube
789.03Abdominal pain, right lower quadrant
789.04Abdominal pain, left lower quadrant
34 The Female Patient | VOL 35 MAY 2010
cysts. The vast majority of cysts are functional and
will regress within the subsequent 2 to 3 menstrual cycles. If they are persistent or enlarge on
follow-up ultrasound, or the patient becomes
symptomatic, surgical intervention is required.
The recommended approach is laparoscopic
unless a malignancy is suspected.
The author reports no actual or potential conflict
of interest in relation to this article.
REFERENCES
1. Laufer MR, Goldstein DP. Ovarian cysts and neoplasms
in infants, children, and adolescents. UpToDate. 2007.
www.uptodate.com/patients/content/topic.do?topicKey=~
YT9KHy/FABXPLQ. Accessed January 21, 2010.
2. Strickland JL. Ovarian cysts in neonates, children and adolescents. Curr Opin Obstet Gynecol. 2002;14(5):459-465.
3. Shapiro EY, Kaye JD, Palmer LS. Laparoscopic ovarian cystectomy in children. Urology. 2009;73(3):526-528.
4. Spinelli C, Di Giacomo M, Cei M, Mucci N. Functional ovarian lesions in children and adolescents: when to remove.
Gynecol Endocrinol. 2009;25(5):294-298.
5. Templeman C. Ovarian cysts. J Pediatr Adolesc Gynecol.
2004;17(4):297-298.
Philip N. Eskew Jr, MD
Diagnostic procedures referred to in the article include:
76830 Ultrasound, transvaginal
76856Ultrasound, pelvic (nonobstetric), real time with image
documentation; complete
76857Ultrasound, pelvic (nonobstetric), real time with image
documentation; limited or follow-up (eg, for follicles)
72192Computed tomography, pelvis: without contrast material
If you use the transvaginal ultrasound for each visit, you have only
the one code to choose from. If you use the abdominal ultrasound
code, then you would use 76857 for your follow-up ultrasounds.
The procedures to surgically treat or remove the ovarian cysts
are:
58661Laparoscopy, surgical; with removal of adnexal
structures (partial or total oophorectomy and/or
salpingectomy)
58925Ovarian cystectomy, unilateral or bilateral
58940Oophorectomy, partial or total, unilateral or bilateral
Philip N. Eskew Jr, MD, is past member, Current Procedural
Terminology (CPT) Editorial Panel; past member, CPT Advisory
Committee; past chair, ACOG Coding and Nomenclature Committee; and instructor, CPT coding and documentation courses
and seminars.
All articles are available online at www.femalepatient.com.