Most ovarian cysts in teenagers do not require surgery. Yet, over the years as a clinician, I have seen many teenagers who have presented to emergency centres and been subjected to an unnecessary surgical procedure.

Ovarian cysts are common in teenagers

Ovarian cysts are common in teenagers. The vast majority are simple cysts that develop following ovulation of an egg from the ovary. These “functional” or “simple” cysts are usually smaller than 4cm in diameter.

The image above is a simple ovarian cyst from one of my patients (provided with consent). The finding of the simple ovarian cyst was incidental when she was having a laparoscopy for another indication. Needless to say, I left her ovary well alone and four months later an ultrasound reported the cyst had spontaneously resolved.

Most “simple” ovarian cysts will resolve within six months and are asymptomatic.

Ovarian cysts can bleed or rupture

Occasionally “simple” ovarian cysts do cause problems.

This usually happens if they rupture, releasing fluid that irritates the lining of the abdomen to cause pain. Alternatively, there might  be bleeding from a small blood vessel lining the cyst wall. The blood causes the cyst to swell and become painful.

In both cases the pain is usually mild and resolves within few days.

However, occasionally pain may be more severe and result in hospital presentation.

This is where things can go astray. One typical scenario I have encountered after the event (that is after the teenager has had her ovary removed surgically!) involves the teenager being brought into the emergency department after hours by an anxious mother. The teenager reports she has developed pelvic pain. An ultrasound is performed and the “simple” ovarian cyst is misreported as being “complicated.” This is because blood inside the cyst causes ultrasound waves to be reflected and the cyst appears to have “internal echoes”.

A CT may be ordered to examine the cyst in more detail. Apart form exposing the teenager to a dose of radiation, this adds little to the diagnostic process. However, the intervention cascade that follows often ends up with emergency surgery, rather than the correct management of pain relief.

Even pain relief can go wrong. Keen young resident doctors frequently prescribe strong  codeine based analgesics. This can result in the patient re-presenting a few days later with a different cause of pain – constipation.  If a  CT was not ordered the first time around, it is certainly ordered on re-presentation. If the patient avoided surgery the first time, she may not be so lucky again facing an eager young registrar champing to operate.

The message is simple.

First, don’t operate on cysts in young women unless a consultant has reviewed the films and determined this is not a “simple” cyst or it is one of those very rare situations described below where emergency surgery is indicated.

Secondly, be careful with strong codeine based analgesia in young women. It leads to constipation and can confuse the presentation.

Ovarian torsion

Of course there are exceptions to every rule.

Ovarian torsion is the first exception.

Ovarian torsion occurs when the ovary twists around on its own blood supply. This stops blood flowing to the ovary and the lack of oxygen causes the ovary to become swollen and painful. It is a rare condition occurring in 4.9 per 100,000 women. It is more common in women over 20 years of age (1-3).

Ovarian torsion is a medical emergency as the ovary will die unless torsion is corrected.

Fortunately ovarian torsion can usually be distinguished by the clinical story (onset of pain is abrupt and there is frequently vomiting), the size of the cyst (larger cysts) and ultrasound features (abnormal blood flow seen on doppler of the ovarian vessels).

Ovarian tumours

These are rare in young women – exceedingly rare. Tumours usually look different on ultrasound. They may be solid, or have solid components with internal septations that delineate compartments within the cyst. Blood tests may demonstrate elevations in proteins called tumour markers, that rise in association with certain ovarian tumours.

Suspicious cysts in teenagers should always involve specialist management. It is usually wise to gather the correct information, and refer the teenager to a specialist hospital to be managed by gynaecology oncology staff, rather than rush and operate as an emergency. Even if specialist deem the cyst to be suspicious, and a decision is made to operate, it will still often be benign or harmless. In one series of 52 UK teenagers with suspicious ovarian cysts requiring surgery , only 3 tumours were eventually reported to be a malignant cancer (4).

Do unnecessary surgical procedures happen on simple ovarian cysts in teenagers?

The short answer is yes.

In one retrospective survey of children and teenagers presenting to the Royal Children’s Hospital in Melbourne with an ovarian cyst, 60% of the admitted patients had a “simple” cyst. despite this, many of the teenagers with “simple” cysts underwent a surgical procedure (5).

However, if the cyst is large, or the presentation is unusual, then consideration must be given to exclude a tumour.

So when in doubt, ask for a more senior opinion, and ask for your management options. Being admitted and observed is reasonable in some cases, rather than rushing to surgery.

References

1. Hibbard LT. Adnexal torsion. Am J Obstet Gynecol. 1985;152:456–61.
2. Dunnihoo DR, Wolff J. Bilateral torsion of the adnexa: a case report and review of the world literature. Obstet Gynecol. 1984;64:55S–59S.
3. Kokoska ER, Keller MS, Weber TR. Acute ovarian torsion in children. Am J Surg. 2000;180:462–5.
4. Tsikouras P1, Liberis V, Galazios G, et al. A 15-year report of pathological and benign ovarian tumors in teenagers. Eur J Gynaecol Oncol. 2008;29(6):602-7.
5. de Silva KS, Kanumakala S, Grover SR, et al. Ovarian lesions in children and adolescents–an 11-year review. J Pediatr Endocrinol Metab. 2004 Jul;17(7):951-7.