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.