Neonatal and Pediatric Ovarian Cysts

Normal follicles or physiologic ovarian cysts are seen by ultrasound examination of the ovaries in all healthy prepubertal girls. Most of these are <1 cm in diameter and not pathologic. In the neonatal period, physiologic follicular cysts due to maternal estrogen stimulation usually resolve spontaneously and may be followed with serial ultrasounds in the asymptomatic child. Children with an ovarian mass might have no symptoms and the mass may be detected incidentally or during a routine examination. Other children present with abdominal pain that may be accompanied by nausea, vomiting, or urinary frequency or retention. The cyst’s most common complication, ovarian torsion, can result in loss of the ovary (autoamputation of the ovary has been documented to occur antenatally). Successful reports of antenatal aspiration and postnatal laparoscopic treatment exist. Large cysts (>4-5 cm), those with complex characteristics, or any ovarian cyst in premenarchal girls with associated signs or symptoms of hormonal stimulation deserve prompt evaluation. The incidence of ovarian cysts increases again with puberty.

Functional Cysts

Hemorrhagic cysts are an expected part of follicular development during the menstrual cycle. Normally, a dominant follicle forms and increases in size. Following ovulation, the dominant follicle becomes a corpus luteum that, if it bleeds, is termed a hemorrhagic corpus luteum. These can become symptomatic owing to size or peritoneal irritation from blood, and they have a characteristic complex appearance on ultrasound. Expectant management for a presumed functional or hemorrhagic cyst is appropriate. Physiologic cysts are usually no larger than 5 cm and resolve over the course of 6-8 wk during subsequent ultrasound imaging. Monophasic oral contraceptives can be used to suppress follicular development to prevent formation of additional cysts.

Teratomas

The most common neoplasm in adolescents is the mature cystic teratoma (dermoid cyst). Most are benign and contain mature tissue of ectodermal (skin, hair, sebaceous glands), mesodermal, or endodermal origin. Occasionally well-formed teeth, cartilage, and bone are found. Calcification on an abdominal radiograph is often a hallmark of a benign teratoma. These tumors may be asymptomatic and found incidentally, or they can manifest as a mass or with abdominal pain (associated with torsion or rupture). If the major component of the dermoid is thyroid tissue (struma ovarii), hyperthyroidism can be the clinical presentation. Benign teratomas should be carefully resected, preserving as much normal ovarian tissue as possible. Oophorectomy (and salpingoophorectomy) for this benign lesion is excessive treatment. During surgery, both ovaries should be evaluated, and if there is any question about the nature of the lesion, the specimen should be evaluated by a pathologist. An association of dermoid tumors with neural elements and anti-NMDA receptor encephalitis has been reported. Excision of the ovarian tumor has led to improvement in neurologic symptoms in some patients.

Immature teratoma of the ovary is an uncommon tumor, accounting for less than 1% of ovarian teratomas. In contrast to the mature cystic teratoma, which is encountered most often during the reproductive years but occurs at all ages, the immature teratoma has a specific age incidence, occurring most commonly in the first 2 decades of life. By definition, an immature teratoma contains immature neural elements. Because the lesion is rarely bilateral in its ovarian involvement, the present method of therapy consists of unilateral salpingo-oophorectomy with wide sampling of peritoneal implants.

Cystadenomas

Serous and mucinous cystadenomas are the second most common benign ovarian tumor. These cystic lesions can become very large, yet with care, the tumor can be resected, preserving normal ovarian tissue for future reproductive potential.

Polycystic Ovarian Syndrome (PCOS)

See Chapter 546.

Endometriomas

Endometriosis is a syndrome defined by the presence of ectopic endometrial tissue usually located within the pelvis and abdomen. The principal clinical symptoms in adolescents consist of severe menstrual pain and pelvic pain. Endometriomas (chocolate cysts) form when the ovaries are involved and are collections of old blood and hemosiderin within an endometrium-lined cyst. They have a typical homogeneous echogenic appearance on ultrasound, and are more common in adults than in adolescents. Conservative management (suppressive therapy with ovulation suppression, and nonsteroidal anti-inflammatory drugs [NSAIDs]) and ovarian cystectomy with preservation of as much functioning ovary as possible is recommended for adolescents.

Pelvic Inflammatory Disease and Tubo-ovarian Abscess

Pelvic inflammatory disease complicated by a tubo-ovarian abscess should be considered in a sexually active adolescent with an adnexal mass and pain on examination (Chapter 114). These patients also typically exhibit fever with leukocytosis and cervical motion tenderness. Treatment consists of administration of intravenous antibiotics. If the lesion persists or is refractory to antibiotics, drainage of the pelvic abscess by interventional radiology should be considered.

Adnexal Torsion