Snapshot A 6-year-old girl is brought to the pediatrician by her father for vaginal bleeding. The father reports that he was changing her and noticed blood on her pants. The patient is obese but otherwise healthy. She just started kindergarten and gets allow well with her classmates. On physical examination, the patient has Tanner stage 3 breasts. There is no axillary or pubic hair. A pelvic ultrasound reveals a right ovarian cyst with smooth, thin lining and no solid areas. Hormonal analysis reveals an elevated estradiol level. (Follicular cyst) Introduction Introduction clinical definition fluid-filled sac(s) within an ovary Studies diagnostic approach imaging pelvic/vaginal ultrasound studies tumor markers (i.e., CA-125, alpha-fetoprotein, beta-HCG, or inhibin B) if concerned for malignancy Differential dermoid cyst/teratoma endometrioma ovarian tumor Treatment observation if small and asymptomatic surgical resection if large (> 5 cm) or symptomatic Complications ruptured ovarian cyst presentation unilateral lower abdominal pain/pelvic pain sudden onset usually after physical activity signs of acute abdomen/shock risk factors endometrioma dermoid cyst bleeding diathesis anticoagulation imaging pelvic ultrasound free fluid usually in the rectouterine pouch treatment conservative symptom management if hemodynamically stable laparoscopy for hemorrhage control if hemodynamically unstable ovarian torsion presentation unilateral lower abdominal/pelvic pain sudden onset nausea vomiting imaging pelvic ultrasound with Doppler enlarged ovary with decreased blood flow treatment detorsion if viable ovary Follicular Cyst Follicular cyst demographics most common form pathogenesis non-neoplastic expansion of unruptured graafian follicle cyst lined with follicular epithelium Presentation most often asymptomatic associated with hyperestrogenism (i.e., abnormal vaginal bleeding or enlarged breasts) endometrial hyperplasia Imaging pelvic ultrasound thin-walled unilocular Corpus Luteal Cyst Corpus luteal cyst demographics most common pelvic mass within 1st trimester of pregnancy can also develop physiologically during menstrual cycle pathogenesis failure of corpus luteum to regress after ovum release Presentation most often asymptomatic may have delayed menses due to production of progesterone Imaging pelvic ultrasound diffusely thick wall peripheral vascularity “ring of fire” Theca-Lutein Cyst Theca-lutein cyst risk factors associated with gonadotropin stimulation multifetal pregnancy polycystic ovary syndrome (PCOS) clomiphene ovulation induction gestational trophoblastic disease pathogenesis excessive circulating gonadotropins (such as beta-HCG) causes hyperplasia of theca interna cells Presentation most often asymptomatic can cause hyperandrogenism hirsutism alopecia acne Imaging pelvic ultrasound bilateral, enlarged, multicystic ovaries Treatment management of underlying causes usually regress when beta-HCG levels decrease