An ovarian cyst is a small hollow formation (a protrusion in the form of a sac) filled with fluid. Typically, cysts develop in a woman’s ovary from a maturing follicle. Most ovarian cysts do not pose any danger to a woman’s health, do not require any treatment and go away on their own within a few menstrual cycles. In rare cases, an ovarian cyst may be complicated by rupture or bleeding, may twist or put pressure on neighboring organs, which requires adequate medical care (surgery to remove the cyst).

What is an ovarian cyst?

An ovarian cyst is a round protrusion that forms on the surface of the ovary. Anatomically, an ovarian cyst is a thin-walled cavity filled with fluid. The size of ovarian cysts can range from several centimeters to 15-20 cm in diameter. This article will discuss only functional ovarian cysts, which are formed from maturing follicles. In addition to functional cysts, which account for more than 90% of all cases of ovarian cysts, there may also be dysontogenetic cysts (see below), which are formed in the process of disruption of the formation and growth of the ovaries and tumor cysts, which will be described in more detail in the section Ovarian cancer. Ovarian cysts should also be distinguished from Polycystic Ovarian Syndrome, in which the causes of ovarian cysts and their treatment differ significantly from those of functional ovarian cysts.

How do functional ovarian cysts appear?

Every healthy woman has two ovaries, which contain and gradually mature eggs (female reproductive cells). The ovaries are located on both sides of the uterus and are connected to the latter via the fallopian tubes. The size of one ovary is approximately equal to the size of a walnut. As a rule, one egg matures and is released in each menstrual cycle. Before release, the egg grows in a special cavity (sac) - the follicle. The size of a mature follicle is about 5-10mm. In the middle of the menstrual cycle, the follicle ruptures (rupture of the follicle is called ovulation) and the egg is released into the fallopian tubes, where it can be fertilized by sperm. During an ultrasound examination of healthy ovaries, before ovulation, several small cysts can be seen in each ovary - these are maturing follicles. At the time of ovulation, only one or two follicles will burst. In some cases, for unknown reasons, a large amount of fluid accumulates in the maturing follicle, due to which it greatly increases in size. Such enlarged follicles are called follicular (functional) cysts. If the follicle does not rupture and the egg is not released, the follicular cyst may persist and grow for some time, but within a few cycles its growth slows, it shrinks and disappears.

After the follicle ruptures and the egg is released, a “corpus luteum” is formed at the site of the follicle - a section of ovarian tissue that actively produces progesterone. Fluid can accumulate in the corpus luteum, as well as in the maturing follicle. In this case, a corpus luteum cyst is formed. Corpus luteum cysts, like follicular cysts, usually go away on their own, gradually decreasing in size. If a follicular or corpus luteum cyst fills with a large amount of blood for some reason (for example, a rupture of a blood vessel inside the cyst), then the cyst is called hemorrhagic.

What types of ovarian cysts can there be?

The vast majority of ovarian cysts are benign formations, that is, they are not tumors capable of aggressive growth. Only in very rare cases, ovarian cysts, as mentioned above, can be signs of ovarian cancer. The most common type of benign ovarian cyst is a functional cyst. Functional cysts can form from the follicle or from the corpus luteum:

Follicular cyst: is formed from the beginning of the menstrual cycle until the moment of ovulation and can grow to approximately 5 cm in diameter. The rupture of such a cyst can cause sharp pain in the ovarian area (pain in the lower abdomen, radiating to the lower back). Follicular cysts go away on their own, without treatment, within a few months. In such cases, the doctor’s role is limited to monitoring the woman’s condition and the development of the cyst. Corpus luteum cyst: appears after the release of the egg from the follicle (after ovulation). As mentioned above, after the release of the egg, the follicle turns into a “corpus luteum”. In some cases, the corpus luteum may fill with fluid or blood and remain in the ovary for a longer time. A corpus luteum cyst is usually found on only one ovary and does not cause any symptoms. Hemorrhagic cyst: appears due to hemorrhage inside a formed follicular cyst or corpus luteum cyst. Hemorrhagic cysts are characterized by the appearance of pain in the abdomen, from the side of the ovary on which the cyst is located.

Other types of benign ovarian cysts include:

Dermoid cyst: This is a dysontogenetic cyst that usually appears in young women and can reach up to 15 cm in diameter. A dermoid cyst is a benign tumor. It may sometimes contain bone, hair, or cartilage tissue. Such cysts appear differently on ultrasound, but they are very clearly visible on computed tomography or MRI. A dermoid cyst can become complicated by inflammation or twisting, which can cause severe abdominal pain and require urgent surgical intervention. Endometrioma: may appear in women suffering from endometriosis and is formed in the ovary from endometrial tissue (the inner lining of the uterus). The size of endometrioma can vary from 2 to 20 cm. Due to endometrioma, severe abdominal pain may appear during menstruation. Polycystic ovary: characterized by an increase in the size of the ovaries with multiple small cysts on the outside of the ovary. A similar phenomenon occurs both in healthy women and in women suffering from certain endocrinological diseases. It should be noted that polycystic ovary syndrome is different from polycystic ovary syndrome. Cystic adenoma (cystadenoma, cystadenoma): is a type of benign tumor that forms from ovarian tissue. Cystadenoma can reach very large sizes - up to 30 cm in diameter or more.

Causes of ovarian cysts

The risk of developing ovarian cysts is higher in the following situations:

Symptoms and signs of ovarian cyst

Typically, ovarian cysts do not cause any symptoms and are discovered during a routine pelvic ultrasound examination. However, in some cases, an ovarian cyst may present with one or more of the following symptoms:

• Pain in the lower abdomen that may appear and disappear suddenly. The pain can be very severe and sharp
• Irregular menstruation
• Feeling of heaviness or pressure in the abdomen or pelvis
• Prolonged pain in the lower abdomen during menstruation
• Pain in the lower abdomen after vigorous exercise or after sexual intercourse
• Pain or squeezing sensation during urination or bowel movements
• Intermittent nausea and vomiting
• Vaginal pain and bloody vaginal discharge
• Infertility

When should you see a doctor?

If you know that you have or have had an ovarian cyst, you should definitely consult a doctor if you experience:

• Increased body temperature (38.5 C and above)
• Unusual pain in the abdomen or pelvis
• Nausea or vomiting
• Weakness, dizziness, or loss of consciousness
• Pallor
• Unusually heavy or irregular periods
• Unusual enlargement of the abdomen for an unexplained reason
• Abdominal pain while taking anticoagulants, such as warfarin
• Excessive facial hair growth (male pattern)
• High or low blood pressure
• Increased thirst or excessive urination
• Unexplained weight loss
• Palpable mass in the abdomen

Diagnosis of ovarian cyst

In order to detect the presence of an ovarian cyst, the following medical tests can be performed:

1. Transvaginal ultrasound examination. According to the nature of the cyst image on ultrasound, there can be simple cysts (filled only with liquid), combined cysts (containing both liquid and hard tissue) and solid cysts (containing only hard tissue).
2. Computed tomography and NMR: if it is impossible to determine the type of cyst based on ultrasound results, the doctor may prescribe a CT or NMR examination, which allows a more accurate assessment of the structure of the formation.
3. Laparoscopic surgery: With laparoscopy, you can not only see the ovarian cyst, but, in some cases, remove it.
4. CA-125 marker test: This blood test detects a substance called CA-125, a tumor marker associated with ovarian cancer. Such an analysis is carried out in order to determine the nature of the formation found in the ovaries and determine whether it is a malignant tumor. In some cases, benign formations may also be associated with increased levels of CA-125 in the blood, so it is impossible to make an accurate diagnosis of ovarian cancer based on the results of this test alone.
5. Hormone tests: if you suspect hormonal disorders that could lead to the formation of a cyst, your doctor may order tests for LH, FSH, estradiol and testosterone.
6. Detection of pregnancy: Treatment of ovarian cysts differs between pregnant women and non-pregnant women. It is also necessary to exclude ectopic pregnancy, since the symptoms of an ovarian cyst may be similar to the symptoms of an ectopic pregnancy.
7. Posterior vaginal vault (pouch of Douglas) puncture: This test involves collecting fluid from the posterior vaginal vault using a needle inserted through the vaginal wall behind the cervix. Such an examination is carried out very rarely if there is a suspicion of rupture or bleeding from an ovarian cyst.

Treatment of ovarian cyst

Functional cysts are the most common type of ovarian cyst and usually do not require any treatment. Only cysts larger than 10 cm in size, or cysts that do not go away on their own within 3 menstrual cycles, can be removed surgically. In case of complications of the ovarian cyst (rupture, torsion, compression of neighboring organs), surgery is also necessary. Currently, most operations for ovarian cysts are performed using the laparoscopic method, which leaves only a few small wounds on the patient’s abdomen that quickly heal without noticeable marks.

Ovarian cysts and oral contraceptives

Some experts believe that the risk of certain types of ovarian cysts (functional cysts) can be reduced by using hormonal birth control pills because their mechanism of action includes suppressing ovulation. If you are prone to developing ovarian cysts, your doctor may suggest that you take birth control pills, as they suppress ovulation and may reduce the risk of cysts. Also, birth control pills can reduce the size of an existing functional cyst.

How can you relieve the pain caused by a cyst?

Sometimes an ovarian cyst can cause severe, constant pain. Painkillers such as paracetamol or ibuprofen can be used to relieve pain from an ovarian cyst. Some women find a hot bath or a heating pad (hot water bottle) applied to the area of ​​greatest pain to help relieve pain. This helps relax the muscles and relieve tension. The same method is used to relieve painful menstruation. When using this method, be careful to place the heating pad on your clothing and not on your skin to avoid burns. If possible, it is recommended to limit physical activity and avoid sudden movements, jumping, and vigorous exercise to avoid rupture or twisting of a large cyst.

Observing the evolution of the cyst

Once a cyst is detected, its growth is monitored. Ultrasound examinations are performed regularly to monitor the cyst (usually immediately after menstruation). If the cyst persists for more than 3 menstrual cycles, the doctor may suggest surgery to remove the cyst and determine its nature.

Prognosis for treatment of ovarian cysts

The prognosis for a woman with an ovarian cyst depends on the type and size of the cyst, as well as her age. In the vast majority of cases, ovarian cysts are benign and go away without any treatment.

Age: the development of a functional ovarian cyst is closely related to hormonal stimulation of ovarian function. The likelihood of developing ovarian cysts is highest in women of childbearing age who menstruate. In women after menopause, there is a low likelihood of developing a functional ovarian cyst, and an increased risk of malignancy. Therefore, during the postmenopausal period, it is recommended to remove any cyst larger than 2-5 cm. Size and shape of the cyst: as a rule, functional cysts are no more than 5 cm in diameter and contain only one chamber (cavity) filled with fluid. The wall of the cyst is usually thin, and the inner side of the wall is smooth. All these characteristics can be seen using a transvaginal ultrasound examination. In such cases, the cyst is considered functional and does not require intervention.

Association of ovarian cysts with infertility and pregnancy

In most cases, functional ovarian cysts do not interfere with a woman’s fertility. The occurrence of pregnancy in a woman with a functional ovarian cyst, as a rule, leads to a rapid reduction and disappearance of the cyst. During pregnancy, functional ovarian cysts occur extremely rarely.

During an ultrasound examination of the ovaries, the main “screening” task of the doctor is to identify space-occupying formations of the appendages, since they are quite common and can be malignant. However, taking into account the intensive development in recent years of reproductive technologies and gynecological endocrinology, the need has arisen for a thorough assessment of the structure and function of non-enlarged ovaries. Therefore, during an extended examination, when describing the ovaries, it is necessary to indicate not only their size, structure, the presence or absence of a dominant follicle (corpus luteum), but also it is necessary to evaluate intraovarian blood flow and blood flow in the vessels of the follicle (corpus luteum) in color and pulse Doppler modes.

When an ovarian mass is detected, the following characteristics are indicated: location, relationship with adjacent organs, shape, size, edges, contours, echostructure, echogenicity, presence of internal and external wall growths, as well as, if possible, the nature and speed characteristics of blood flow.

LACK OF IMAGE OF OVARIES AND DEVELOPMENTAL ANOMALIES

The absence of an image of one of the ovaries is common in clinical practice and can be associated with a wide range of reasons. Difficulties with visualization of the ovary may be associated with inadequate preparation of the patient for the examination, a history of surgical interventions, atypical location of the organ, as well as with an infrequent malformation - a unicornuate uterus, when one of the paramesonephric canals that form the ovary and fallopian tube does not develop. The absence of an image of the ovaries can be observed in the period of deep postmenopause due to a significant decrease in the size of the organ and its isoechoicity in relation to surrounding tissues.

Anomalies of ovarian development include: ovarian agenesis, gonadal dysgenesis and, extremely rarely, an increase in the number

ovaries. Since it is impossible to prove the complete absence of gonadal tissue sonographically, suspicion of ovarian agenesis may arise in cases where a pelvic examination fails to obtain an image of the uterus, but it must be remembered that a similar picture occurs in some forms of hermaphroditism and gonadal dysgenesis.

Gonadal dysgenesis is a rare genetically determined malformation of the gonads, in which there is no functionally active hormone-producing ovarian tissue. In the vast majority of cases, in patients with gonadal dysgenesis, it is not possible to obtain a conventional echographic image of the ovaries, since they are replaced by undifferentiated cords in the form of fibrous strips 20-30 mm long and about 5 mm wide. When examining the pelvis, a wide variety of images of the uterus are possible - from pronounced hypoplasia with a barely visible endometrium to a slight decrease in size and a practically unchanged structure. If gonadal dysgenesis is suspected, the patient should be referred to determine the karyotype, and the ultrasound examination itself should be carried out with a targeted search for tumors, since in the presence of the Y chromosome, malignant neoplasms occur in 20-50% of cases.

UNCHANGED IN STRUCTURE AND DIMENSIONS,

BUT UNFULLY FUNCTIONING OVARIES

Luteinization of a non-ovulated follicle is a condition in which regular menstrual bleeding occurs against the background of cyclic hormonal changes, however, due to the inferiority of these changes, ovulation of the follicle does not occur. Over time, the follicle does not rupture, but becomes smaller, luteinized, and disappears by the beginning of the next cycle. At the same time, there is no decrease in the numerical values ​​of the resistance index (IR) of blood flow in the ovarian vessels - the indices of vascular resistance of the follicle remain at a constant, fairly high level during all phases of the cycle (0.54-0.55). The endometrium in echostructure and thickness corresponds to the phase of the cycle (Fig. 3.1). In some cases, an unovulated follicle can be detected over several menstrual cycles.

Insufficiency of the luteal phase of the cycle is a hypofunction of the corpus luteum of the ovary, manifested echographically by a decrease

echogenicity, decreased wall thickness, hypovascularization of the wall of the corpus luteum (decreased blood flow intensity when assessed in the color flow mode and increased IR), decreased endometrial thickness (Fig. 3.2).

OVARIES CHANGED IN STRUCTURE BUT SMALLLY CHANGED IN SIZE

No image of the dominant follicle.

When visualizing ovaries of normal size, it is necessary to evaluate their structure and its correspondence to the phase of the menstrual cycle. Attention should be paid to the absence of a dominant follicle in the periovulatory phase of the cycle. This sign, with normal ovarian sizes, can be observed in the following pathological conditions: resistant ovarian syndrome, ovarian wasting syndrome, postpartum hypopituitarism, hyperthecosis. In the case of resistant ovarian syndrome, in approximately half of patients with amenorrhea and normal levels of gonadotropins, there is no image of the follicular apparatus. In other patients, small follicles are detected, but the dominant follicle does not mature. The uterus may be normal or slightly reduced in size.

In patients under 40 years of age with amenorrhea, ovarian wasting syndrome is often diagnosed. In this case, a significant increase in the level of gonadotropins is determined in the laboratory, and during ultrasound examination the size of the ovaries is slightly reduced, the follicular apparatus is practically absent (Fig. 3.3), the uterus is reduced in size, the endometrium is thinned, and intraovarian blood flow is depleted.

Postpartum hypopituitarism develops after massive blood loss or bacterial shock in the postpartum period. Clinically, the syndrome manifests itself as oligomenorrhea, anovulation, and infertility. Echographically, the syndrome is characterized by normal or slightly reduced size of the ovaries, a decrease in the number of follicles to single small ones (up to 5 mm), lack of visualization of the dominant follicle, and thinning of the endometrium.

Hyperthecosis is a disease characterized by the proliferation of the ovarian stroma, which undergoes the processes of proliferation and luteinization, as well as hyperproduction of androgens with clinical manifestations of virilization. Sonographic signs of hyperthecosis are ovaries enlarged in size due to stromal hyperplasia, a decrease in the number of follicles to single small ones, lack of visualization of the dominant follicle, thickening of the tunica albuginea.

The absence of an image of the dominant follicle can be observed in the case of drug exposure, for example, when taking oral contraceptives. As a complication after discontinuation of long-term hormonal contraception, it sometimes occurs

syndrome of hyperinhibition of the gonadotropic function of the pituitary gland. The main echographic sign of this pathological condition, clinically manifested by amenorrhea, is the absence of visible structures of the follicular apparatus in the reduced ovaries. The condition may be accompanied by a decrease in the thickness of the endometrium and the size of the uterus.

And finally, the dominant follicle may not be visualized and is normal - 2-3 anovulatory cycles per year are natural, and in women over 35 years of age there may be more of them.

Ovarian microtumors: tumors of the sex cord stroma that produce hormones (thecoma, granulosa cell tumor, androblastoma) - can be small in size and practically do not lead to an enlargement of the ovary, but are accompanied by clinical symptoms and changes in the structure of the affected organ.

It is also necessary to consider the possibility of the existence of metastatic tumors in the ovaries. Metastatic tumors are characterized by bilateral involvement of the ovaries and are often small in size. In the initial stages of development, metastatic tumors have an oval shape, repeating the contours of the ovary, and imitate slightly enlarged ovaries. The echostructure of the affected ovary is almost uniform, predominantly of low and medium echogenicity; a characteristic feature is the absence of an image of the follicular apparatus.

CHANGED STRUCTURE AND ENLARGED OVARIES

Bilateral enlargement and changes in structure occur in patients with multifollicular ovaries, polycystic ovaries, ovarian hyperstimulation, endometriosis, acute oophoritis, and Krukenberg tumors. Unilateral ovarian enlargement occurs in acute oophoritis, ovarian torsion, ovarian pregnancy, tumor formations and ovarian neoplasms, including cancer.

The term "multifollicular ovaries" should be used to describe ovaries with multiple follicular structures found in women who do not have clinical or other manifestations of polycystic ovary syndrome. The main echographic characteristics of multifollicular ovaries are: moderate or slight increase in ovarian size, visualization of more than 10 small follicles (5-10 mm)

in one section, unchanged echogenicity of the stroma, maturation of the dominant follicle, ovulation and formation of the corpus luteum (Fig. 3.4). During a dynamic ultrasound examination, the disappearance of structural changes in the ovaries may be observed. A transient change in the structure of the ovaries in the form of multiple small anechoic inclusions can be observed in a number of conditions during puberty, with psychogenic dysmenorrhea, with hormonal contraception, with chronic inflammatory diseases and other processes that in most cases have a reverse development.

The term “polycystic ovaries” is understood as a pronounced and persistent change in the structure and function of the ovaries as a result of neurometabolic endocrine disorders, leading to massive atresia of the follicles and anovulation. The frequency of this pathological condition in the structure of gynecological morbidity ranges from 0.6 to 11%. Most often, ultrasound examination reveals enlarged ovaries, the volume of which exceeds 9-13 cm 3. In most cases, polycystic ovaries become round in shape. At the same time, an oblong shape is common due to a predominant increase in the length of the ovary. Characteristic of polycystic ovaries are multiple anechoic inclusions (more than 10 in one section with two-dimensional echography and more than 20 in the entire volume of the ovary when scanning in volumetric echography mode) of small sizes (from 2 to 8 mm) (Fig. 3.5). In most cases, the latter are located along the periphery of the ovary (the “necklace” symptom, peripheral cystic type), less often they can be located diffusely, i.e. both along the periphery and in the central part of the ovary (generalized cystic type).

An additional sign can be considered thickening and increased echogenicity of the ovarian stroma. Due to this, the area of ​​hyperechoic stroma increases in relation to the area of ​​the follicles (>0.34). The thickness of the tunica albuginea of ​​the ovaries is not an indicative echographic sign of polycystic disease. The leading criterion is that during dynamic ultrasound examination during the menstrual cycle the dominant follicle and corpus luteum are not detected. An additional sign is the discrepancy between the structure of the endometrium and the phase of the menstrual cycle; hyperplastic processes are often observed. Doppler examination reveals an increase in stromal vascularization, monotonous

highly resistant nature of intraovarian blood flow throughout the menstrual cycle.

It should be emphasized that ultrasound signs are not an unambiguous basis for establishing the diagnosis of polycystic ovary syndrome. This diagnosis is clinical and can only be made if other criteria for this disease are present.

While taking drugs that induce ovulation, ovarian hyperstimulation syndrome may occur. In a mild form of the syndrome, a small number of echo-negative structures with a diameter of about 20 mm are detected in the ovaries. In moderate and severe forms, the size of the ovaries increases significantly due to many thecal lutein cysts measuring up to 50-60 mm (Fig. 3.6). In this case, free fluid can be detected in the pelvic cavity, abdominal and pleural cavities. In such cases, the resulting image of the ovaries is practically no different from the echograms of cystadenomas. Doppler sonography reveals pronounced vascularization of the “septa,” which also complicates differential diagnosis with multilocular neoplasms. However, in contrast to them, with ovarian hyperstimulation syndrome, all of these changes undergo spontaneous regression within 2-3 (maximum 6) months after cessation of stimulation or drug correction. The basis of differential diagnosis is an indication of the use of ovulation stimulants.

Rice. 3.6. Ovary with hyper- Fig. 3.7. Ovarian endometriosis. TV stimulation. scanning.

Endometriosis ranks high among the causes of infertility. However, echographic detection of endometrioid heterotopias in the ovaries, which have the appearance of small focal or even pinpoint inclusions, is an extremely difficult diagnostic task. No less difficult is the differentiation of ovarian endometriosis from other, sometimes echographically very similar pathological processes. Among the few ultrasound signs, one can note a slight enlargement of the ovaries, blurring of their contours, the appearance of hypoechoic structures in them about 2-3 mm in diameter during menstruation, the presence of small hyperechoic inclusions along the periphery, as well as an adhesive process leading to a fixed position of the ovaries during TV examination (Fig. 3.7). Larger endometrioid heterotopias are usually called ovarian endometriomas. They are round, anechoic, with a thick echopositive suspension of inclusions with clear, even contours, and poor peripheral blood flow.

Inflammatory diseases are the most common cause of ovarian enlargement. In the initial stages of acute oophoritis, an enlargement of the ovaries is noted, while the shape of the ovary becomes round, the structure becomes hypoechoic, and the contour becomes unclear. The follicular apparatus may not correspond to the phase of the menstrual cycle and may not be clearly visualized. Additionally, the following can be determined: fluid in the pelvis, changes in other organs (sactosalpinx). Doppler measurements indicate an increase in blood flow with an increase in speed and a decrease in resistance. TV examination is usually painful.

Subsequently, small hyperechoic inclusions can be detected, both on the surface and in the stroma of the ovary.

Chronic oophoritis, in contrast to an acute inflammatory process, is practically devoid of specific echographic signs.

Ovarian pregnancy is extremely rare - on average, 1 case in 25,000 - 40,000 births. An adnexal mass in combination with the absence of a fertilized egg in the uterine cavity and a positive pregnancy test (hCG) is an important echographic sign most often observed in ectopic pregnancy. A carefully conducted ultrasound examination reveals a fertilized egg in the structure of the enlarged ovary. With progressive ovarian pregnancy, visualization of the embryo is possible (Fig. 3.8). During Doppler ultrasound, a “vascular ring” of ectopically located trophoblast can be detected if the gestation period exceeds 5 weeks. It should be remembered that the corpus luteum and tubo-ovarian formations can give an echographic and Doppler picture similar to ectopic pregnancy.

Rice. 3.8. Progressive ovarian pregnancy: the embryo is clearly visible.

OVARIAN TUMORAL FORMS

Among the various pathological conditions that cause ovarian enlargement, the most common are cysts. Distinguish

follicular cysts, corpus luteum cysts, endometrioid and thecalutein cysts of the ovaries. Paraovarian cysts are a variant of developmental anomaly and are defined as formations of the adnexal region. The main clinical symptoms in patients with functional ovarian formations are pain in the lower abdomen and/or menstrual irregularities.

Follicular cysts are formed due to the accumulation of fluid by osmosis in an unovulated follicle. The sizes of follicular cysts range from 2.5 to 10 cm, but are rarely more than 6-7 cm in diameter. During ultrasound examination, these cysts look like unilateral, thin-walled, single-chamber, round-shaped formations, usually located on the side or posterior to the uterus, and are easily displaced during examination. The internal contours are always smooth, the structure is completely echo-negative (Fig. 3.9). Behind the cyst, a pronounced acoustic effect of distal enhancement (“track”) is determined. With small sizes (30-50 mm), ovarian tissue is often visualized along the periphery of the formation. Most follicular cysts typically disappear spontaneously within 4-8 weeks, with a maximum of 12 weeks. One of the most common complications is torsion of the feeding pedicle, which is echoographically manifested by fragmentary thickening of the cyst wall (up to the appearance of a double contour) and a change in the internal echo-negative echo structure to a heterogeneous echo-positive one. With spontaneous rupture of a cyst, no echographic signs, except for the presence of fluid in the retrouterine space, usually appear. With CDK, single zones of vascularization are identified located along the periphery of the cyst.

The image of a follicular cyst can almost completely coincide with the image of a smooth-walled serous cystadenoma, so a certain oncological alertness should be exercised, especially in postmenopausal patients.

Corpus luteum cysts are formed due to hemorrhage and accumulation of fluid in the cavity of the ovulated follicle. Cysts of the corpus luteum can reach 9-10 cm in diameter, but on average they are about 5 cm. In some cases, cysts of the corpus luteum can look like completely echo-negative formations and are practically no different from follicular and paraovarian cysts (Fig. 3.10.). However, most often corpus luteum cysts on echograms

Rice. 3.9. Follicular cyst. Rice. 3.10. Corpus luteum cyst.

are represented predominantly by regular rounded echo-negative formations with echo-positive inclusions of various shapes and sizes, often in the form of delicate mesh structures of increased echogenicity. The walls of the cysts are usually thickened. The inner contour is fuzzy. It should be emphasized that the internal contents of corpus luteum cysts can be extremely polymorphic and often create the illusion of septa of varying thickness and even solid inclusions, especially in the case of massive hemorrhage inside the cyst (Fig. 3.11).

The peculiarity of the internal structure can lead to false-positive diagnoses of an ovarian tumor or tubo-ovarian inflammatory formation. However, with any variants of a complex structure, there is always a pronounced effect of distal enhancement. Clinical symptoms and laboratory examination data help differentiate the corpus luteum from a tubo-ovarian inflammatory formation. For the purpose of differential diagnosis, you should also use the Color Doppler mode, which helps to exclude the presence of vascularization zones in the internal structures of corpus luteum cysts (characteristic of cystic ovarian tumors). It should be added that intense blood flow along the periphery of corpus luteum cysts with a low resistance index in some cases can imitate malignant neovascularization. To clarify the diagnosis, dynamic ultrasound monitoring of the condition of the ovary is carried out; the next study is carried out after the next menstruation. Corpus luteum cysts tend to regress after menstruation, in more rare cases within 8-12 weeks.

Rice. 3.11. Corpus luteum cyst with blood Fig. 3.12. Thecal lutein cysts with left effusion (arrows). second ovary.

A feature of the development of corpus luteum cysts is their tendency to spontaneous rupture, leading to ovarian apoplexy. Apoplexy most often occurs at the stage of development of the corpus luteum, i.e. at the beginning of phase II of the cycle. In this case, rupture of the right ovary is more often observed. Echographic signs of apoplexy, with the exception of the accumulation of fluid (blood) in the retrouterine space, are not demonstrative. The ovary increases in size, the contours become unclear, uneven, and the echogenicity of the parenchyma increases. The structure is heteroechoic with small hypo- and anechoic inclusions. It is necessary to differentiate this condition from ectopic pregnancy and appendicitis. Ectopic pregnancy is characterized by delayed menstruation and other subjective and objective signs of pregnancy. Bleeding is not typical for appendicitis.

Thecal lutein cysts occur when the ovary is exposed to high concentrations of human chorionic gonadotropin, for example, with trophoblastic disease, with hyperstimulation of ovulation, and sometimes with multiple pregnancies. These tumor-like formations tend to disappear after the effect of the source of human chorionic gonadotropin ceases (within 8-12 weeks). Thecal lutein cysts sometimes reach large sizes (up to 20 cm in diameter) and in most cases occur in both ovaries. Multiple cysts can be detected, which creates the impression of a multilocular neoplasm. The internal structure of cysts is predominantly echo-negative, with numerous linear echo-positive inclusions (Fig. 3.12), which often makes them

Rice. 3.13. Endometrioid cyst Fig. 3.14. Two endometrioid cysts of the right ovary. in the right ovary.

indistinguishable from epithelial cystadenomas, cystadenocarcinomas, polycystic ovaries, pelvic inflammatory formations. In moderate and severe forms of hyperstimulated ovarian syndrome, ascites and effusion in the pleural cavity can be detected. During the Doppler study, the intense nature of the blood flow is determined. The history data and determination of the level of human chorionic gonadotropin should be of decisive importance for diagnosis.

Endometrioid, or “chocolate” cysts, which received this name due to the old blood they contain, are a form of external genital endometriosis. They are very varied in size - from 3 to 20 cm in diameter. In a third of cases they develop in both ovaries. Localization behind the uterus is quite typical for cysts. The pronounced adhesive process that occurs due to multiple microperforations makes endometriotic cysts immobile. Endometrioid cysts are most often single-chamber, but several closely spaced cysts can occur, creating the impression of a 2-3-chamber formation. Endometriomas can have different ultrasound images (Fig. 3.13, 3.14). The most common first type is characterized by the presence of homogeneous echo-positive (low and medium echogenicity) internal contents, creating a “frosted glass” effect. The second type, which has a heterogeneous, predominantly echo-positive structure with single or multiple inclusions of various shapes and sizes, is indistinguishable from inflammatory

formations and some types of ovarian cystadenomas. The third, most rare, type with an echopositive (high echogenicity) homogeneous structure has a certain acoustic similarity with solid ovarian formations, but unlike the latter, it has a noticeable effect of distal amplification of the echo signal. The walls of endometrioid cysts are usually thickened, and a double contour of the formation is often visualized. With CDK, the internal contents of endometrioid cysts always appear avascular, while isolated areas of vascularization are found along the periphery. Endometrioid cysts not only do not disappear during dynamic observation, but can increase in size.

Paraovarian cysts are quite common, accounting for about 10% of adnexal formations. They can develop from the pelvic mesothelium, from the supraovarian epididymis, or have a paramesonephric origin. The typical location of cysts is in the mesosalpinx - part of the broad ligament between the tube and the ovary. They are often visualized above the uterine fundus. Their sizes usually do not exceed 5-6 cm in diameter, although they can reach very large sizes. On echograms, cysts look like unilateral thin-walled formations of a round or ovoid shape with a completely echo-negative internal structure. However, only visualization of both ovaries located separately makes it possible to make an assumption about the genesis of the formation (Fig. 3.15). Paraovarian cysts do not undergo spontaneous regression.

Torsion of the ovary and appendages - this acute condition occurs infrequently and, as a rule, is not accurately assessed either clinically or echographically before surgery. There is no specific echographic picture, as it depends on the degree of torsion and the presence or absence of concomitant ovarian pathology. On echograms, first of all, an increase, sometimes very significant, of the ovary is determined with a pronounced change in its internal structure (Fig. 3.16). In some cases, the ovary turns into a predominantly echo-positive formation with single or multiple inclusions of various shapes and sizes. In contrast to ectopic pregnancy, the contours of the formation are smooth and clear, the internal contents are avascular, the blood flow in the walls is either represented by venous plethora or is absent. In some cases, a symptom of a twisted vascular pedicle may be visualized

Rice. 3.15. Paraovarian cyst. Rice. 3.16. Ovarian torsion.

in the form of a round hyperechoic structure with multiple concentric hypoechoic stripes, giving a resemblance to the target, then when using CDK one can see the “whirlpool” symptom along the twisted vessels of the pedicle. In most women, the process affects the right ovary. Additionally, fluid in the pelvis can be determined. Ascites develops in about a third of cases.

Changes in the ovaries that occur during inflammatory processes are extremely variable - from formations of regular shape with clear contours to shapeless, poorly defined conglomerates merging with the uterus. In acute oophoritis, there is a noticeable, sometimes significant, enlargement of the ovaries. In this case, the shape of the ovary becomes round, the structure becomes hypoechoic, the contour becomes unclear, and sound conductivity increases. The follicular apparatus may not correspond to the phase of the menstrual cycle and may not be clearly visualized. Additionally, fluid in the pelvis and sactosalpinx can be detected. Doppler measurements indicate an increase in blood flow with an increase in speed and a decrease in resistance. TV ultrasound is usually painful. Pyovar - purulent melting of the ovary. The ovary takes on the appearance of a predominantly echo-positive formation with single or multiple inclusions of various shapes and sizes. When the fallopian tubes are involved in the inflammatory process, the formation of tubo-ovarian formations or complexes occurs. In these cases, the altered ovary and the fallopian tube filled with contents are visualized closely adjacent to each other (Fig. 3.17). It is believed that for acute processes the presence of bilateral formations is more typical, and for chronic processes - unilateral.

With further progression of inflammation, it may form tubo-ovarian abscess. A distinctive feature of tubo-ovarian abscesses is an extremely polymorphic echographic image and blurred boundaries between the organs involved in the process. The internal structure sometimes changes to such an extent that the appearance of a tumor is created. However, the disease has a fairly clear and specific clinical picture. During ultrasound examination, a tubo-ovarian abscess is characterized by the presence in the area of ​​the appendages (usually adjacent to the posterolateral wall of the uterus) of the formation of a complex echostructure with a predominance of the cystic component. Cystic cavities can be multiple, varying in size and shape. The structure of the conglomerate may contain hyperechoic inclusions with shadows - gas bubbles, partitions, suspension. With TA ultrasound, the contours of the abscess may appear blurred, and in most cases the ovary is not clearly identified. In these cases, TV echography is crucial in establishing an accurate diagnosis. Sometimes it is possible to visualize the contour of the formation, find the wall and determine the blood flow in it. In the acute phase of inflammation, intensive blood supply is noted with a decrease in the resistance index (Fig. 3.18). Subsequently, the blood supply decreases and the resistance index increases. The size of a unilateral abscess is on average 50-70 mm, but can reach 150 mm. With bilateral localization of a tubo-ovarian abscess, it is not always possible to establish even conventional boundaries between the pelvic organs.

In these observations, inflammatory formations are visualized as a single conglomerate of irregular shape, with a thickened capsule, multiple internal septa and heterogeneous contents. Interpretation of echograms in patients with suspected tubo-ovarian abscess should be carried out in accordance with the clinical symptoms of the disease.

OVARIAN TUMORS

Ovarian tumors are a common gynecological pathology, ranking second among tumors of the female genital organs. According to various authors, the frequency of ovarian tumors among other genital tumors is increasing and over the past 10 years has increased from 6-11 to 19-25%.

Unlike earlier ones, the modern WHO classification does not provide for the division of ovarian tumors into benign and malignant. She distinguishes benign, borderline and malignant variants among various histotypes of tumors. Borderline type includes tumors that have some, but not all, morphologic features of malignancy (eg, no infiltrative growth).

The majority of ovarian tumors (approximately 70%) are epithelial tumors. Among them, benign and borderline variants account for about 80%, and malignant variants account for approximately 20%. They are divided depending on the type of content into serous and mucinous. Based on the presence or absence of septations and growths, serous cystadenomas are divided into smooth-walled and papillary.

Serous smooth-walled cystadenomas in 75% of cases during ultrasound examination are characterized by completely echo-negative contents with clear internal contours. The shape of the formations is usually round or oval (Fig. 3.19). Serous cystadenomas can reach large sizes, but usually do not exceed 15 cm in diameter. Doppler examination reveals single vessels with moderately resistant blood flow in the walls of the tumor. These signs make cystadenomas similar to follicular cysts. Main

The diagnostic difference from follicular cysts is their long existence (they do not disappear or decrease during dynamic observation for 8-12 weeks). In approximately 10% of patients, tumors can be found in both ovaries; sometimes the tumors have an intraligamentary location. Ascites is rare. “Benign” echographic characteristics cannot exclude the malignant nature of the neoplasm, therefore a certain oncological alertness should be exercised, especially in postmenopausal patients.

Serous papillary cystadenomas are characterized by multi-chamber and the presence of papillary growths in 60% of observations inside and in 40% outside. Papillary growths on echograms have the appearance of parietal echopositive structures of various sizes and echogenicity. The septa, as a rule, are single and have the appearance of thin echogenic linear inclusions. Quite characteristic of this type of tumor is the presence in the papillary structures and septa of zones of neovascularization with an average level of blood flow resistance (Fig. 3.20). Bilateral ovarian involvement can be expected in approximately 25% of cases. The mobility of formations is often reduced. Ascites is often noted. It should be remembered that these formations are borderline tumors and the risk of malignancy can be 50%.

Superficial papillomas on echograms they may appear as vegetations on the surface of the ovary - an irregularly shaped mass

with unclear contours, heterogeneous internal structure (with multiple areas of low and high echogenicity), directly adjacent to the tissue of an almost normal image of the ovary.

Smooth-walled mucinous cystadenomas during ultrasound examination they look like oval-shaped formations with clear internal contours, a predominantly echo-negative structure with the presence of multiple linear echogenic inclusions (suspension). Characterized by multi-chamber (Fig. 3.21). The contents of some chambers may be hypoechoic. Bilateral ovarian lesions and interligamentous location are quite rare. Ascites is uncommon. Mucinous tumors tend to grow rapidly and can reach very large sizes. With CDK, zones of neovascularization can be detected in septa and echogenic inclusions. When a formation ruptures, most often resulting from rupture of the tumor capsule, for example during surgery, a serious complication arises - peritoneal myxoma, almost always accompanied by ascites. Ovarian myxoma is a type of mucinous cystadenomas. On echograms, the myxoma has similar features to the maternal tumor (Fig. 3.22). Almost always, ovarian myxoma is accompanied by ascites.

Papillary mucinous cystadenomas. A feature of papillary mucinous cystadenomas is echopositive

inclusions of oval or irregular shape (papillary growths) of various locations (Fig. 3.23).

Rare types of epithelial tumors that do not have very specific echographic signs include endometrioid cystadenomas, Brenner tumors, clear cell and mixed epithelial tumors.

Germ cell tumors- a group of tumors originating from the germ cells of the ovary. This group includes teratomas and dysgerminomas. These neoplasms have age-related characteristics. During the reproductive period, they account for approximately 15% of all ovarian tumors, and only 3-5% of them are malignant. In childhood and adolescence, germ cell tumors predominate, with malignant tumors accounting for 30%. This group of neoplasms is often found in pregnant women.

Teratomas Depending on the degree of differentiation of tissue elements, they are divided into mature (benign) and immature (malignant). The ratio of mature to immature teratomas is approximately 100:1. Mature teratomas account for approximately a quarter of benign ovarian tumors. The most common type of mature teratoma is dermoid cysts. Mostly the tumors are unilateral, less often bilateral. The average size of teratomas is from 5 to 10-15 cm. The tumors are mobile, as they have a long feeding stalk. Pronounced morphological polymorphism leads to a variety of ultrasound images (Fig. 3.24). In 60% of cases, teratoma has a typical heteroechoic pattern - predominantly hypoechoic

echo-positive formation with an echogenic inclusion of a round shape. This component in most cases is characterized by fairly smooth contours. In a third of observations, an acoustic shadow appears directly behind it, since it usually contains hair, bone fragments, teeth and other derivatives of the dermis. In 20% of patients, teratomas may have a completely echopositive (high echogenicity) formation. In some observations, “invisible tumors” are encountered, characterized by a structure of medium echogenicity with almost blurred contours, merging with the surrounding tissues (Fig. 3.25). With CDK, mature teratomas have single zones of vascularization, and the resistance index is within normal values.

Immature teratomas, like all malignant neoplasms, have an irregular shape, a bumpy surface and are characterized by a chaotic internal structure. On echograms, tumors are revealed as formations of a mixed structure with uneven contours. Dopplerography reveals areas of pronounced neovascularization with low resistance index values. Ascites practically does not occur.

Dysgerminomas can be benign, but are often malignant in nature, representing the most common malignant tumor detected during pregnancy and childhood. On echograms, the tumor has a predominantly echo-positive structure and uneven contours; a “lobed” structure is typical. Multiple echo-negative and echogenic inclusions are reflections from frequently occurring areas of degenerative changes and petrification. The shape of the tumor is usually irregular and lumpy. Bilateral lesions occur in 10% of cases. The tumor grows quickly, reaching quite large sizes. The parameters determined by Doppler ultrasound are usually nonspecific, however, the determination of zones of vascularization by septa is quite typical. In the presence of a mixed tumor structure (with elements of chorionic carcinoma), a high level of hCG can be detected.

Sex cord stromal tumors arise from the sex cord cells of the embryonic gonad and account for approximately 10% of all ovarian tumors. These include hormonally inactive fibromas and hormonally active theca, granulosa and adrenocyte tumors.

Fibroids They are almost always unilateral and, when examined bimanually, are characterized by a dense, almost rocky consistency. Tumors are more common in postmenopausal women. On echograms they look like a round or oval formation with fairly clear, even contours (Fig. 3.26). The internal structure is echo-positive, with average or reduced echogenicity. In a third of cases, multiple echo-negative inclusions are detected, indicating the presence of degenerative necrotic changes. Directly behind the tumor, a fairly pronounced effect of absorption of ultrasonic waves often occurs. Fibroids can be multiple. With CDK, vessels in fibromas, as a rule, are not detected; in rare cases, single color loci are determined along the periphery of the tumor. The main differential diagnosis should be made with subserous myomatous nodes, in which visualization of intact ovaries is possible. Despite their benign nature, fibroids are in some cases accompanied by Meigs syndrome, characterized by ascites, pleural effusion and anemia. After the tumor is removed, the above complications disappear. Hormonal activity is not typical for fibroids.

A characteristic feature of hormone-producing neoplasms is the severity of clinical symptoms despite their relatively small size.

Granulosa cell tumors(folliculomas) are more common between the ages of 40 and 60 years. On echograms they usually have the appearance of unilateral round-shaped formations with a predominantly echo-positive (solid) internal structure, sometimes lobulated, and echo-negative, often multiple, inclusions

(areas of hemorrhagic changes and necrosis). The tumor can have cystic variants and is practically no different from ovarian cystadenomas. The size of the tumor rarely exceeds 10 cm in diameter. Visualization of intratumoral blood flow of a mosaic type (heterogeneous in speed and direction) is characteristic. The frequency of malignant variants of granulosa cell tumors ranges from 4 to 66%. Often the tumors themselves have a benign course, but the hyperestrogenization they cause is a risk factor for the development of endometrial hyperplastic processes. Given the high probability of developing pathological processes in the endometrium, a thorough examination is recommended. Additionally, signs of Meigs syndrome can be detected: ascites, pleural effusion.

Theca cell tumors (thecomas) are usually unilateral and often have a predominantly solid, fibroma-like structure with possible dystrophic changes. Echographically, the internal structure of theca cell tumors may also be similar to ovarian folliculomas. The size of tumors is usually less than 10 cm. Theca cell tumors are three times less common than granulosa cell tumors. Visualization of the central intratumoral blood flow of a mosaic type is characteristic. Additionally, signs of Meigs syndrome can be detected: ascites, pleural effusion. In most cases, tumors are characterized by distinct symptoms of hyperestrogenization, and therefore examination of the uterus helps to identify the tumor, since excess estrogen levels cause changes in the endometrium.

Adrenocellular tumors (androblastomas) have similar ultrasound signs to granulosa and theca cell tumors - a predominantly echo-positive structure with the presence of multiple hyperechoic areas and hypoechoic inclusions. Visualization of intratumoral blood flow is also characteristic. The tumor is characterized by slow growth and a predominantly benign course. In most cases, the size of the tumor does not exceed 15 cm in diameter. Malignant variants occur in approximately a quarter of patients. The tumor in most cases has virilizing properties, leading to defeminization of patients. The average age of patients is 25-35 years. Bilateral lesions are quite common

ovaries. Androblastomas account for about 1.5-2% of ovarian neoplasms.

MALIGNANT OVARIAN TUMORS

In the structure of female mortality from malignant neoplasms of the internal genitalia, ovarian cancer accounts for approximately 50%. The sensitivity of TV echography in diagnosing ovarian cancer is about 85%, the specificity is about 70%, i.e. During ultrasound examination, malignancy is not detected in approximately 15% of malignant tumors, and in 30% of cases an erroneous diagnosis of non-existent cancer is made.

Serous, mucinous, endometrioid cystadenocarcinomas, malignant cystadenofibromas and other malignant variants of epithelial tumors are echographically very similar to each other and in most cases have the appearance of formations of a mixed structure (Fig. 3.27). The contents of cancerous tumors on echograms often take on a bizarre character, and the more bizarre the structure of the formation, the greater the likelihood of cancer. Lumpy, uneven and unclear contours also indicate a malignant process. The presence of echogenic structures and inclusions (papillary growths) in predominantly echo-negative formations is characteristic of 80% of malignant tumors and only 15% of benign ones. Linear echogenic inclusions (septa) are not a differential diagnostic feature, but if they are detected in a significant number and at the same time have fragmentary thickenings with signs of vascularization, then the conclusion about the possibility of a malignant process is quite reasonable. Involvement of neighboring organs, the appearance of free fluid in the pelvis and abdominal cavity are prognostically unfavorable signs. With CDK, in the vast majority of cases, numerous zones of neovascularization with chaotically scattered vessels are revealed inside malignant tumors (resistance index< 0,4, максимальная систолическая скорость >15 cm/s) (Fig. 3.28).

Ovarian cancer is characterized by the appearance of ascites. At the same time, for cancerous ascites, the image of the loops of the small intestine in the form of a motionless “atomic mushroom”, which occurs due to damage to the mesenteric lymph nodes, is quite specific. With ascites,

accompanying benign diseases, intestinal loops remain free-floating. With “malignant” ascites, against the background of free fluid, metastatic nodules of various sizes scattered throughout the peritoneum can be detected.

METASTATIC TUMORS

Tumors of various locations and histological structures can metastasize to the ovaries - cancers, sarcomas, hypernephroma, melanoma, etc. The first place is occupied by metastases from breast cancer (about 50%), followed by metastases from the gastrointestinal tract (about 30%) and genitals (about 20%). Metastatic tumors are characterized by bilateral involvement of the ovaries and are often small in size. In the initial stages of development, metastatic tumors have an oval shape, repeating the contours of the ovary, and resemble enlarged ovaries. With small sizes, a characteristic feature of the internal structure of the tumor, which is predominantly echopositive (low and medium echogenicity), is the absence of an image of the follicular apparatus. Increasing in size, the tumors acquire uneven, lumpy contours, the internal structure becomes heterogeneous - predominantly echo-positive with numerous echo-negative inclusions. Metastatic tumors practically do not change the size of the ovary, but can also reach quite large sizes - 30-40 cm in diameter. In 70% of cases, ascites is detected.

2013-06-28 08:38:23

Katya asks:

Good afternoon
I am 27 years old, I weigh 47 kg.
Tell me, what is the probability of confusing an ovarian cyst with a follicle?
From time to time I was bothered by pain in the lower abdomen, the doctors, based on my words and an ultrasound scan, suggested that I had a cyst. But the surgeon and gynecologist, according to the latest ultrasound, said that there was no cyst.
The ultrasound results are described in the following words:

A year ago (day 12 of the cycle):
Right ovary 51x33 mm, "in the ovarian tissue there is a hypoechoic formation of an ovoid shape with an even contour and a homogeneous structure measuring 36x23"
Left ovary 34x17 mm

After 8 months (day 16 of the cycle)
Right ovary 50x28 mm (+ tube?). The contours are uneven, the structure is heterogeneous, the follicles are 1-5 mm.
The left ovary is 30x19 mm, pulled towards the uterus. The contours are uneven, the structure is heterogeneous, the follicles are 1-4 mm.

02.2013 (11th day of the cycle)
The right ovary is enlarged 45x29 mm. The structure is “heterogeneous due to the liquid 29x23 mm.”
The left ovary is enlarged 44x33 mm, the structure is “heterogeneous due to liquid 21 mm.”

04.2013 (11th day)
Right ovary 46x35 "with a cyst of heterogeneous structure 40x34 mm, "mesh structure"
Left ovary 29x18 mm, “small follicles”

06.2013 (18th day of the cycle):
“ovaries with clear, regular contours, normal shape and size;
right ovary 43x23x24 mm.,
left - 39x19x21;
their structure is moderately heterogeneous, slightly reduced echogenicity, with the presence of a corpus luteum in the right ovary with a diameter of 20 mm."

All ultrasounds were performed by different doctors using different machines.

I think I can say that I have frequent urination (I read that this can be a symptom of a cyst).
According to the results of the ultrasound, my bladder is distended. There are no stones or sand in it.
I have a sedentary job and don’t play sports.

The pain in my lower abdomen is usually not severe, not all day, sometimes on the right, sometimes on the left, sometimes on both sides at once. There are pulling ones, there are sharper ones. It hurts in the area of ​​the ovaries, sometimes somewhere in the middle, probably where the uterus is) and this is not associated with the onset of menstruation. Sometimes it hurts quite badly, then it probably lasts all day. I didn’t track or remember this before. I thought that if it hurt, something was wrong. I saw on Wikipedia that pain can be associated with ovulation and this is normal. But this month I specifically noted when and how much it hurt, and I had unpleasant sensations from the 4th day of the 18-day cycle, most strongly on days 7-9.
When I put pressure on the right ovary, there is no discomfort.
I haven’t treated the cyst with anything yet.

Please tell me how likely it is that the cyst was confused with the corpus luteum? Maybe I did an ultrasound on the wrong days and the follicle was confused with a cyst?

Should I be worried about my pain in the ovarian area or is this normal? Maybe I should check them some other way? Or ask some correct clarifying question to my gynecologist? After all, she accepts the symptoms from my words, and I may not know how much my sensations are within the normal range.

I really hope for your answer regarding the presence of a cyst, because... my gynecologist is on vacation now.
Thank you very much in advance.

Answers Lazarevich Alla Eduardovna:

Good afternoon, the diagnosis of a cyst is made when an ultrasound visualizes a formation more than 30 mm in diameter, anything smaller is not a cyst. Cysts are functional (the follicle has not burst, there is an anovulatory cycle), they do not require treatment and go away on their own, the pain syndrome can indeed be associated with ovulation and not necessarily in the middle of the cycle. Ovulation can be early or late.

2011-05-04 10:27:38

Elena asks:

Hello! I am 34 years old, now more than ever I am tormented by rashes on my face (acne), there are rashes on my chest and back, I recently took Yarina tablets, for 4 months, my skin was perfectly clear (I had an ovarian cyst in my medical history), after taking Yarina the cyst disappeared, I I stopped taking the pills and am now suffering from acne. I understand this is a hormonal problem? please tell me what hormone tests I need to take to determine my hormonal imbalance?

2011-02-16 14:16:50

Vitaly asks:

Can a man get infected? what if a woman has an ovarian cyst? and what are the signs if you are infected?

2010-07-06 02:55:15

ilonaa asks:

Hello. I have the following problem: 2 months ago I noticed a sharp enlargement of my abdomen, more in the lower part - it increases from the chest and hangs like a ball at the bottom. I am 21 years old, I am not sexually active, pregnancy is excluded. height 1.50 cm, weight has always been under 40 kg, and even now the ribs are visible - which means she has not gained weight. You can’t just “bloat up” for no reason at all... your periods are normal, regular, there’s no pain either... before your period you sometimes have pain in the kidney area and vomiting bile. There doesn’t seem to be any flatulence either, no constipation either, well, maybe heaviness after eating... in vain I don’t want to go to the doctor, and it’s not clear which one. I read on the Internet that an ovarian cyst can manifest itself in this way, but my period has already passed and is now coming, but my stomach still doesn’t deflate.. maybe this is somehow related to gynecological problems? maybe the belly will just inflate like that?) but will it deflate???)) it’s hard to walk with such a posture... thank you in advance for your understanding))

Answers Medical consultant of the website portal:

Hello, Ilona! At your age, a girl should “in vain” visit a gynecologist at least once every 6 months - such a visit is called a medical examination. And now you definitely need to see a doctor. An enlarged abdomen can be either a symptom of flatulence or a manifestation of the presence of a cyst or tumor growth. Contact your gynecologist as soon as possible - tumors and cysts do not always manifest as menstrual irregularities; sometimes they remain virtually asymptomatic for a long time. Take care of your health!

2016-07-13 05:38:23

Elena asks:

Good afternoon. Age - 28 years. Complaints: periodic pain in the right ovary. Ultrasound protocol for the 5th day of the cycle, uterus anteversio, contours - smooth, fuzzy (gases), dimensions - length - 44 mm, width - 32 mm, thickness 30 mm. The echostructure is homogeneous, the thickness of the endometrium is 3 mm, single-layer. The uterine cavity is not dilated. The cervix is ​​length 30 mm, thickness 29 mm, width 28 mm. The structure is homogeneous. Ovaries: on the right, an oval anechoic formation 43*31 mm is located on the lateral wall of the uterus, ovarian tissue is located in the lower pole. The left ovary on the side wall of the uterus is 28*22 mm, the contours are uneven, the structure is heterogeneous, the follicle d is 25 mm. Ultrasound conclusion: Follicular cyst of the right ovary; preovulatory follicle (persistence?) on the left.
After the ultrasound, we sent a test for tumor markers. Indicator CA-125-59.8
The gynecologist sends you for a consultation with a gynecological oncologist. The family doctor says that such a consultation is not necessary, because... Follicular cysts are not malignant, and you need to choose OK and observe the cyst. Regarding the tumor marker test, the family doctor says that without context it cannot be considered as an indicator of cancer. And my indicator indicates the presence of a cyst. Do I really need to consult a gynecological oncologist? And if necessary, what tests or diagnostics need to be done so that the gynecological oncologist has a more detailed picture. There is no way to go back and forth into the city. I would like to know what other tests may be needed.

Answers Bosyak Yulia Vasilievna:

Hello, Elena! Today it is premature to draw any conclusions; it is necessary to observe the dynamics of the cyst in the right ovary. After the next menstruation, it is rational to undergo a control ultrasound scan. Follicular cysts disappear on their own after the next menstruation. I’m not sure that with the size you described, the cyst is really follicular. There is also no talk of oncology; CA 125 itself is not informative. My advice is to wait until your next period and get an ultrasound scan. If the cyst continues to be visualized or increases in size, then you need to consult a gynecologist.

2015-11-17 08:03:14

Svetlana asks:

Hello! My name is Svetlana, on November 10, 2015 I had a strip operation to remove a tube (ectopic pregnancy) from the left and resection of the ovary (removed a cyst) also from the left! What worries me is that all this time the temperature has remained at 37-37.4! For three days They gave me Metronidazole and Ringer's solution... But it didn't bring down the temperature, now they've been giving me Azithromycin for two days instead, but the temperature remains the same! They said that this could be because the body is “stressed”. They looked at the stitch today, they said it was fine, they removed part today, and the second part tomorrow! Question: 1) Is it normal that the temperature is still 37-37.4? ??
2) How long do they stay in the hospital after such an operation???
3) What are the consequences after such operations???

Answers Palyga Igor Evgenievich:

Hello, Svetlana! Low-grade fever after such surgery can last for the first few days, up to a week. Discharged from the hospital after the stitches are removed. The consequences of the operation can be different and they depend on the correctness of its implementation and the state of your reproductive sphere. Theoretically, an inflammatory process is possible, which leads to the formation of adhesions, so I advise you to take an enzyme preparation (longidase or distreptase) for preventive purposes. What type of cyst was diagnosed? Most likely, upon discharge, you will be prescribed COCs for a period of 3-6 months. What size was the cyst and how much of the ovary was resected? It is clear that after surgery, the ovarian reserve will be reduced, so I advise you to plan a pregnancy after 6 months in the absence of an inflammatory process in the remaining fallopian tube.

2015-08-13 10:57:01

Julia asks:

Good afternoon, Igor Evgenievich!
I am 33 years old, height 160 cm, weight 58 kg. I'm planning a pregnancy. We have only been dealing with this issue for 6 months. back. I constantly do ultrasound monitoring (folliculometry), as a result, the following picture is obtained: in the right ovary, the growing follicle does not burst and turns into a follicular cyst of about 4 cm, which resolves during menstruation. Last time, the growing follicle in the right ovary was 1.4 cm, but then resolved before menstruation (it did not grow more than 1.4 cm, but did not turn into a follicular cyst). There were no follicular cysts in the left ovary. The growing follicle was maximum 1.5 cm, did not grow any further and immediately resolved. And it also happened that there were annullary cycles.
My periods are scanty; on ultrasound, the endometrium is never larger than 1 cm. Uterus dimensions: 4 cm x 3.2 cm x 3.6 cm. Ovarian dimensions: OD - 3.7 cm x 3.2 cm, OS - 3.4 cm x 3.2 cm. There are always a lot of antral follicles!
I took tests in Sinevo for hormones (on the 7th day of MC), all tests seemed to be within normal limits, except for Anti-Mullerian hormone, which = 8.04 (and the norm is 1.0 - 2.5) and antigens are the highest limit of normal:
Anti-Mullerian hormone - 8.04
Cortisol (serum) - 12.02
TSH - 1.37
T3 free - 3.21
T4 free - 1.31
Thyroid peroxidase, antibodies (ATPO) - 11.03
Thyroglobulin, antibodies (ATTG) - 17.1
Prolactin - 14.12
LH - 8.4
FSH - 4.6
Progesterone - 0.574
Estradiol (E2) - 65.61
Total testosterone (T total) - 1.58
Sex hormone binding globulin (SHBG) - 77.12
Free androgen index (total testosterone/SHBG) - 2.05

I didn’t take hormone tests during the second phase of the MC! TORCH infection everything is normal! Flora is normal. My husband's spermogram is also within normal limits.
Early diagnosis of COS was made.

10 years ago, after a road accident, there was abdominal surgery (splenectomy), there may be adhesions. I didn't check the pipes.

Igor Evgenievich, please tell me what should I examine, what tests should I take or retake, what should I treat and how? And what is my possible diagnosis?

Answers Palyga Igor Evgenievich:

Hello, Yulia! Thank you for reaching out to me. You absolutely correctly decided to address the issue of family planning, because... After 34 years, a woman’s fertility (ability to conceive) decreases. Have you been prescribed any medications during folliculometry in the last 6 months? Have you ever taken COCs? Based on the information you sent, I can primarily suspect PCOS (high AMH and a large number of antral follicles, anovulation). Most likely this is the main cause of infertility. It is also rational to check the patency of the fallopian tubes. This research will help guide future strategies. If you wish, send me your husband’s spermogram by email, I will analyze it. There may be several ways to solve your problem. You can try stimulation with clomiphene in the natural cycle or during intrauterine insemination (IUI), provided that the fallopian tubes are completely patency. The option is budget-friendly, but it must be taken into account that many patients with PCOS are resistant to clomiphene and, in addition, the effectiveness of IUI is no more than 10-15%. The second option is to conduct mini IVF. The cost of treatment is higher, but the chances of success are up to 40-50%. If you are planning mini IVF, then before the program it is rational to undergo a hysteroscopy to assess the condition of the uterine cavity. I will be glad to help and answer all your questions!

2015-06-16 13:51:15

Larisa asks:

Hello! I ask for advice, if possible.
I am 24 years old. I was not sexually active. The monthly cycle is inconsistent, usually every 40 days, sometimes every two periods. Conclusion Ultrasound of the thyroid gland - chronic thyroiditis;
Periodicity of menstruation in 2015: 12.01; 25.02;8.04;9.06
conclusion of pelvic ultrasound (AFTER PELVIC ultrasound, IN THE SECOND HALF OF THE DAY MENSTRUGS STARTED): cervix 39x23 without features, uterine body 52 thickness 31 width 46 mm, smooth, homogeneous, endometrium 9.9 mm. The right ovary is 41x22x22, the contour is clear, the structure with follicles up to 6.1 mm, throughout. The left ovary is 57x47x47, clear contour, structure VIScystic formation 49x38x43, wall thickness up to 3.8 mm, with echo (+) layers in CPK, vascularization along the periphery. Free fluid is not visualized. CONCLUSION: MULTIFOLICULAR RIGHT OVARY, LEFT OVARIAN CYST. Results of laboratory tests (which are abnormal) globulins 33.38%; albumins 66.62%; international normalized ratio (MHO/INR) 1.04, ALBUMIN 52.3 g/l; total testosterone 2.71 nmol/l; sex hormone binding globulin (SHBG) 148 nmol/l; free thyroxine (FT4) -0.834 ng/dl; FT3 - 61.21 IU/ml. Does this mean that ovulation is always absent?
I go to doctors regularly: gynecologist, gynecologist-endocrinologist, endocrinologist.
In my case, is there a chance of getting pregnant naturally in the future or is the diagnosis clear - infertility. Since I have not given birth and am not sexually active, treatment with hormones is not offered. I'm afraid it will get worse.
Maybe there are some herbal remedies to prevent the diagnosis from worsening. Laparoscopy of the left ovary is prescribed.
Thanks for any truthful answer!

Answers Palyga Igor Evgenievich:

Hello, Larisa! You definitely have an endocrine problem, that’s it. Secondly, a cyst is visualized, which until you remove it by laparoscopy will not normalize hormonal levels. No herbal remedies will help here. I advise you to plan a laparoscopy in the near future, monitor the dynamics after surgery and, if you have multifollicular ovaries, take hormone therapy.

2014-04-07 02:22:09

Raisa asks:

Hello, can I ask a question? My mother, 60 years old, has been suffering from terrible pain of unknown origin since December. There are attacks, but mostly the pain is constant. I can describe everything in detail, maybe you can help her. First it starts to bake, it burns in the anus, then throughout the abdomen it can radiate into the buttocks of the tailbone, thighs , there are goosebumps all over the body, the pain is terrible, and if there is such an attack, then the whole body burns. There is a constant heaviness in the stomach, there is gas, but not always. We just don’t know what to do. We did an MRI, sigmoidoscopy, then a procedure with barium. I spent time in the hospital, but there were no results, it was not clear what they were treating. Even when they did enemas and there were a lot of them, it was very difficult to bear them after that it became even worse. It seems to me that there was no treatment at all, the only hope is for you. Please help me what can actually cause such pain , I beg you, at least write down what medicines we should take. She has almost no urge to defecate. Sometimes gas will come out or air will come out and that’s all. The stool is not thick, but thin. Very often she goes to the toilet a little at night. There is no female uterus or ovary, they removed it 20 years ago. Here are the tests. Sigmoidoscopy: the mucous membrane is moderately hyperemic, the folds are swollen, mobile, and easily corrected. No tumors or ulcers were found. Diagnosis: proctitis. There is nothing written about barium in the extract, only diagnoses: dolichosigma, colon hypertension, atrophic colitis. At the hospital she was injected with spasmolgon, spazmolak, spazmomen, biogaia, nolpaza and some other injections for the stomach. At home she took sulfasalazine 4 times a day for 12 days, biogaia, then lactiale, methylorucinic and sea buckthorn suppositories, and before the hospital she pierced something in her back for five days. Doctor, I ask you, please help me, she no longer wants to live, she can only be saved by spasmolgon and ranitidine, before 5 years ago she was in bed with stomach She had constant problems: ulcers, gastritis, pancreatitis. Thank you for listening, please help. MRI
The liver is normally positioned and has smooth edges and is of normal size. In segments II and VII, single cysts measuring up to 6 mm are detected. The system of the portal vein and hepatic veins is not changed. Intra- and extrahepatic bile ducts are normal.
The gallbladder is pear-shaped, the walls are not thickened, and no radiopaque stones are detected.
The spleen is of normal size and normally located. It has smooth contours and a homogeneous internal structure.
The pancreas is normal size and usually located. Fatty involution of the gland parenchyma is noted. The pancreatic duct is not dilated.
The stomach, loops of the small and large intestines are filled antegradely with the X-ray negative contrast agent “Diagnol”. The position of the intestinal loops is normal. The sigmoid colon is elongated to form an additional half-loop. The jejunum is partially collapsed. No thickening of the walls, filling defects, or narrowing of the lumen were detected. The mucous membrane is uniformly enhanced by contrast.
The adrenal glands are normal, not enlarged.
Both kidneys are normally located and of normal size. The width of the renal parenchyma is normal. In the parenchyma of the upper pole of the left kidney there is a cyst measuring 35x30x27 mm, spreading intrarenally - up to 2/3. There is no ectasia of the kidneys. The excretory function of the kidneys is preserved. The ureters are passable along their entire length. The bladder is tightly contrasted, without any features. On the right there is a doubling of the ChLS.
The vessels have normal outlines, there are no signs of lymphadenopathy.
Visible parts of the lungs without focal infiltrative changes.
Bone destructive changes are not detected.
Diffuse osteoporosis is noted. The height of the intervertebral spaces is unevenly reduced, the endplates are sclerotic, deformed, there are rough marginal osteophytes, and at the level of Th9-L1 the anterior longitudinal ligament is calcified. Interspinous arthrosis is expressed at the L1-S1 level. The articular surfaces of the facet joints are sclerotic, deformed, and the joint spaces are sharply narrowed. The L4-L5 disc prolapses circularly up to 4.5 mm. Disc L5-S1 with vacuum effect. The sacroiliac joints are not changed. The tailbone is of normal shape, size, and position.
CONCLUSION: Single liver cysts. Left kidney cyst. Incomplete duplication of the right kidney. Diffuse osteoporosis. Severe osteochondrosis, def. spondylosis, spondyloarthrosis of the lower thoracic and lumbosacral spine. Fixing ligamentosis in segments Th9-L1. L4-L5 disc protrusion.

The pathology predominantly affects children, adolescents and young adults, much more often females. Almost 90% of patients with ACC are under 20 years of age, but the tumor is rare in children under 5 years of age.

Histology and pathogenesis of aneurysmal bone cyst

An aneurysmal bone cyst is a bone lesion consisting of large thin-walled cavities filled with blood and communicating with each other, having tissue fragments in the walls, reminiscent of a blood-filled sponge. The walls separating the cavities consist of fibroblasts, giant osteoclast-like cells and coarse fibrous bone. In approximately 1/3 of cases, characteristic mesh-lace chondroid structures are found in the walls of the cysts.

An aneurysmal bone cyst can develop after trauma, and in 1/3 of cases it accompanies benign tumors: most often (19-30% of cases) GCT, less often - chondroblastoma, chondromyxoid fibroma, osteoblastoma, solitary cyst, FD, EG, as well as malignant bone tumors : osteosarcoma, fibrosarcoma and even cancer metastasis. In such cases, ACC is called secondary, contrasting it with primary ACC, in which no previous bone lesions are detected, although theoretically hemorrhage can completely destroy the tissue of such a lesion. Based on these data, it was believed that ACC occurs as a result of intraosseous hemorrhages caused by trauma or vascular changes in the previous tumor. This idea goes back to the works of one of the founders of the ACC doctrine, H.L. Jaffe (1958). S.T. Zatsepin (2001) actually considers ACC as a pseudoaneurysm, highlighting in its course:

• acute stage with a very rapid increase in size due to intraosseous hemorrhage and destruction of bone tissue;
• the chronic stage, when the process stabilizes and reparative changes occur.

According to M.J. Kransdorf et al. (1995), the development of ACC reflects only nonspecific pathophysiological mechanisms, and the main task of the clinician is to recognize pre-existing lesions when possible. If no such lesions are found, ACC can be treated with curettage and bone grafting. If more aggressive lesions are identified, treatment should be directed towards them. In other words, in case of osteosarcoma with secondary ACC, osteosarcoma must be treated, and in case of GCT with secondary ACC, local relapses are more likely to be expected.

Although ACC is not considered a true tumor and does not metastasize, and in rare cases even undergoes spontaneous regression after biopsy, its rapid growth, extensive bone destruction and spread into adjacent soft tissue require aggressive therapy. In at least 10-20% of cases, single or repeated relapses are observed after surgery. It is also necessary to mention the good effect of radiation therapy, after which the growth of ACC stops and recovery processes develop.

A solid variant of the aneurysmal bone cyst are lesions that contain the reticular lace-like chondroid material seen in conventional ACCs, but without the typical cystic cavities. This option accounts for 5-7.5% of all ACC cases. Its similarity to giant cell reparative granuloma of the jaws, as well as giant cell granuloma of long bones and small bones of the feet and hands, has been noted. All of them are regarded as a reaction to intraosseous hemorrhage. The clinical and imaging manifestations of classic ACC and the solid variant do not differ.

Symptoms and radiological diagnosis of aneurysmal bone cyst

Clinical examination

Damage to long bones predominates: of these, ACC is most often located in the tibia, femur and humerus. Frequent localization is the spine (from 12 to 30% of cases) and pelvic bones. These three main sites account for at least 3/4 of ACC cases. The bones of the feet and hands account for approximately 10% of cases. Most patients present with pain and swelling lasting no longer than 6 months.

In the spine, the thoracic and lumbar regions are most often affected. The ACC is usually located in the posterior parts of the vertebra: in the pedicle and arch plate, in the transverse and spinous processes. Often a paravertebral soft tissue component is formed, which can lead to atrophy of the adjacent vertebra or rib from pressure. The vertebral bodies are involved in the process less frequently, and their isolated damage is completely rare.

Radiation diagnostics

In most cases of secondary ACC, the imaging pattern is typical of the original lesion. Primary ACC presents with a bone defect, often eccentrically located, with a swollen “ballooning” cortex and often with a delicate trabecular pattern. In approximately 15% of cases, radiographs reveal a flocculent mass within the lesion (mineralized chondroid in the cyst wall), and in some cases this may simulate a cartilaginous tumor matrix.

In long bones, damage to the metaphyses predominates; diaphyseal localization is less common and epiphyseal localization is very rare. The most typical eccentric or marginal (with initial intracortical or subperiosteal localization of ACC) position of the destructive focus with significant swelling and sharp thinning of the cortical layer.

With the marginal location of the aneurysmal bone cyst, in the foreground in the X-ray picture there is a soft tissue formation with penetration of the cortical layer, traces of the periosteal shell and Codman’s triangle, which resembles a malignant tumor. The similarity can be completed by trabeculae extending perpendicular to the axis of the bone into the soft tissue. However, the soft tissue component corresponds in length to the length of the bone lesion and is covered at least partially by the periosteal bone shell. The initial period is characterized by a dynamic x-ray picture with very rapid growth, like no other bone tumor. At this stage, the internal contour becomes blurred, later it can become clear, sometimes bordered by a sclerotic rim. In such cases, the picture is quite indicative and often allows one to confidently diagnose an aneurysmal bone cyst.

When a vertebra is affected, radiographs reveal bone destruction and swelling. Sometimes there are lesions of adjacent vertebrae, sacrum and pelvis.

The picture of an aneurysmal bone cyst on osteoscintigraphy is nonspecific and corresponds to the cystic nature of the lesion (accumulation of radiopharmaceuticals along the periphery with weak activity in the center of the lesion). CT is most useful for assessing the size and location of intraosseous and extraosseous components in anatomically complex areas. CT and MRI reveal a well-defined focus of the lesion (often with a lobulated outline), swelling of the bone, and septa delimiting the individual cyst cavities. MRI on a T2-weighted image also reveals solitary or multiple levels between layers of fluid with different densities or magnetic resonance signals, which is due to the sedimentation of hemoglobin breakdown products. Although such levels are less commonly seen on T1-weighted imaging, increased signal on T1-weighted imaging both below and above the levels confirms the presence of methemoglobin in the fluid. Horizontal levels can also be observed in secondary aneurysmal bone cysts in various tumors. There is often a thin, well-defined border of reduced signal around the lesion and along the internal septa, probably due to fibrous tissue. After administration of a contrast agent, an increase in the signal of the internal septa is observed.

With large cysts and their superficial location, there may be signs of swelling of the surrounding soft tissues according to MRI. The value of MRI is that it allows:

• establish a diagnosis in cases with an uncertain or suspicious picture on radiographs (up to 40% of cases);
• plan biopsy of a solid component when this intervention is decisive in the differential diagnosis;
• detect postoperative relapses earlier.

Differential diagnosis

In the bones of the hands and feet, ACC is characterized by a central location in the bone and symmetrical swelling, and it must be differentiated from enchondroma and bone cyst, in which swelling is usually less pronounced, as well as from the brown tumor accompanying hyperparathyroid osteodystrophy, and other lesions. When the epiphysis is involved, an aneurysmal bone cyst may resemble a GCT, differing from it in a greater degree of swelling, and in children also by a periosteal reaction at the edges of the lesion focus. However, the precise distinction between ACC and T-bills can be difficult. It should be taken into account that ACC most often occurs in the immature skeleton, while GCT, almost without exception, occurs after bone growth has completed.

When a vertebra is affected, the X-ray picture of ACC is characteristic, when the tumor is limited only to the transverse or spinous process of the vertebra, although osteoblastoma and hemangioma can cause similar changes. It is more difficult to distinguish from malignant tumors other localizations of aneurysmal bone cysts, accompanied by a pronounced soft tissue component - in the pelvic bones, ribs, scapula and sternum.

MRI may also reveal a solid component along with the cystic component, which does not refute the diagnosis of primary ACC, but requires differential diagnosis with telangiectatic osteosarcoma and secondary ACC.

39170 0

Functional ovarian cysts, such as follicular and corpus luteum cysts, account for 25-30% of all benign formations in young women.

Follicular cyst

A. Follicular cyst- a tumor process that forms as a result of the accumulation of follicular fluid in a cystic follicle and is characterized by the absence of true proliferative growth.
The diameter of follicular cysts ranges from 2 to 12 cm. The shape in the vast majority of cases (94.1%) is round. The internal structure of the cysts is completely homogeneous, anechoic, and has high sound conductivity. The wall of follicular cysts is even, smooth; its thickness averages 1.0±0.3 mm.

Dynamic echographic observation shows that during the first menstrual cycle, 25.9% undergo spontaneous regression, the second - 33.4%, and the third - 40.7% of follicular cysts. At the same time, a relationship was noted between the size of the cyst and the period of its disappearance. Thus, formations more than 6 cm in diameter regress within 3 menstrual cycles. This is apparently due to the fact that the wall of the follicular cyst is devoid of vascularization, so involution occurs through gradual passive collapse of the walls of the cavity and resorption of the fluid contained in the cyst.

Endoscopic picture

Follicular cysts are usually unilateral, their diameter is 2-12 cm, their shape is round, they have a thin smooth wall, a single-chamber structure and a tight-elastic consistency. The capsule is smooth, whitish or pale pink, the contents are transparent. The proper ligament of the ovary is not changed. The course of the vessels of the mesovarium has the usual direction. When enucleating a cyst, the wall is difficult to separate from the ovarian tissue and breaks.

Corpus luteum cyst

B. Corpus luteum cyst is formed at the site of a progressive corpus luteum, in the center of which, as a result of circulatory disorders, liquid contents accumulate.

The cyst has dimensions from 2 to 8 cm. Four echographic variants of the structure of the corpus luteum cyst have been described.

1. In option 1, most often the cyst has a mesh structure of medium echogenicity. In most cases, the mesh component fills all or most of the cyst.
2. In option 2, the contents of the cyst are homogeneous and anechoic. In its cavity, multiple or single, tender, complete or incomplete, irregularly shaped septa are determined.
3. In the 3rd option, dense, highly echogenic inclusions (blood clots) are detected in the cyst cavity. More often they are small in size (1-1.7 cm in diameter), single (1-3) and localized near the wall. These formations can be either irregular or club-shaped or spindle-shaped.
4. In option 4, the contents of the cyst are completely homogeneous and anechoic. Its echographic image resembles a follicular cyst.

Despite the differences in the internal structure of corpus luteum cysts, their sound conductivity is always high. The wall thickness ranges from 2 to 4 mm, averaging 2.8±0.4 mm.

In most women, cysts regress spontaneously. The duration of involution depends on the size, and not on the internal structure of the cyst. Unlike follicular cysts, corpus luteum cysts in the vast majority of cases (86.2%) regress within 1-2 menstrual cycles.

Endoscopic picture

Cysts of the corpus luteum are usually unilateral, although the presence of a small cyst (up to 4 cm in diameter) is possible in the other ovary. The size of the cyst is 2-8 cm, the shape is round or oval, the wall of the cyst is thickened, folding of the inner surface is noted, the contents are hemorrhagic. The cyst has a bluish-purple tint.

The proper ligament of the ovary is not changed. The course of the vessels of the mesovarium has the usual direction. When enucleating a cyst, the wall is separated from the ovarian tissue with great difficulty and often ruptures.

Paraovarian cyst

B. Paraovarian cyst- retention formation located between the leaves of the broad ligament of the uterus.

The sizes of paraovarian cysts range from 3 to 15 cm. The thickness of the cyst wall varies from 1 to 3 mm, averaging 1.5±0.4 mm. There is a clear correlation between the possibility of ultrasound diagnosis of paraovarian cysts depending on their size. Only when the cyst diameter is more than 5 cm, in all cases, transvaginal ultrasound reveals an unchanged ovary.

With large paraovarian cysts, the ovary is not always visualized. In 88% of patients, the ovary is identified as a separate anatomical formation, and as the size of the cyst increases, careful scanning using transabdominal and transvaginal sensors is necessary to identify the ovary. Unlike follicular cysts and corpus luteum cysts, paraovarian cysts do not regress.

Endoscopic picture

Paraovarian cysts, as a rule, are unilateral formations up to 10-15 cm in diameter, round or oval in shape, tight-elastic consistency, the capsule is usually thin but quite strong, the contents are transparent. Depending on the size of the cyst, the fallopian tube is located differently, sometimes it is spread out on the surface of the cyst. The paraovarian cyst and the ovaries are defined as separate anatomical structures.

Peritoneal cystic formations

D. Peritoneal cystic formations. Peritoneal cystic formations (serosoceles) are also among the rather difficult to diagnose pelvic formations. Differential diagnosis of serosocele, tumor-like formations and ovarian tumors presents significant difficulties.

Anamnestic data

Anamnestic data have some features: transection is detected in 80% of cases, acute inflammation of the uterine appendages with pelvioperitonitis - in 10-25%, common forms of endometriosis - in 5-15%. The duration of existence of serosocele ranges from 3 months to 4.6 years (after previous operations), and among women with acute pelvioperitonitis - from 2 to 5 months.

Criteria for serosocele

1. Liquid formation in the pelvic area, detected after operations or an acute inflammatory process of the internal genital organs.
2. Absence of a clearly visualized wall (capsule) on the echogram.
3. Irregularity of the contours of the cystic structure located in the pelvis.
4. Change in the shape of the formation during repeated ultrasounds.

Endoscopic picture

Peritoneal formation can be single-chamber or multi-chamber, the walls are represented by adhesions. The shape is round or oval, sizes from 1 to 25 cm, tight-elastic consistency, filled with a yellowish opalescent liquid. The adhesive process in the abdominal cavity and pelvis causes certain technical difficulties during laparoscopy.

Mature teratomas

D. Mature teratomas. According to the WHO International Classification (1977), ovarian teratomas are classified as germ cell tumors. Mature teratomas are benign neoplasms containing tissue elements that do not differ from similar structures of the body (the most often found elements are skin, hair, fat, smooth muscle fibers, cartilage and bone tissue, elements of the nervous system).

In 80% of cases, mature teratomas are unilateral formations. Often a relapse of the disease is diagnosed with the identification of a teratoma in the other ovary. More often (60-70% of cases) the tumor comes from the right ovary.

Simultaneous transabdominal and transvaginal ultrasound can improve diagnostic accuracy and identify 6 types of echographic images of mature teratomas.

1. In type 1, the tumor has a completely anechoic internal structure and high sound conductivity. On the inner surface of the tumor, a parenchymal tubercle of medium or high echogenicity, round or oval, can be detected.
2. In type 2, the tumor has a completely dense internal structure, its structure is hyperechoic and mostly homogeneous.
3. In type 3 teratomas, they are characterized by a cystic-solid structure, the dense component usually has a homogeneous structure, high echogenicity and occupies from 1/3 to 3/4 of the tumor volume; in the cystic component, multiple hyperechoic small linear-striated inclusions are determined.
4. Type 4 is characterized by a completely solid tumor structure, consisting of two components - hyperechoic and dense, giving an acoustic shadow.
5. Type 5 teratomas have the most complex internal structure and are characterized by the presence of all of the above components (cystic, dense and hyperechoic solid, giving an acoustic shadow), they do not exceed 5 cm in diameter.
6. Type 6 teratomas have a varied internal structure (liquid with septa of varying thickness, dense inclusion of a spongy structure, fine- and medium-dispersed hyperechoic suspension).

The greatest difficulties arise in differentiating cystic teratomas (type 1) and serous cystadenomas. When performing an ultrasound in such cases, special attention should be paid to the condition of the inner wall of the formation. The presence of a smooth wall in most cases suggests a smooth-walled cystadenoma.

The detection of a dense component of a spongy structure on the inner surface of the tumor often indicates papillary cystadenoma. If the parietal component has a homogeneous structure and contains dense hyperechoic inclusions, especially those giving an acoustic shadow, then this most likely indicates a mature teratoma.

Certain difficulties arise in the differential diagnosis of mature teratomas (type 6) and ovarian fibromas that give an acoustic shadow. When performing an ultrasound, it should be borne in mind that with fibromas, the tumor area located between its upper pole and the acoustic shadow generally has low echogenicity, and with teratomas, high echogenicity.

Of particular value is the identification of mature teratomas in the thickness of the ovary, when the size of the ovary is not increased and the surface is not changed. In these clinical observations, the diagnostic capabilities of ultrasound are superior to those of laparoscopy.

Endoscopic picture

Macroscopically, the wall of a dermoid cyst consists of dense, sometimes hyalinized connective tissue. The shape is round or oval, the consistency is dense. Dimensions 1-16 cm. The surface is smooth or lumpy, elastic in some places, very dense in others.

The location of the cyst in the anterior fornix (in contrast to other types of tumors, usually located in the utero-rectal space) has a certain differential diagnostic significance.

When the cyst is cut, its thick, lard-like contents pour out, sometimes it looks like balls (dermoid with balls). Along with the fat, tufts of hair are found in the cyst. The inner surface of the cyst wall is smooth over a considerable extent, but in one area there is usually a protrusion - the so-called head, or parenchymal, tubercle. Teeth, bones, and parts of organs are often found in the tubercle.

Serous, or cilioepithelial, tumors

E. Serous, or cilioepithelial, tumors are divided into smooth-walled and papillary, and papillary, in turn, into inverting (papillae are located inside the tumor capsule) and everting (papillae are located on the outer surface of the capsule). There are also mixed tumors, when the papillae are located on both the inner and outer surfaces of the capsule.

Serous cystadenoma

1. Serous cystadenoma- the simplest form of serous tumors, usually unilateral, single-chamber and smooth-walled. The epithelium lining the tumor wall is single-row cubic, less often cylindrical.

Endoscopic picture

The shape is spherical or oval, the surface is smooth, shiny, whitish in color. The contents of the cyst are transparent, with a yellowish tint. Sizes can vary significantly. In appearance, serous smooth-walled cystadenomas resemble follicular cysts, but unlike retention formations, the tumor has a different color - from bluish to whitish-gray, which is due to the uneven thickness of the capsule.

Papillary cystadenoma

Endoscopic picture

The tumor is usually visible as a mass with a dense, opaque whitish capsule. The most characteristic sign is papillary growths on the outer surface of the tumor capsule.

With pronounced dissemination of capillary growths (cauliflower type), the everting form of the tumor can be mistaken for cancer.

Papillary cystadenoma can be a bilateral formation, in advanced cases it is accompanied by ascites, an inflammatory process in the pelvis, possibly an intraligamentous location of the tumor and proliferation of papillae throughout the peritoneum.

The contents of cystadenomas are liquid, transparent and have a brown, reddish or dirty yellow color. Unlike mucinous tumors, there is no pseudomucin.

Mucinous cystadenoma

Endoscopic picture

The surface of the tumor is mostly uneven, with numerous protrusions due to the presence of chambers. The size of the tumor varies widely. The tumor is irregular in shape with a dense, thick, opaque capsule, the color ranges from whitish to bluish. In side lighting, the boundary between the cameras is visible.

On section, the tumor is rarely single-chamber; for the most part it is multi-chamber with the formation of daughter and grandchild cavities. Between the individual cavities, the remains of partitions are visible, destroyed due to significant pressure from the tumor contents. The inner surface is smooth.

Torsion of the pedicle of an ovarian tumor

G. Torsion of the pedicle of the ovarian tumor occurs quite often, especially under favorable conditions: high mobility of the tumor, small size, significant stretching of the anterior abdominal wall (saggy abdomen), pregnancy, and the postpartum period. Most often, torsion occurs before sexual activity begins.

Endoscopic picture

In case of torsion of the pedicle of the ovarian tumor, a bluish-purple formation is visualized. Its appearance is determined by the degree of torsion of the tumor pedicle by 180° or more (partial or complete torsion) and the time elapsed from the moment of circulatory disturbance to endoscopic surgery.

Ovarian apoplexy

Ovarian apoplexy- sudden hemorrhage, accompanied by a violation of the integrity of the ovarian tissue and bleeding into the abdominal cavity. Among the causes of intra-abdominal bleeding, 0.5-2.5% of cases are due to ovarian apoplexy.

The most common source of bleeding is the corpus luteum or its cyst. The possibility of rupture of the corpus luteum during pregnancy cannot be ruled out.

Endoscopic picture

The affected ovary is of normal or enlarged size due to a previous hematoma, usually bluish in color. Even a small tear (up to 1 cm) can lead to heavy bleeding. There are blood clots and free blood in the pelvis and abdominal cavity.

The operation is performed as conservatively as possible. The ovary is removed only if there is massive hemorrhage that completely affects the ovarian tissue. If the corpus luteum of pregnancy ruptures, it is sutured without performing a resection, otherwise the pregnancy will be terminated.

Apoplexy is often combined with ectopic pregnancy and acute appendicitis. Apoplexy can be bilateral. In this regard, during the operation it is necessary to examine both ovaries, fallopian tubes and appendix.

Polycystic ovaries

In accordance with the WHO International Classification of Diseases, 9th Revision, 1993, “polycystic ovaries” or the synonym “Stein-Leventhal syndrome” is coded as 256.4 in section No. 3 “Diseases of the endocrine system”.

The frequency of polycystic ovaries in the structure of gynecological diseases varies widely - from 0.6 to 11%.

Endoscopic picture

Characteristic signs of polycystic ovaries: slight bilateral enlargement of organs (up to 4-5 cm), a smooth thickened capsule with a vascular pattern of varying severity, the presence of subcapsular cysts, and the absence of free peritoneal fluid.