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Ovarian Cyst, Ruptured

BASICS

  • Ovarian cysts are common in reproductive-aged women.
  • Rupture typically presents with acute unilateral lower abdominal pain.
  • Triggers: Sexual intercourse, luteal phase, exercise, trauma, pregnancy, or idiopathic.
  • Important: Exclude emergent causes—ectopic pregnancy, ovarian torsion, and non-gynecologic sources of pain.
  • Most can be managed conservatively with pain control; surgery is rarely needed.

DESCRIPTION

  • Most cysts are benign physiologic follicles (functional cysts) related to ovulation.
  • Symptoms: enlargement (mass effect) or rupture → peritoneal irritation/pelvic organ irritation.

EPIDEMIOLOGY

  • Many ruptured cysts are asymptomatic or incidental findings.
  • Ultrasound: Ovarian cysts in nearly all premenopausal and up to 18% postmenopausal women.
  • 13% of ovarian masses in reproductive-aged women are malignant; much higher in postmenopausal.
  • Right ovary more often involved (63%).
  • Incidence: 7% of women worldwide have a symptomatic cyst in their lifetime.
  • Pregnancy: Prevalence 1–5.3% (symptomatic 0.63%; malignant 1%).

ETIOLOGY & PATHOPHYSIOLOGY

  • Ovulation: follicle matures & ruptures → oocyte release → corpus luteum forms.
  • Follicular cyst: if follicle fails to rupture.
  • Corpus luteum cyst: if corpus luteum fails to involute.
  • Both are functional/physiologic (not malignant).
  • Other cysts: endometriomas, dermoid cysts, malignancy.

RISK FACTORS

  • Ovulation induction agents: Clomiphene, aromatase inhibitors, GnRH agonists
  • Tamoxifen (in reproductive-aged women)
  • PCOS (common), McCune-Albright syndrome (rare)
  • Endometriosis

GENERAL PREVENTION

  • Combined hormonal contraceptives (CHCs): Mainstay for prevention of recurrent cysts

COMMONLY ASSOCIATED CONDITIONS

  • Endometriomas in 20–55% with endometriosis
  • PCOS

DIAGNOSIS

Key steps:

  • Always exclude ectopic pregnancy (urine β-hCG).
  • Evaluate for other emergencies: ovarian torsion, tubo-ovarian abscess, appendicitis, renal colic, etc.

History

  • Acute, unilateral lower abdominal pain
  • Association with sex, exercise, trauma, or luteal phase
  • Last menstrual period, vaginal bleeding, nausea, vomiting, shoulder pain (suggests hemoperitoneum)
  • Hypotension, dizziness, clamminess (if significant blood loss)
  • Past ovarian cysts, reproductive history

ALERT: Patients on anticoagulation/bleeding diathesis can have severe bleeding.

Physical Exam

  • Usually normal vitals, unless significant bleeding
  • Signs of blood loss: pallor, tachycardia
  • Significant lower abdominal/adnexal tenderness, possibly acute abdomen
  • Occasionally palpable adnexal mass (caution during bimanual exam)

Differential Diagnosis

  • Gynecologic: Ectopic pregnancy, ovarian torsion, tubo-ovarian abscess, degenerating fibroid, endometrioma, cystadenoma, hydrosalpinx, malignancy
  • Non-gynecologic: Appendicitis, diverticulitis, UTI, renal colic, GI/lower tract tumors

DIAGNOSTIC TESTS & INTERPRETATION

  • Rule out pregnancy in all reproductive-age women (urine β-hCG)
  • CBC: Monitor for anemia (hemorrhage); leukocytosis (infection)
  • Urinalysis/STD panel: Exclude UTI/PID
  • Type & screen if surgery/blood needed

Imaging: - Transvaginal ultrasound: First-line for diagnosis, assessing hemoperitoneum - Doppler flow: Confirms ovarian blood flow (excludes torsion) - CT/MRI: For equivocal US or when excluding other acute conditions

Procedures: - Laparoscopy: Diagnostic/therapeutic in unstable or undiagnosed cases

TREATMENT

General Measures

  • Most cases self-limited—pain resolves with conservative (outpatient) care
  • Conservative management: rest, observation, NSAIDs, oral narcotics as needed
  • 80% managed conservatively (even on anticoagulation, with team approach)

Medications

  • NSAIDs, oral narcotics—pain control
  • OCPs: Prevention of recurrent cysts (not effective for treating existing cysts)

Surgical/Other Interventions

  • Indications for surgery: Hemodynamic instability, large hemoperitoneum, failed conservative management, suspicion for malignancy
  • Laparoscopy preferred (diagnostic/therapeutic): faster recovery, less morbidity
  • Laparotomy: If unstable, untrained surgeons, or concern for malignancy
  • Aspiration: Not generally recommended; consider only in non-surgical high-risk patients

ISSUES FOR REFERRAL

  • OB/GYN: Adnexal mass in pregnancy, cyst >12 weeks or not resolving
  • Gynecologic oncology: Complex mass, ↑CA-125, symptoms of malignancy (ascites, septations, early satiety, pleural effusion)
  • General surgery: Suspected GI cause (appendicitis, diverticulitis)

ONGOING CARE & FOLLOW-UP

  • Stable, managed conservatively: Re-evaluate at 72 hours or sooner for worsening/new symptoms
  • Complete symptom resolution: Follow-up as needed; counsel about recurrence/prevention
  • Post-surgical: Follow-up 2 weeks after surgery
  • Incidental cysts: Follow-up based on cyst size

PREGNANCY CONSIDERATIONS

  • Most adnexal masses in pregnancy are benign—expectant management unless high risk for rupture/torsion or malignancy
  • MRI is safe for further characterization if needed

PATIENT EDUCATION

  • Most ovarian cysts are benign and self-limiting
  • Ectopic pregnancy must always be excluded
  • Outpatient management is safe for most; surgical intervention is rarely needed
  • OCPs may help prevent recurrence

COMPLICATIONS

  • Surgical complications
  • Reduced ovarian reserve—especially if >5 cm cyst or surgery needed
  • Impact on future fertility should be considered

ICD-10 Codes

  • N83.20 Unspecified ovarian cysts
  • N83.0 Follicular cyst of ovary
  • N83.1 Corpus luteum cyst

Clinical Pearls

  • Functional ovarian cysts are common, usually self-limiting
  • Ectopic pregnancy must always be ruled out
  • Painful ruptured cysts: Outpatient management with analgesia and follow-up
  • Combined hormonal contraception is preventive—not curative