History and Examination of a Patient with Ovarian Cyst

INTRODUCTION

HISTORY

1. Presenting Complaint

• Lower abdominal or pelvic pain (dull, aching, or sharp)
• A feeling of lower abdominal fullness or "pressure"
• Incidentally detected swelling on examination or ultrasound
• Menstrual irregularity
• Sudden severe pain (suggests complication - torsion or rupture)

2. History of Presenting Complaint (HOPI)

• Abdominal distension or bloating - persistent bloating is a symptom of significance, particularly for larger cysts or malignancy
• Urinary symptoms - frequency or urgency from bladder compression by a large cyst
• Bowel symptoms - constipation or altered bowel habit from pressure on the rectum
• Nausea and vomiting - prominent in torsion due to autonomic reflex responses
• Dizziness or syncope - suggests significant hemoperitoneum (ruptured corpus luteum cyst)

"The onset of the torsion and subsequent abdominal pain frequently coincides with activities such as lifting, exercise, or intercourse. Autonomic reflex responses (e.g., nausea, emesis, tachycardia, and apprehension) are usually present." - Berek & Novak's Gynecology

3. Menstrual History

• LMP (Last Menstrual Period) - essential to:
  • Exclude pregnancy (ectopic pregnancy is a major differential)
  • Time the cyst with the menstrual cycle (functional cysts often appear mid-cycle or in the luteal phase)
  • In S. Das's words: "History of the last menstrual period is very important and must always be asked"
• Cycle regularity - irregular cycles suggest PCOS (polycystic ovarian syndrome)
• Dysmenorrhoea - painful periods suggest endometrioma ("chocolate cyst")
• Menorrhagia or metrorrhagia - heavy or irregular bleeding
• Amenorrhoea - must always prompt a pregnancy test; corpus luteum cysts can delay menses
• Dyspareunia - pain during intercourse, suggestive of endometrioma or large ovarian cyst

4. Obstetric History

• Gravida, Para, Abortus (GPA status)
• History of infertility (related to PCOS or endometriosis)
• Previous ectopic pregnancies (alters differential diagnosis significantly)
• Molar pregnancy history (associated with theca lutein cysts)

5. Contraceptive History

• Use of oral contraceptive pills (OCPs): OCPs suppress ovulation and reduce the risk of functional cysts
• Clomiphene citrate or gonadotropin use (ovulation induction): significantly increases risk of functional and theca lutein cysts
• IUCD (intrauterine contraceptive device): may be associated with pelvic inflammatory disease (important differential)

6. Past Medical and Surgical History

• Previous ovarian cysts - history of a known lump clinches diagnosis of twisted ovarian cyst (S. Das)
• Previous pelvic or abdominal surgery
• Known endometriosis
• History of malignancy (breast, colon, endometrial cancer increase suspicion for ovarian malignancy)
• Bleeding disorders or anticoagulant use (increases risk of hemorrhagic corpus luteum rupture)
• Clotting disorders

7. Family History

• Ovarian cancer - first-degree relatives with ovarian cancer significantly raise risk (BRCA1/BRCA2 mutations)
• Breast cancer, endometrial cancer, colorectal cancer (Lynch syndrome / hereditary cancer syndromes)
• "A personal and family medical history is helpful in detecting individuals at increased risk for the development of ovarian cancer" - Berek & Novak's Gynecology

8. Review of Systems (relevant)

• Fatigue, unexplained weight loss (malignancy)
• Hirsutism, acne, virilisation (PCOS or androgen-secreting tumour)
• Precocious puberty in a child (granulosa cell tumour - oestrogen-secreting)
• Back pain, leg swelling (large pelvic mass compressing pelvic veins)
• Shoulder tip pain (hemoperitoneum - diaphragmatic irritation)

9. Social History

• Smoking: associated with increased risk of functional ovarian cysts
• Marijuana use: similarly associated
• Sexual history (relevant for ruling out PID / tubo-ovarian abscess)

EXAMINATION

General Examination

"Orthostasis resulting from hypovolemia is present only when there is intravascular volume depletion, such as with a hemoperitoneum." - Berek & Novak's Gynecology

Abdominal Examination

• Abdominal distension (large cyst; ascites with malignancy)
• Visible mass in hypogastrium or lower abdomen (large ovarian cysts can rise above the umbilicus)
• Umbilical changes (Cullen's sign - bluish discolouration, rare, seen in massive hemoperitoneum)
• Caput medusae, distended veins (massive tumour compressing IVC)
• Scars from previous surgery

• Begin away from the site of pain
• A large uncomplicated ovarian cyst presents as a smooth, cystic, rounded, mobile mass in the lower abdomen or hypogastrium
• Characteristics of the mass:
  • Site: hypogastric / iliac fossa (right or left)
  • Size: small functional cysts are intrapelvic and not palpable; large cysts may extend above the umbilicus
  • Surface: smooth (benign) vs. nodular (malignant)
  • Consistency: cystic (fluid-filled), may be soft or fluctuant
  • Margins: well-defined (benign) vs. ill-defined (malignant, adherent)
  • Mobility: freely mobile in different directions (characteristic of ovarian cyst)
  • Tenderness: non-tender when uncomplicated; acutely tender with torsion, rupture, or infection
  • Movement with respiration: ovarian cysts do NOT move with respiration (unlike liver or spleen)
• In torsion: "tense, tender and cystic with definite smooth margin moving in the lower abdomen" (S. Das); overlying rigidity may mask the lump
• In rupture with hemoperitoneum: generalized tenderness, guarding, and rebound tenderness

• Cystic mass is typically dull to percussion
• Shifting dullness: positive when there is significant ascites (large tumour or hemoperitoneum)
• The dullness of an ovarian cyst is central (compared to flanks - ascites), and the central area of resonance with flanks being dull shifts when the patient turns (to differentiate from ascitic fluid)

• Reduced or absent bowel sounds with peritonitis
• Normal bowel sounds in uncomplicated cyst

Per Speculum Examination

• Inspect the cervix and vaginal walls
• Note any discharge (cervicitis, PID)
• Cervical os: open (miscarriage) or closed
• Bluish discolouration of cervix - Chadwick's sign of pregnancy (important differential)
• Take high vaginal and endocervical swabs if PID is a differential

Bimanual (Per Vaginal) Examination

• A mass is palpable in the adnexal area, separate from the uterus
• Freely mobile, smooth, cystic
• Non-tender unless complicated (torsion, rupture, infection)
• Large pelvic mass on bimanual examination is an important sign of adnexal torsion (Berek & Novak's)
• If the cyst is small (entirely intrapelvic), abdominal examination may be negative but bimanual will reveal the adnexal mass

"If it be small enough to be situated entirely within the pelvis the lump will not be palpable abdominally. Vaginal examination in this case may be helpful." - S. Das, Manual on Clinical Surgery

• Ovarian cyst: separate from uterus, moves independently; uterus can be felt as a distinct structure
• Uterine fibroid: moves with the uterus; cannot separate from uterus on bimanual

Rectovaginal Examination (if required)

• Useful to palpate masses in the pouch of Douglas
• Helps assess posterior pelvic wall fixity (suggestive of malignancy)
• Useful in endometriosis: nodularity of the uterosacral ligaments

SUMMARY: KEY HISTORY AND EXAMINATION FEATURES BY TYPE

DIFFERENTIAL DIAGNOSIS OF PELVIC MASS (to keep in mind)

• Uterine - fibroid (moves with uterus), pregnancy, cornual pregnancy
• Fallopian tube - ectopic pregnancy (positive beta-hCG, amenorrhoea, shock), PID / tubo-ovarian abscess (fever, vaginal discharge, CMT)
• Ovarian - functional cyst, endometrioma, dermoid, epithelial tumour
• Bowel - appendiceal mass, diverticular abscess, carcinoma of colon
• Urinary - full bladder (always ask patient to void before examination), pelvic kidney
• Retroperitoneal - sacral meningocele, lymph node mass

COMPLICATIONS TO LOOK FOR (Acute Presentations)

1. Torsion - sudden severe pain, vomiting, tachycardia, tender adnexal mass on bimanual
2. Rupture / haemorrhage - sudden pain, peritoneal signs, signs of haemodynamic instability
3. Infection - fever, discharge, cervical motion tenderness
4. Malignant change - ascites, fixed mass, weight loss, nodular mass, raised CA-125

IMPORTANT PRACTICAL POINTS FOR MBBS STUDENTS

1. Always ask LMP first in any woman of reproductive age with abdominal pain - to exclude ectopic pregnancy before anything else
2. Always ask patient to void before pelvic/abdominal examination - a full bladder mimics a pelvic mass
3. Pelvic examination is not sensitive or specific for detecting pelvic masses, especially in obese patients; ultrasound is much more reliable (Textbook of Family Medicine)
4. Never forget to ask about family history of ovarian/breast cancer (genetic risk)
5. Bimanual examination remains essential - note whether the mass is separate from the uterus, its mobility, and whether there is cervical motion tenderness
6. In a woman with sudden lower abdominal pain + vomiting + known ovarian cyst - think torsion until proven otherwise
7. In a woman with sudden pain + dizziness + delayed menses - think ruptured corpus luteum or ectopic pregnancy