J Pediatr Adolesc Gynecol (2004) 17:297–298

In Training

Ovarian Cysts

Editor: Julie StricklandAuthor: Claire Templeman, MDLos Angeles, California, USA

Introduction

The presence of an ovarian cyst in a child provokesanxiety in parents and often prompts a physician visit.An understanding of the normal physiology of theovary is essential to prevent inappropriate intervention.This outline will highlight some of the managementissues confronting practitioners who manage pediatricand adolescent gynecology patients with ovarian cysts.

Antenatal and Neonatal Ovarian Cysts

DiagnosisBased on ultrasound data, the incidence of antenataldiagnosed ovarian cysts is estimated at 1 in 2625female births. However, data from stillbirth and neo-natal death autopsies suggests that the incidence ofcysts under 1 cm may be as high as 30% of all femalebirths. Fetal ovarian cysts are typically functional be-cause the ovary is stimulated by fetal gonadotropins,maternal estrogen, and placental chorionic gonadotro-phin (HCG). The diagnosis is made almost exclusivelyin the third trimester of pregnancy and improvements inultrasound technology have resulted in this diagnosisbeing made more commonly. The differential diagno-sis includes: mesenteric and urachal cysts, mesonephriccysts, hematometra with vaginal agenesis, and gastro-intestinal duplication cysts. Therefore, to confirm thisdiagnosis, antenatal ultrasound exam must detail fe-male sex, a normal urinary tract (kidneys, ureter, andbladder), and a normal gastrointestinal system (stom-ach, large and small bowel).

ManagementSince the incidence of malignancy in neonatal cystsapproaches zero, postnatal management for asymp-tomatic, simple cysts involves observation with regularultrasound review. Expected cyst resolution is 50% by

� 2004 North American Society for Pediatric and Adolescent GynecologyPublished by Elsevier Inc.

1 month, 75% by two months, and 90% by threemonths of age. Postnatal surgical intervention isreserved for cyst persistence, enlargement, symp-toms, or an echogenic (complex) appearance on ultra-sound examination. These factors are suggestive ofa cyst complication such as hemorrhage or torsion.

Prepubertal Ovarian Cysts

Incidence and PathogenesisDuring both infancy and childhood the ovaries areactive. Cysts in this age group are the result of gonado-trophin stimulation producing follicular activity. Theirincidence decreases in early childhood and increasesas puberty approaches. Ovarian cysts (mean � 7.5mm)have been demonstrated in up to 80% of girls between1 and 24 months and 68% of girls between 2 and 10years. Of these, 90% are 9mm or less in size with anovarian volume of 1 cm3.

DiagnosisOccasionally ovarian cysts are functional, secreting es-trogen resulting in vaginal bleeding or breast develop-ment. This clinical presentation creates concern forprecocious puberty. If ovarian cysts are associated withlarge cafe au lait spots, and vaginal bleeding, the syn-drome of McCune Albright involving gonadotrophin-independent hormone secretion should be considered.Enlarged, multicystic ovaries should prompt investiga-tion for hypothyroidism.

TreatmentIn both these conditions, treatment should be directedtowards the underlying medical condition and not theovarian cyst. However, in the event of ovarian torsionor a solid ovarian mass in this age group, primarymanagement of the ovarian mass is indicated.

1083-3188/04/$22.00doi:10.1016/j.jpag.2004.05.006

298 Templeman: Ovarian Cysts

Adolescent Ovarian Cysts

DiagnosisThe early post-menarcheal period is often associatedwith anovulation. Ovarian cysts in this age group maybe the result of anovulation or failure of involution.These cysts are often detected on a pelvic ultrasoundperformed for pain and typically will resolve sponta-neously. However, if there is concern over the etiology,follow-up ultrasound 4 to 6 weeks later is helpful. Per-sistent ovarian cysts raise the possibility of paratubalmasses, benign tumors, endometriomas, complicationsof pelvic inflammatory disease including tuboovarianabscess or hydrosalpinx, and rarely germ cell malig-nancies. The possibility of pregnancy must always beconsidered in a teenager with an adnexal mass.

Each of these conditions may have accompanyingsymptoms, making history and examination importantin determining likely etiology.

ManagementManagement will depend upon the diagnosis however;preservation of ovarian tissue should be the primaryconcern. This approach is reasonable given a reportedovarian malignancy rate of 4.4% in girls between theages of 15 and 21 years.

The presence of abdominal pain in a patient withan ovarian mass should increase concern for ovarian

torsion. This diagnosis should still be consideredeven in the presence of flow on Doppler examination.Once confirmed at surgery, detorsion and preserva-tion of the ovary should be pursued unless the ovaryis obviously necrotic.

Conclusions

Ovarian cysts in childhood and adolescence are mostcommonly functional and therefore can be managedconservatively. The incidence of malignancy is smallbut should be considered with persistent, complex ap-pearing cystic or solid ovarian masses.

Additional Reading

Strickland JS: Ovarian cysts in neonates, children and adoles-cents. Curr Opin Obstet Gynecol 2002; 14:459

Templeman C, Fallat ME, Blinchevsky A, et al: Noninflam-matory ovarian masses in girls and young women. ObstetGynecol 2000; 96:229

Breen JL, Maxson WS: Ovarian tumors in children and adoles-cents. Clin Obstet Gynecol 1977; 20:607

Goldstein DP, Laufer MR: Benign and malignant ovarianmasses. In: Pediatric and Adolescent Gynecology. Edited bySJ Emans, MR Laufer, DP Goldstein. Philadelphia, Lippincott-Raven, 1998, pp 553–585.