Ovarian Cysts

Ovarian cysts are usually benign sacs that contain fluid or semisolid material. Although these cysts are usually small and produce no symptoms, they may require thorough investigation as possible sites of malignant change. Cysts may be singe or multiple (polycystic ovarian disease). Most ovarian cysts are physiologic, functional; that is they arise during the normal ovulatory process. Physiologic ovarian cysts include follicular cysts, theca-lutein cysts, which are commonly bilateral and filled with clear, straw-colored liquid, and corpus luteum cysts. Granulosa-lutein cysts, which occur within the corpus luterum, manifest as non-neoplastic enlargements of ovaries. They may appear early and may reach 2 to 2-1/2" [5 to 6cm] in diameter; however, they usually shrink during any time between puberty and menopause, including during pregnancy. The prognosis for benign ovarian cysts is excellent. The presence of a functional ovarian cysts does not increase the risk for malignancy.

Causes 
- Granulosa-lutein cysts : excessive accumulation of blood during hemorrhagic phase of menstrual cycle
- Theca-lutein cysts : hydatidiform mole, choriocarcinoma, hormone therapy (human chorionic gonadotropin[HCG) or clomiphene citrate).

Pathophysiology
Follicular cysts are generally very small and arise form follicles that either haven't ruptured or have ruptured and resealed before their fluid is reabsorbed. Luteal cysts develpo if a mature corpus luteum persists abnormally and continues to secrete progesterone. They consist of blood or fluid that accumulates in the cavity of the corpus luteum and are typically more symptomatic than follicular cysts. When such cysts persists into menopause, they secrete excessive amounts of estrogen in response to the hypersecretion of follicle-stimulating hormone and luteinizing hormone that normally occurs during menopause. 
Dermoid cysts are tumors of developmental origin consist of a fibrous wall lined with stratified epithelium and may contain hair follicles, sweat glands, sebaceous glands, nerve elements, and teeth.

Signs and symptoms
- Large or multiple cysts : mild pelvic discomfort, low back pain, dyspareunia, abnormal uterine bleeding
- Ovarian cysts with tortion : acute abdominal pain similar to that of appendicitis
- Granulosa-lutein cysts : in pregnancy unilateral pelvic discomfort, in nonpregnant women delayed menses, followed by prolonged or irregular bleeding. 

Treatment
- If cyst disappears spontaneously within one to two menstrual cycles - no treatment
- Persisting cyst indicates excision to rule out malignancy
- Functional cysts that that appear during pregnancy - analgesics 
- Theca - lutein cysts : elimination of hydatidiform mole, destruction of choriocarcinoma, discontinuation of HCG or clomiphene therapy
- Persistent or suspicious ovarian cyst : laparoscopy or exploratory laparotomy with possible ovarian cystectomy or oophorectomy, if necessary during pregnancy, optimal time is second trimester
- Ruptured corpus luteum cyst : culdocentesis to drain intraperitoneal fluid, surgery for ongoing hemorrhage.
 ​
+ Polycystic ovarian syndrome is a metabolic disorder characterized by multiple ovarian cysts. About 22% of the women in the Untied States have the disorder, and about 50% to 80% of these women are obese. Among those who seek treatment for infertility, more than 75% have some degree of polycystic ovarian syndrome, usually manifested by anovulation alone.

+ A general feature of all anovulation syndromes is a lack of pulsatile release of gonadotropin-releasing hormone. Initial ovarian follicle development is normal. Many small follicles begin to accumulate because there's no selection of a dominant follicle. These follicles may respond abnormally to the hormonal stimulation, causing an abnormal pattern of estrogen secretion during the menstrual cycle.


Pelvic Inflammatory Disease

Pelvic inflammatory disease(PID) is any acute, subacute, recurrent, or chronic infection of the oviducts and ovaries, with adjacent tissue involvement. It includes inflammation of the fallopian tubes (salpingitis) and ovaries (oophoritis), which can extend to the connective tissue lying between the broad ligaments (parametritis). Early diagnosis and treatment prevent damage to the reproductive system. Untreated PID may cause infertility and may lead to potentially fatal septicemia and shock. PID may also lead to complication that  include chronic pelvic pain and formation of scar tissue (adhension).

Causes
- Infection with aerobic or anaerobic organisms, such as : Neisseria gonorrhoeae and Chlamydia trachomatis (most common), staphylococci, streptococci, diphtheroids, Pseudomonas, Escherichia coli
- Predisposing conditions : Conization or cauterization of the cervix, Insertion of an intrauterine device, Use of a biopsy curette or an irrigation catheter, Tubal insufflation, Abortion, Pevic surgery, Infection during or after pregnancy.

Pathophysiolgy
Normally, cervical secretions have a protective and defensive function. Conditions or procedures that alter or destroy cervical mucus impair this bacteriostatic mechanism and allow bacteria present in the cervix ar vagina to ascend into the uterine cavity. Uterine infection can also follow the transfer of contaminated cervical mucus into the endometrial cavity through the bloodstream or from drainage from a chronically infected fallopian tube, a pelvic abscess, a ruptured appendix, diverticulitis of the sigmoid colon, or other infectious focus. Uterine infection can result from contamination by one or several common pathogens or may follow the multiplication of normally nonpathogenic bacteria in an altered endometrial environment. Bacterial multiplication is most common during parturition because the endometrium is atrophic, quiescent, and not stimulated by estrogen.

Signs and symptoms
- Profuse, purulent vaginal discharge
- Low-grade fever, malaise
- Lower abdominal pain
- Severe pain on movement of cervix or palpation of adnexa

Treatment
- Antibiotic therapy beginning immediately after culture specimens are obtained and reevaluated as soon as laboratory results are available (usually after 24 to 48 hours). Infection may become chronic if treated inadequately. PID therapy reqimens should provide broad-spectrum coverage of likely etiologic pathogenic : C. trachomatis, N. gonorrhoeae, anaerobes, grain-negative rods, and streptococci
- Adequate drainage if pelvic abscess forms
- Ruptured abscess (life-threatening complication) : total abdominal hysterectomy with bilateral salpingo-oophorectomy, laparoscopic drainage with preservation of the ovaries and uterus appears to hold promise. 


Important Points in the Differentiation of  Gynecological Disorders

The Key signs and symptoms in diagnosing are those relating to menstruation, leucorrhoea, pregnancy and labor. Systemic signs and symptoms are secondary in importance and should be disregarded if they conflict with the key symptoms.

Deficiency-Type Patterns

Qi Deficiency
Clinical manifestations include a shortened menstrual cycle with profuse thin, pinkish flow, uterine bleeding, uterine prolapse, persistent pale lochia following childbirth and spontaneous secretion of milk after delivery.

Blood Deficiency 
Clinical manifestations include a prolonged menstrual cycle with scanty thin, pinkish flow, amenorrhoea, post menstrual abdominal pain, miscarriage and insufficient lactation. 

Spleen Deficiency 
Clinical manifestations include persistent uterine bleeding, a profuse thin, odorless, white vaginal discharge, pernicious vomiting and oedema during pregnancy.

Kidney Deficiency 
The manifestation of Kidney Yin Deficiency include a scanty red  or dark menstrual flow, irregular menstruation, uterine bleeding, amenorrhea, miscarriage and eclampsia or threatened eclampsia.

The manifestation of Kidney Yang Deficiency include a thin, pinkish menstrual flow, irregular menstruation, uterine bleeding, a profuse thin vaginal discharge and infertility or miscarriage.


Excess-Type Patterns

Qi Stagnation
Clinical manifestations include an irregular menstrual cycle, hesitant and painful menstrual menstruation, pelvic inflammation, pernicious vomiting, palpable abdominal masses and retarded secretion milk.

Blood Stagnation
Clinical manifestations include a prolonged menstrual cycle, dysmenorrhoea, uterine bleeding, amenorrhea, pelvic inflammation, palpable abdominal masses, persistent purple lochia with clots and boring abdominal pain which is aggravated by pressure.

Phlegm-Damp
Clinical manifestations include a profuse vaginal discharge, amenorrhoea, infertility, pernicious vomiting and oedema during pregnancy.


Heat Patterns

Excess-type Heat Patterns
Clinical manifestations include a shortened menstrual cycle with profuse deep-red flow, epistaxis during menstruation, uterine bleeding, vaginal bleeding during pregnancy and thick, deep-yellow leucorrhoea.

Deficiency -type Heat Patterns
Clinical manifestations include a shortened menstrual cycle with bright-red flow, or a prolonged dribbling flow, hypertension during pregnancy and threatened eclampsia.


Cold Patterns

Deficiency-type Cold patterns
Clinical manifestations include a prolonged menstrual cycle with scanty pinkish flow, dysmenorrhoea, amenorrhoea, a watery vaginal discharge, pernicious vomiting, infertility, palpable abdominal masses and lingering abdominal pain which is alleviated by warmth and pressure.

Excess -type Cold Patterns
Clinical manifestations include a prolonged menstrual cycle with scanty dark-red flow, infertility, palpable abdominal masses, dysmenorrhoea, amenorrhoea and abdominal colic which is alleviated by warmth.




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