Case Write-Up

Obstetrics and Gynecology Clerkship 1

Case Write-Up
Case 2 – Ovarian Cyst
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Obstetrics and Gynecology Clerkship 2

Patient Information:
 Name: M.B
 Gender: Female
 Age: 26
 Date of Birth: 22/7/1996
 Nationality: Ethiopian
 Date of Admission: 5/1/2023
 Insurance: Daman Basic

Chief Complaint: 26 year old female presenting with lower left quadrant pain that started 6
months ago.

History of Present Illness:

M.B is a 26-year-old female, known case of anemia, who came to the ER complaining of lower
left quadrant pain that she had been suffering from for 6 months. The pain had an insidious onset
and started 6 months ago. It is localized to the left lower quadrant and does not radiate. The pain
is sharp and has a fluctuating intensity, the patient said it comes and goes. M.B rated the pain a
5/10. An exacerbating factor is her menstrual cycle. Nothing relives the pain, the patient tried
taking Panadol and ibuprofen, but they do not relieve the pain. Associated symptoms are
menorrhagia during her period. The pain has become more severe as time went on. M.B also
complains of fatigue and decreased energy. There is no fever, weight loss, headache, chest pain,
SOB, palpitations, decreased urine output, changes in bowel movement.

Review of System:
Constitutional symptoms: Fatigue, decreased activity, no fever, no weight loss
Skin symptoms: No rash
ENMT symptoms: No ear pain, no sore throat, no nasal congestion.
Respiratory symptoms: No shortness of breath, no cough
Cardiovascular symptoms: No chest pain, no palpitations.
Gastrointestinal symptoms: No vomiting, no diarrhea, no constipation.
Genitourinary symptoms: No hematuria, no vaginal discharge.
Musculoskeletal symptoms: No back pain, no Muscle pain, no Joint pain.
Neurologic symptoms: No headache, no dizziness, no altered level of consciousness
Psychiatric symptoms: No anxiety, no depression, no sleeping problems.
Past Gynecological history :
 Menarche: patient does not remember
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 Menses:
o Regular
o Last 4 days
o Heavy bleeding (mainly first 2 days)
o Accompanied by pain (dysmenorrhea)
o No intermenstrual bleeding
 LMP: 26/12/2022
 Never been sexually active
 No history of gynecological medical problems

Past Obstetric history:

 Nulliparous

Medication:
 No current medication
 Not using any herbal medication

Allergies:
 No allergies

Past Medical history:

 History of menorrhagia
 Known case of anemia caused by the menorrhagia
 1 past admission on 14/11/2022 for anemia (Hb: 55)
o On this same admission she had a blood transfusion of 2 units of packed
RBC

Past Surgical history:

 No previous surgeries

Family history:
 No family history diabetes or hypertension
 No family history of gynecological cancer/ disease
 No family history of genetic diseases

Social history:
 Single
 Occupation: full time housemaid
 Diet: doesn’t eat meat or chicken
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 No smoking, alcohol, or recreational drug use

Summary: M.B is a 26-year-old single female who presented to the ER with left lower quadrant
pain for 6 months, associated with fatigue. She had history of menorrhagia during her periods
and is a known case of anemia.

Physical Examination:
Vitals:

 Temperature: 36.7 degC

 Respiratory Rate: 18 br/min
 Peripheral Pulse Rate: 71 bpm
 Systolic blood Pressure: 130 mmHg
 Diastolic blood pressure: 82 mmHg
 Oxygen Saturation: 99%
 Weight: 58.9 kg
 Height: 161cm
 BMI: 22.72 kg/m2

General Condition:

 The patient was laying in the bed alert and oriented, in moderate distress due to the pain.
The patient’s sponsor was with her sitting at the bedside
 Eye: Pupils are equal and reactive to light, normal vision
 Neck: No lymphadenopathy, no masses.
 Respiratory: No chest pain, breathing comfortably
 Cardiovascular: Normal rate, Regular rhythm, no palpitations
 Gastrointestinal: Soft, tenderness in the left lower quadrant, non-distended and no
guarding, mass palpable in the left lower quadrant
 Genitourinary: No costovertebral angle tenderness, No inguinal tenderness.
 Neurologic: no diplopia, normal reflexes, no clonus

Abdominal Examination:

 Inspection: the abdomen is flat, not distended, no scars, masses, lesions

 Palpation: Abdomen is soft, non-distended, no guarding. There is localized tenderness
over the lower left quadrant.
 Auscultation: normal bowel sounds present
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Vaginal examination: Bimanual and speculum examination were not done because the
patient is a virgin.

Investigations:

- Relevant Lab investigations

Test Result/interpretation
Complete blood count
RBC 3.99 x 1012 /L
Hb 110 g/L (LOW)
WBC 3.99 x 109 /L (LOW)
Platelet 292 x 109 /L
Blood type
ABO Rh A POS
Antibody screen No antibodies detected
Tumor markers (30/11/2022)
CEA 0.68 mcg/L
CA 19-9 18.1 units/mL
CA 125 <2.0 units/mL

- Imaging (Ultrasound):
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 Ultrasound was done for history of menorrhagia and suspicion of an ovarian mass/cyst
results showed:
o Anteverted uterus with 1.0cm endometrial thickness.
o Endometrium is thickened to 2.0cm to 2.2cm with slightly hypoechoic
appearance within the entire endocavitary
o Right ovary with two follicles measuring 1.8cm and 2.0cm.
o 10.3 x 5.8 x 7.2cm anechoic cystic lesion with thick complete septa noted in
the left adnexa, no obvious internal echoes seen, origin could be ovarian.
o Peripheral color flow noted.
o Trace of fluid in cul-de-sac.

Differential Diagnosis for Ovarian mass:

M.B has an adnexal mass which was seen in the ultrasound and felt on physical examination.
The nature of this mass could be benign or malignant.

Benign Ovarian masses (most likely in our case):

1. Follicular cyst of the ovary (most common ovarian mass in young women)
a. Develops when a Graafian follicle does not rupture and release the egg
(ovulation) but continues to grow
b. Eventually develops into a large cyst (∼ 7 cm)
c. US findings: single, anechoic, no internal doppler flow (the same finding’s on
our patient’s US)
2. Corpus luteum cyst
a. Enlargement and buildup of fluid in the corpus luteum after failed regression after
the release of an ovum
b. Produces progesterone and is associated with progesterone-only contraceptive
pills and ovulation-inducing medication
c. US findings: unilocular, thick walls, peripheral vascularity, intracystic echogenic
debris may be present
d. Our patient has no history of progesterone only OCP or ovulation inducing
medication. In addition, this cyst is common during pregnancy. None of these
features apply to our patient
3. Theca lutein cysts
a. Multiple cysts that typically develop bilaterally
b. Result from  exaggerated stimulation of the theca interna cells due to excessive
amounts of circulating gonadotropins such as β-hCG (resolves when β-hCG
normalizes)
c. Strongly associated  gestational trophoblastic disease and multiple gestations
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d. US: bilateral, multilocular cysts, thin wall, fluid filled + may have solid
component
e. Our patient’s cyst is unifocal, patient is menstruating normally (no gestational
trophoblastic disease, not pregnant)
4. Dermoid cyst
5. Chocolate cyst (Endometrioma)
6. Mucinous cystadenoma
7. Serous cystadenoma
8. Tubo-ovarian abscess
Malignant ovarian masses: this is a less likely possibility in our patient since these tumors mostly
occur in women >55 years. Moreover, the US findings of such masses tend to more often be
multilocular, have solid components and in some cases show signs of invasion. Furthermore, the
tumors markers measured in M.B were all normal (no elevation), even though they are mainly
used for follow up and treatment response but tumor markers like CA-125 can be elevated in
around 80% of epithelial ovarian tumors (most common ovarian malignancy).
1. Epithelial ovarian tumors
a. Cystadenoma
b. Brenner tumor
c. Cystadenocarcinoma
d. Endometrioid carcinoma
e. Clear cell tumor:
2. Germ cell ovarian tumors (Tumor markers)
a. Dysgerminoma > LDH & b-hCG
b. Yolk sac tumor > AFP
c. Immature teratoma > AFP, LDH , CA-125
d. Choriocarcinoma > b-hCG
e. Embryonal carcinoma > AFP, b- hCG
3. Sex cord and stromal ovarian tumors

Final Diagnosis:
 Not yet determined
 M.B has been booked for surgery to resect the ovarian mass and the mass will be sent
for pathological examination to determine the nature of the mass.

Treatment Plan:
 Admit the patient
 Give analgesics for pain management:
o IV acetaminophen (1000mg every 6 hours)
 Book for elective ovarian cystectomy (on 3/2/2023):
o The nature of the mass seen on the US and the negative tumor markers make it
more likely to be benign
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o If the cyst is large (>10 cm), if the patient is symptomatic, or if there is concern
for torsion, it should be removed  these are all features that apply to our patient
Patient counselling:
 The nature of the treatment for our patients means that she will have the cyst removed
without removing the ovary as a fertility preserving approach considering that she is
young and nulligravida. Even though the patient’s fertility will be preserved it is
important to explain the nature of the procedure with her.
 It is important also to explain the importance of doing the surgery with relation to the risk
of ovarian torsion and the complications of the surgery.

Evidence based decision making: (Dose having an ovarian cyst effect

fertility?)
1. Some ovarian cysts can affect the fertility in some females, but it all depends on the type
of cyst that the patient has. The most common type of ovarian cysts that are linked as a
cause of infertility is polycystic ovarian syndrome.
2. While surgery allows for a histological diagnosis, helping to exclude possible malignant
tumors, the ovarian reserve can be reduced after cystectomy, reducing fertility outcomes.
3. A retrospective study was done in Germany from 2002 to 2011 on 550 women with
asymptomatic ovarian cysts. 328 of those women underwent an ovarian cystectomy while
the rest were treated conservatively. Based on the outcome of the whole cohort’s IVF
treatment after they received their respective treatments for the cysts it was postulated
that surgery does not seem to worsen fertility outcomes as much as the presence of an
ovarian cyst does.
4. In symptomatic women, an ovarian cystectomy does not significantly reduce fertility
outcomes. Patients who are considering a surgical approach should however be carefully
advised beforehand about how it could potentially impair their ovarian reserve. On the
other hand, asymptomatic older women who have lower ovarian reserves are more likely
to benefit from more conservative treatment strategies.

Resources:
Approach to Patient with adnexal mass:
https://www-uptodate-com.uaeu.idm.oclc.org/contents/approach-to-the-patient-with-an-adnexal-
mass?search=ovarian%20cyst
%20treatment&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=
1#H355087288

Ovarian Mass – Amboss https://next.amboss.com/us/article/aO0QIT?q=ovarian%20mass

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Mobeen S, Apostol R. Ovarian Cyst. [Updated 2022 Jun 13]. In: StatPearls [Internet]. Treasure
Island (FL): StatPearls Publishing; 2022 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK560541/]

Gomez, Ruth et al. “Fertility After Ovarian Cystectomy: How Does Surgery Affect IVF/ICSI
Outcomes?.” Geburtshilfe und Frauenheilkunde vol. 79,1 (2019): 72-78. doi:10.1055/a-0767-
6722