User:R. Dela Cruz, UCSF/Theca lutein cyst

Theca lutein cyst
Theca lutein cyst is a type of bilateral functional ovarian cyst filled with clear, straw-colored fluid. These cysts result from exaggerated physiological stimulation (hyperreactio luteinalis) due to elevated levels of beta-human chorionic gonadotropin (beta-hCG) or hypersensitivity to beta-hCG.

Theca lutein cysts are associated with gestational trophoblastic disease (molar pregnancy), choriocarcinomas and multiple gestations. In some cases these cysts may also be associated with diabetes mellitus and alloimmunisation to Rh-D. They have rarely been associated with chronic kidney disease (secondary to reduced hCG clearance) and hyperthyroidism (given the structural similarity with thyroid stimulating hormone (TSH)).

Usually, these cysts spontaneously resolve after the molar pregnancy is terminated. Rarely, when the theca-lutein cysts are stimulated by gonadotropins, massive ascites can result. In most cases, however, abdominal symptoms are minimal and restricted to peritoneal irritation from cyst hemorrhage. Surgical intervention may be required to remove ruptured or infarcted tissue

Physiology
Theca Lutein Cysts commonly form due to an elevated level of chorionic gonadotropin, a lutenizing hormone othrewise known as beta human chorionic gonadotropin (beta-hCG). Theca Lutein cysts are occur almost exclusively in pregnancy and have an increased incidence in pregnancies complicated by gestational trophoblastic disease. But additionally, Theca Lutein Cysys may develop in conditions such as placentomegaly that may accompany diabetes, anti-D alloimmunization, mutifetal gestation, and individausls undergoing fertility treatment including chorionic gonadotropin or clomiphene therapy and are often seen in patients with choriocarcinoma or hydatidiform mole and in patients undergoing fertility treatments including chorionic gonadotropin or clomiphene therapy. Rarely these type of cysts are present in normal pregnancy. But in the event they do occur in an otherwise uncomplicated pregnancy they are most likely associated with elevated levels of hCG.

Characteristics
Theca Lutein Cysts are an uncommon type of follicular cysts that reflect a benign ovarian lesion of a physiological exaggeration of follical stimulation often termed as hyperreactio lutealis,. Theca Lutein Cysys are lined by theca cells that may or may not be luteinized or have granulosa cells. They are usually bilateral and are filled with clear, straw-colored fluid. Overall these cysts can be characterized by the luteniziation and hypertrophy of their theca interna layer. The resulting bilateral cystic ovaries are variably enlarged with multiple smooth-walled cysts forming and ranging in size from 1 to 4 cm in diameter.

Symptoms
Usually asymptomatic and minimal, hemorrhage into the cysts can cause acute abdominal pain in addition to a sense of pelvic heaviness or aching may be described.

Maternal virilization may be seen in up to 30 percent of women, however, virilization of the fetus has only rarely been reported. Maternal findings that include temporal balding, hirsutism, and clitoromegaly are associated with massively elevated levels of androstenedione and testosterone.

In most cases, when the presence of a rupture of the cyst may result in intraperitoneal bleeding, in this case symptoms maymimics the signs of a hemorrhagic corpus luteum cyst. Additionally, continued signs and symptoms of pregnancy, especially hyperemesis and breast paresthesias, are reported in cases of histologically proven theca lutein cysts.

Diagnoses
Theca Lutein cysts are detected and diagnosed during a pelvic examination followed by a thorough evaluation. The evaluation includes a collection of the person's age, family history, and previous histories of ovarian or breast cancers. A full physical examination is performed to check for tenderness, peritoneal signs, and a frozen pelvis. Further work up involves imaging, such as a pelvic ultrasound or CT scan. Labs are also collected to evaluate leukocytes and tumor markers, such as beta-hCG and cancer antigen 125 (CA125).

Risk Factors
Oral contraceptives containing only progestin can increase the occurrence of follicular cysts. The use of levonorgestrel-releasing intrauterine system (LNG-IUS) or progestin implants are also associated with the occurrence of follicular cysts.

Women who are of pre- and postmenopausal age with breast cancer and are being treated with tamoxifen are at increased risk for the development of benign ovarian cysts. However, many of these cysts are functional and can resolve with time.

Smoking can cause an increased risk for functional cysts.

Treatments
Theca Lutein cysts usually spontaneously resolve on their own after the source of hormonal stimulation is removed such as the removal of the molar pregnancy, removal of the choriocarcinoma, stopping fertility therapy or after delivery. It may take months for the cysts to resolve on their own. Treatment for theca lutein cysts is very conservative due to their benign nature and ability to disappear after the removal of hormonal stimulation.

Surgical treatments may be needed for serious complications due to Theca Lutein cysts. Surgery is considered an option when signs of torsion and hemorrhage are present. Removal of the ovaries may also be performed if large areas of tissue continue to infarct despite resolving the torsion.

Surgery Due to Ovarian Torsion
Ovarian cysts such as Theca Lutein cysts can cause ovarian torsion. The cysts cause an imbalance in the ovaries resulting in the twisting of the fallopian tubes. This restricts blood flow to the ovaries which can cause infarction of the tissue. Thus, this requires prompt surgical treatment. Detorsion surgery is done laparoscopically, often trying to keep the ovaries functional.

Surgery Due to Hemorrhage
Theca lutein cysts have the potential to rupture and hemorrhage resulting in acute abdominal pain as well as intraperitoneal bleeding. Laparoscopic surgery is performed to control bleeding and remove unwanted blood clots and fluid. The cyst is then removed surgically. A laparotomy may need to be performed if the cyst is large or more complicated.