Enlarged Ovaries with Follicular Cysts and Stromal Changes: Causes and Evaluation

Enlarged ovaries with multiple follicular cysts and increased stromal cellularity suggest several diagnostic possibilities:

Most Common: Polycystic Ovary Syndrome (PCOS)

• Rotterdam criteria: 2 of 3 – oligo/anovulation, hyperandrogenism (clinical/biochemical), polycystic ovaries on US (≥20 follicles 2–9mm or volume >10 mL)
• Increased stroma = hyperthecosis (stromal luteinization) from androgen excess
• Associated: insulin resistance, obesity, infertility, metabolic syndrome

Other Causes

• Hormonal imbalances: Thyroid dysfunction, hyperprolactinemia, Cushing's syndrome, congenital adrenal hyperplasia
• Ovulation induction: Gonadotropins, clomiphene, letrozole → multiple follicular recruitment
• Functional cysts: Physiologic follicular cysts (usually unilateral, resolve spontaneously)
• Neoplasms: Granulosa cell tumor (estrogen-producing), Sertoli-Leydig (androgen), metastatic disease (rare)
• Pregnancy: Corpus luteum cysts, theca-lutein cysts (high hCG)

Evaluation

• Pelvic ultrasound (transvaginal preferred)
• Hormonal panel: testosterone, DHEAS, androstenedione, 17-OHP, LH/FSH, prolactin, TSH, insulin/glucose
• Consider MRI if complex mass

Management targets the underlying etiology: lifestyle/insulin sensitizers for PCOS, treat thyroid/prolactin, adjust fertility meds, surgery for suspicious masses.