What is an Ovarian Cyst?
By definition, a “cyst” is a collection of fluid. Ovarian cysts are sacs of fluid which develop in the ovary. These fluid-filled collections can occur on one or both sides, and can be very small or grow to huge proportions. They can sometimes contain solid components, or they may be completely fluid-filled. While most ovarian cysts are benign, some cysts which form in the ovary can be malignant (cancerous).
Cysts are usually diagnosed by sonography (ultrasound).
This technique uses sound waves to “see” structures inside your body, and provides excellent images of fluid-filled structures like cysts. Ultrasound can be performed over your lower abdomen, or preferably, using a wand in the vagina. Transvaginal ultrasound is not painful, and allows us to see details of cyst structure, since it allows us to get so close to the cyst while viewing it. At The Woman’s Health Pavilion, each of our offices is equipped with modern, high-definition, 3-D ultrasound and staffed by experienced and certified sonography technicians; this allows us to see the fine detail in ovarian cysts. The details of cyst structure are important, because they help us to determine whether a cyst is benign or malignant. Cysts are often found using other types of imaging like CT scanning or MRI, but transvaginal ultrasound is still the gold standard for evaluating most ovarian cysts.
Types of Ovarian Cysts
There are dozens of types of ovarian cysts. Common types of cysts include:
- Functional cysts (commonly referred to as “ovulation cysts”)
- Dermoid cysts (benign cystic teratomas)
- Cysts associated with Polycystic Ovary Syndrome (PCOS)
- Cysts associated with ovarian cancer
Functional Cysts of the Ovary
The most common type of ovarian cyst is the “functional” cyst. Commonly referred to as “ovulation cysts,” functional cysts arise from the natural ovulatory function of the ovaries. Prior to ovulation, the cell destined to be released as the “egg” is recruited from among millions of other similar cells in the ovary. As the egg develops in the ovary, it grows within in a tiny collection of fluid called the follicle. Generally, when this collection grows to be about 1.5 centimeters (about the size of a grape) the microscopic egg is released from the follicle. The remaining collection of fluid resolves over the next several weeks, producing hormones which would serve to support a pregnancy if the egg were fertilized.
In some cycles, the collection of fluid around the egg will continue to grow for reasons which are not well understood. These “functional” cysts can grow to be quite large—more of a grapefruit than a grape—and can become quite painful. If they rupture, the pain is acute and severe, and will often result in trip to the emergency room. Because functional cysts produce hormones, women with a growing functional cyst will often notice changes in their menstrual cycle: menstrual bleeding may occur early or late, or may be unusually heavy or disorganized.
Functional cysts are usually diagnosed by transvaginal sonography performed in the office. During this test, a slender wand is gently inserted into the vagina, permitting close examination of the pelvic organs with sound waves, or ultrasound. Transvaginal sonography is not painful, and takes just a few minutes to perform. Functional cysts typically are seen as round, thin-walled structures in the ovaries filled with fluid or blood.
Importantly, functional cysts typically resolve without treatment. For women who are comfortable, it is perfectly appropriate to wait a cycle or two for the cyst to resolve. Of course, the ultimate proof that a cyst is simply “functional” is the fact that it does disappear. As such, follow-up is essential.
Traditionally, gynecologists have prescribed birth control pills to treat functional cysts. Recent evidence suggests that birth control pills do not make functional cysts disappear; being on birth control pills, however, does tend to prevent functional cysts from forming in the first place. Women who are prone to recurrent, symptomatic functional cysts will often benefit from staying on birth control pills, or similar hormonal contraception which suppresses ovulation.
Dermoid Cysts of the Ovary
The dermoid cyst (or technically, benign cystic teratoma) is unique because it grows tissues which belong in other organs. Commonly, for example, a dermoid cyst will contain hair, teeth, or fragments of bone. It may contain glandular tissue (e.g., thyroid tissue) which produces hormones. Usually, these solid components are encased in a thick capsule filled with an oily or cheesy liquid.
Dermoid cysts can be tiny, or grow to be huge. They are most often discovered in women aged 15 to 40, and in 15% of cases will be found in both ovaries. Because dermoids are dense and heavy, they tend to make the ovaries “dangle” in the pelvis. As such, they are particularly prone to torsion: An enlarged ovary containing a cyst will sometimes twist around its blood supply (think of a disco ball or an apple hanging on its stalk), interrupting the blood flow to the ovary. When blood flow to the ovary is interrupted, ovarian tissue rapidly begins to die. Torsion is extremely painful, and usually will result in an emergency room visit. Suspected torsion is a true surgical emergency.
Another common type of cyst in the ovary is an endometrioma or chocolate cyst. An endometrioma is a type of endometriosis, a condition in which the lining of the uterus (womb) flows backwards through the fallopian tubes and deposits in the pelvis. When this tissue deposits on the ovary, an endometrioma can form. Endometriomas are characteristically stubbornly attached to the ovarian tissue and filled with old thick blood, similar in consistency to chocolate syrup—hence the name “chocolate cyst”.
Endometriomas occur in women during their reproductive years, and are frequently seen in conjunction with endometriosis implants elsewhere in the pelvis. Sometimes, women with this condition will experience chronic pain, severe menstrual cramps, painful intercourse, or problems with fertility. Because endometriosis is a chronic condition, women may require ongoing treatment to prevent recurrence.
Many ovarian cysts—even large ones—are completely asymptomatic; other ovarian cysts may cause pain or pressure.
Polycystic Ovary Syndrome (PCOS)
Each month, the ovaries begin to develop several small follicles, tiny collections of fluid which each contain an egg. Early in the menstrual cycle, one follicle is “recruited”: This “dominant follicle” grows larger than the rest, and ultimately releases an egg at the time of ovulation. After ovulation, the follicle is termed a corpus luteum. If fertilization occurs, the corpus luteum will continue to produce hormones which support early pregnancy. If fertilization does not occur, the corpus luteum resolves, and ovulation is followed by a menstrual period two weeks later.
In women with PCOS, many follicles develop inside the ovaries, but an egg is not released regularly: Women with PCOS are usually either anovulatory (they do not ovulate at all) or oligo-ovulatory (they do not ovulate on schedule). Since ovulation is a prerequisite for pregnancy, women with PCOS frequently have difficulty conceiving. Also, since ovulation triggers the chain of events which leads to menstrual flow, women with PCOS often do not get regular periods.
The ovaries in women with PCOS have a characteristic appearance on sonography: The many developing follicles typically look like a “chain of pearls” clustered around the surface of the ovary. Usually, the ovaries are enlarged as a result of all the developing follicles.
Fundamentally, PCOS represents a hormonal imbalance: The ovaries in women with PCOS produce more androgens, or male hormones, than normal. As a result, women may notice increased hair growth on the chin or chest, acne, or thinning hair in a male baldness pattern. The “yin and yang” female hormones estrogen and progesterone are also out of balance: Women with PCOS produce too much estrogen and not enough progesterone. All of these changes contribute to menstrual irregularity and fertility issues observed in women with PCOS.
A woman’s body is designed to build up the inner lining of the uterus (the endometrium) each month, and then to clean it out each month with a period. Over a lifetime, constant buildup without a regular monthly cleanout increases the risk of endometrial cancer, a cancer in the lining of the uterus. Women with PCOS have an increased risk of endometrial cancer.
Ultimately, the precise cause of PCOS is not known, but several contributing factors have been identified. PCOS does seem to run in families: We often encounter sisters who each report having irregular periods and/or fertility problems. For many women, PCOS is caused by being overweight: Because fat cells are hormonally active, excess body fat disrupts a woman’s hormonal balance. It is well-known that overweight women who do not get their periods regularly will often resume regular monthly periods if they lose just 10% of their body weight.
In addition to weight loss, birth control pills are often used to “cycle” women with PCOS. Women who want to conceive may be offered medications which stimulate ovulation. Finally, because PCOS is linked to diabetes, certain medications which are commonly used to treat diabetes (e.g., metformin) may be used to treat PCOS.
Symptoms of Ovarian Cysts
Many ovarian cysts—even large ones—are completely asymptomatic; other ovarian cysts may cause pain or pressure. A slowly-growing cyst may produce mild or moderate pain, pressure, or heaviness over weeks to months, while a ruptured cyst may cause acute and severe pain that sends women to the emergency room. Pain may be constant or intermittent, or may occur only with activity or intercourse. Some women will also have bleeding abnormalities, since certain ovarian cysts produce hormones which can alter the menstrual cycle. Chronic complaints of bloating and vague urinary symptoms are also common among women with ovarian cysts.
When a cyst ruptures, the fluid contained inside is spilled into the pelvis and abdomen, causing pain. Technically, ovulation is a type of cyst rupture: In the ovary, eggs develop within a sac of fluid called a “follicle.” At the time of ovulation, the follicle ruptures, releasing the egg together with a small amount of fluid into the pelvis. While this process is completely normal, ovulation can be very painful for some women. Painful ovulation is known as mittleshmerz and is one of the more common reasons we see women in the emergency room. If you suffer from recurrent mittleshmerz, effective treatments are readily available.
Torsion occurs when the ovary containing a cyst twists around the “stalk” that contains its blood supply, like an apple twisting on a tree. When the blood supply of the ovary is interrupted, oxygen does not reach the ovarian tissue, and it begins to die. Like rupture of a cyst, torsion is severely painful, and may be associated with nausea, vomiting, and a low-grade fever. Torsion can often be diagnosed by a special Doppler ultrasound, which can demonstrate the lack of blood flow to the ovary. Torsion is a true surgical emergency.
Is it Cancer?
When women are diagnosed with an ovarian cyst, many will be concerned about the possibility of ovarian cancer. Ovarian cancer is indeed a frightening disease, one that affects 1 in 70 women in this country. Most women with ovarian cancer are first diagnosed when they already have advanced-stage disease. Unfortunately, this means that the prognosis of ovarian cancer is often not as favorable as many other types of cancer.
Certain women are particularly at risk for ovarian cancer. Age is an important risk factor: Ovarian cancer is rare before age 40; nearly half of ovarian cancers occur in women over age 63. Obese women have up to 50% higher risk of ovarian cancer. Women without children have a higher risk of ovarian cancer. Interestingly, women who spend a few years on birth control pills have a significantly lower risk of ovarian cancer.
Traditionally, ovarian cancer has been regarded as a “silent killer”: It has been widely taught that the disease has few early symptoms, and thus nearly impossible to catch in its early stages. While only about 20% of ovarian cancers are discovered in their early stages, recent studies suggest that most women with ovarian cancer do indeed have symptoms, even with early-stage disease.
The most common symptoms of ovarian cancer are:
- Abdominal bloating
- Pelvic and/or abdominal pain
- Feeling full quickly after eating
- Urinary urgency and/or frequency
In recent studies, almost all women diagnosed with ovarian cancer reported symptoms—although sometimes vague and non-specific—when carefully questioned. These recent findings underscore the importance of a careful medical evaluation for even vague pelvic and abdominal symptoms.
The diagnosis of ovarian cancer may be suspected based on findings of imaging studies like sonography, CT scan, or MRI. While none of these tests can tell the difference between benign cysts of the ovary and cancerous growths with 100% accuracy, ovarian cancers do tend to have a different appearance than benign cysts, especially on sonogram. Tumor markers in the blood (for example, CA-125) can be used in some women to gain additional information.
If a cancerous growth of the ovary is suspected, surgery is usually indicated. Ideally, surgery is performed in consultation with a gynecologic oncologist—a gynecologist with special training in the treatment of gynecologic cancers. Most women with ovarian cancer will require removal of both ovaries, together with the uterus, the fallopian tubes, the omentum (fatty tissue around the intestine), and lymph nodes in the abdomen and pelvis. Usually, chemotherapy is required after surgical staging.
Treatment of Ovarian Cysts
Typically, we make the diagnosis of an ovarian cyst using the high-resolution sonogram equipment located in each of our offices. Our equipment is modern, 3-D and Doppler capable, so we are able to collect as much information as possible about ovarian cysts and other types of pathology before you leave.
Once diagnosed, a treatment plan can be developed. For small cysts which are thought to be functional based on their sonographic appearance, patients may be asked to follow up after a few weeks. For larger cysts, or cysts with suspicious characteristics, further testing may be warranted. Testing may include additional imaging (for example, CT scan or MRI) or blood work which measures levels of tumor markers like CA-125.
Occasionally, it may be prudent to simply monitor a small cyst, but in most cases, persistent ovarian cysts will need to be removed. In most cases, ovarian cysts are removed laparoscopically, using a telescope inserted through your navel. This procedure, called laparoscopic ovarian cystectomy, is performed in the hospital, but patients are generally discharged the same day. Typically, women can return to their normal activities about one week after laparoscopic ovarian cystectomy.
There are many types of ovarian cysts, ranging from clinically insignificant to very serious in nature. Because there are so many types of ovarian cysts, any known or suspected ovarian cyst should be evaluated promptly by a gynecologist. The physicians at Woman’s Health Pavilion are well versed in the diagnosis and management of ovarian cysts, and can offer the most up to date treatments available. If you think you might have an ovarian cyst, we encourage you to call us as soon as possible.
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