What is Ovarian Cyst?
Ovarian cysts are sac filled with fluid or semifluid materials that arise within the ovaries. These cysts can develop in any stage of life, from neonatal to postmenopausal. However, most ovarian cysts occur during hormone active periods of development.
Woman can develop a single or multiple ovarian cysts of various sizes. Most of the time the cysts are benign (non-cancerous) and go away on its own. However, they may rupture or cause bleeding and pain. In such cases, surgery is recommended. Very rarely, cysts can turn malignant (cancerous).
Types of Ovarian Cyst?
Ovarian cysts form for numerous reasons. There are several different types of cysts as listed below:
Each month, the ovary produce cyst like structures called follicles. These follicles produce female hormones (estrogen and progesterone) and produce an egg when you ovulate. Occasionally a normal follicle keeps growing and form functional cysts. Functional cysts are often harmless and will resolve on their own. There are 3 forms of functional cysts:
Luteoma of Pregnancy
These are very rare non-cancerous ovarian cyst due to the hormonal effects of pregnancy. This happens due to the surge in androgens (testosterones) in certain females. These usually resolve after pregnancy.
Teratomas (Dermoid Cysts)
Teratomas are a form of germ cell tumors make up of 3 embryonic germ layers i.e. ectoderm, endoderm and mesoderm. Hence teratomas may contain different tissues such as hair, cartilage, teeth, fat and bones. These cysts are non-cancerous, may cause torsion and pain or get inflamed.
These non-cancerous cysts develop from within the ovary and may contain liquid or mucous material. They can grow to very large sizes.
Endometriomas are blood-filled cysts as a result of the condition endometriosis. Endometriosis is a condition whereby the endometrial cells (uterine cells) are found outside the uterus. It usually presents with a triad of dyspareunia (pain during sex), dysmenorrhea (painful menses) and menorrhagia (heavy menses).
Polycystic Ovarian Syndrome
Polycystic Ovarian Syndrome is a condition whereby the ovary is filled with multiple cysts. It will be discussed further in another page on this blog.
Ovarian Cancerous cyst
These are rare and often arise from the surface epithelium of the ovary. Others include germ cell tumors and sex cord stromal tumors. Most of the time 99% cysts are non-cancerous.
Risk factors for ovarian cyst formation
Risk factors for cancerous ovarian cyst
Clinical presentation of ovarian cysts
Most ovarian cysts do not cause any symptoms and will resolve with time. Most of the time they are discovered incidentally during pelvic examination or ultrasound examination. Larger cysts tend to cause more symptoms.
Pain may be felt by patient if the cyst grows rapidly/ruptures bleed or cause torsion (twisting of the ovary cutting off the blood supply).
Pressure Symptoms may be felt by patient due to the pressure effect of cysts on surrounding organs. It may cause abdominal fullness or indigestion, early satiety, pain during sexual intercourse, urination frequency, bowel movements difficulties, urge to defecate and irregular menses.
Physical Findings of Ovarian Cysts
You doctor will do a thorough examination on you. On examination of the abdomen and pelvis, a large cyst may present as a mass, tenderness and as ascites in cancerous cysts. Ruptured/bleeding cyst or ovarian torsion usually present as an acute abdomen with pyrexia, rebound tenderness, guarding requiring surgical intervention.
Cancerous cysts will present as a mass in the abdomen, ascites in abdomen, enlarged lymph nodes and sometimes with pleural effusion. Patients are often very cachexia and breathless.
Investigations for Ovarian Cysts
Treatment for Ovarian Cysts
Simple functional cysts found on ultrasound are usually monitored with periodic ultrasound and do not require surgical intervention unless they cause symptoms. Most of the time they will resolve with time.
In post-menopausal patients who have simple cysts smaller than 5 cm and a normal CA 125 levels can be monitored with periodic ultrasound. Any rise in CA125, increase in size of cysts, change in complexity of cyst structure and suggestion of cancerous change of cyst will warrant a surgical intervention.
Removal of the ovaries and often uterus (bilateral salpingo-oophorectomy) are suggested in this group of patients as risk of cancer increases with age.
Pre-menopausal patients with simple cysts smaller than 8 cm, normal CA125 level and have no symptoms can be monitored with periodic ultrasound too. Hormone therapy like oral contraceptives has not been found to resolve cysts.
Ovarian cysts in neonates should be followed up with serial ultrasound to look for signs of regression, increase in size and complications. Surgery is indicated if there are signs of complications like bleeding or torsion and if the cyst is larger than 5cm.
Pregnancy associated cysts like follicular cysts and corpus luteum will resolve by 14 to 16 weeks of gestation. Any mass that persist longer, increase in size or shows signs suggestive of cancer should be investigated. Surgical removal is indicated if the cyst is cancerous, rapidly growing and causing symptoms like pain.
For patients who experience pain, pain killers like paracetamol, Non-steroidal anti-inflammatory drugs and opioids can be used to control pain.
Surgery can be done via laparotomy (open incision technique over lower abdomen) or laparoscopy (minimally invasive surgery using small incisions as ports to introduce camera and surgical instrumentations. Surgery may be done to remove the cyst alone (cystectomy) or the ovary and the fallopian tube (salpingo-oophorectomy) and the two ovaries and uterus (bilateral salpingo-oophorectomy). The extent of surgical intervention depends on the patient’s condition and is best discussed with your gynecologist.
Laparoscopy is now more preferred as the recovery time is faster and less side effects and complications. The surgery allows the surgeon to assess the cyst directly, obtain peritoneal washings for cytology, to do staging if it’s a cancerous ovary tumor as well as to assess the other ovary and surrounding organs.
Prevention and Screening
The use of oral contraceptives does reduce the risk of ovarian epithelial cancer. It also protects against the development of functional ovarian cysts however it does not regresses pre-existing functional cysts.
There’s no definite way to prevent the formation of ovarian cysts. Annual gynecological examination is recommended to detect any abnormalities early.
Ovarian Cancer will be discussed in another page.