Ovarian Cysts
An ovarian cyst is a fluid-filled sac within the ovary. Often they cause no symptoms. Occasionally they may produce bloating, lower abdominal pain, or lower back pain. The majority of cysts are harmless. If the cyst either breaks open or causes twisting of the ovary, it may cause severe pain. This may result in vomiting or feeling faint.
Most ovarian cysts are related to ovulation, being either follicular cysts or corpus luteum cysts. Other types include cysts due to endometriosis, dermoid cysts, and cystadenomas. Many small cysts occur in both ovaries in polycystic ovary syndrome (PCOS). The pelvic inflammatory disease may also result in cysts. Rarely, cysts may be a form of ovarian cancer. Diagnosis is undertaken by pelvic examination with an ultrasound or other testing used to gather further details.
Often, cysts are simply observed over time. If they cause pain, medications such as paracetamol (acetaminophen) or ibuprofen may be used. Hormonal birth control may be used to prevent further cysts in those who are frequently affected. However, the evidence does not support birth control as a treatment of current cysts. If they do not go away after several months, get larger, look unusual, or cause pain, they may be removed by surgery.
Ovarian Cysts Types
- Functional ovarian cysts – the most common type. These harmless cysts form part of the female’s normal menstrual cycle and are short-lived.
- Pathological cysts – these are cysts that grow in the ovaries; they may be harmless or cancerous (malignant).
The causes are different for each type. We will look at each type in turn.
Functional ovarian cysts
There are two types of functional ovarian cysts:
1) Follicular cysts
Follicular cysts are the most common type. A woman has two ovaries. The egg moves from an ovary into the womb, where it can be fertilized by sperm. The egg is formed in the follicle, which contains fluid to protect the growing egg. When the egg is released, the follicle bursts.
In some cases, the follicle either does not shed its fluid and shrink after releasing the egg, or it does not release an egg. The follicle swells with fluid, becoming a follicular ovarian cyst.
One cyst normally appears at any single time, and it normally goes away within a few weeks.
2) Luteal ovarian cysts
These are less common. After the egg has been released, it leaves tissue behind, known as the corpus luteum. Luteal cysts can develop when the corpus luteum fills with blood. This type of cyst normally goes away within a few months. However, it may sometimes split, or rupture, causing sudden pain and internal bleeding.
Pathological cysts
There are two types of pathological cysts:
1) Dermoid cysts (cystic teratomas)
A dermoid cyst is usually benign. They are formed from the cells that make eggs. These cysts need to be removed surgically. Dermoid cysts are the most common type of pathological cyst for women under 30 years of age.
2) Cystadenomas
Cystadenomas are ovarian cysts that develop from cells that cover the outer part of the ovary. Some are filled with a thick, mucus-like substance, while others contain a watery liquid.
Rather than growing inside the ovary, cystadenomas are usually attached to the ovary by a stalk. By existing outside the ovary, they can grow quite large. They are rarely cancerous, but they need to be removed surgically.
Cystadenomas are more common among women aged over 40 years.
Ovarian Cysts Symptoms
Often times, ovarian cysts do not cause any symptoms. However, symptoms can appear as the cyst grows. Symptoms may include:
- Abdominal bloating or swelling
- Painful bowel movements
- Pelvic pain before or during the menstrual cycle
- Painful intercourse
- Pain in the lower back or thighs
- Breast tenderness
- Nausea and vomiting
Severe symptoms of an ovarian cyst that require immediate medical attention include:
- Severe or sharp pelvic pain
- Fever
- Faintness or dizziness
- Rapid breathing
These symptoms can indicate a ruptured cyst or an ovarian torsion. Both complications can have serious consequences if not treated early.
Ovarian Cysts Causes
Most ovarian cysts develop as a result of your menstrual cycle (functional cysts). Other types of cysts are much less common.
Functional cysts
Your ovaries normally grow cyst-like structures called follicles each month. Follicles produce the hormones estrogen and progesterone and release an egg when you ovulate.
If a normal monthly follicle keeps growing, it’s known as a functional cyst. There are two types of functional cysts:
- Follicular cyst. Around the midpoint of your menstrual cycle, an egg bursts out of its follicle and travels down the fallopian tube. A follicular cyst begins when the follicle doesn’t rupture or release its egg but continues to grow.
- Corpus luteum cyst. When a follicle releases its egg, it begins producing estrogen and progesterone for conception. This follicle is now called the corpus luteum. Sometimes, fluid accumulates inside the follicle, causing the corpus luteum to grow into a cyst.
Functional cysts are usually harmless, rarely cause pain, and often disappear on their own within two or three menstrual cycles.
Other cysts
Types of cysts not related to the normal function of your menstrual cycle include:
- Dermoid cysts. Also called teratomas, these can contain tissue, such as hair, skin or teeth because they form from embryonic cells. They’re rarely cancerous.
- Cystadenomas. These develop on the surface of an ovary and might be filled with a watery or a mucous material.
- Endometriomas. These develop as a result of a condition in which uterine endometrial cells grow outside your uterus (endometriosis). Some of the tissue can attach to your ovary and form a growth.
Dermoid cysts and cystadenomas can become large, causing the ovary to move out of position. This increases the chance of painful twisting of your ovary, called ovarian torsion. Ovarian torsion may also result in decreasing or stopping blood flow to the ovary.
Ovarian Cysts Risk factors
Your risk of developing an ovarian cyst is heightened by:
- Hormonal problems. These include taking the fertility drug clomiphene (Clomid), which is used to cause you to ovulate.
- Pregnancy. Sometimes, the cyst that forms when you ovulate stays on your ovary throughout your pregnancy.
- Endometriosis. This condition causes uterine endometrial cells to grow outside your uterus. Some of the tissue can attach to your ovary and form a growth.
- A severe pelvic infection. If the infection spreads to the ovaries, it can cause cysts.
- A previous ovarian cyst. If you’ve had one, you’re likely to develop more.
Ovarian Cysts Complications
Most ovarian cysts are benign and naturally go away on their own without treatment. These cysts cause little if any, symptoms. But in a rare case, your doctor may detect a cancerous cystic ovarian mass during a routine examination.
Ovarian torsion is another rare complication of ovarian cysts. This is when a large cyst causes an ovary to twist or move from its original position. Blood supply to the ovary is cut off, and if not treated, it can cause damage or death to the ovarian tissue. Although uncommon, ovarian torsion accounts for nearly 3 percent of emergency gynecologic surgeries.
Ruptured cysts, which are also rare, can cause intense pain and internal bleeding. This complication increases your risk of an infection and can be life-threatening if left untreated.
Ovarian Cysts Diagnosis
Your doctor can detect an ovarian cyst during a routine pelvic examination. They may notice swelling on one of your ovaries and order an ultrasound test to confirm the presence of a cyst. An ultrasound test (ultrasonography) is an imaging test that uses high-frequency sound waves to produce an image of your internal organs. Ultrasound tests help determine the size, location, shape, and composition (solid or fluid-filled) of a cyst.
Imaging tools used to diagnose ovarian cysts include:
- CT scan: a body imaging device used to create cross-sectional images of internal organs
- MRI: a test that uses magnetic fields to produce in-depth images of internal organs
- Ultrasound device: an imaging device used to visualize the ovary
Because the majority of cysts disappear after a few weeks or months, your doctor may not immediately recommend a treatment plan. Instead, they may repeat the ultrasound test in a few weeks or months to check your condition.
If there aren’t any changes in your condition or if the cyst increases in size, your doctor will request additional tests to determine other causes of your symptoms.
These include:
- Pregnancy test to make sure you’re not pregnant
- Hormone level test to check for hormone-related issues, such as too much estrogen or progesterone
- CA-125 blood test to screen for ovarian cancer
Ovarian Cysts Treatment
Your doctor may recommend treatment to shrink or remove the cyst if it doesn’t go away on its own or if it grows larger.
Birth control pills
If you have recurrent ovarian cysts, your doctor can prescribe oral contraceptives to stop ovulation and prevent the development of new cysts. Oral contraceptives can also reduce the risk of ovarian cancer. The risk of ovarian cancer is higher in postmenopausal women.
Laparoscopy
If your cyst is small and results from an imaging test to rule out cancer, your doctor can perform a laparoscopy to surgically remove the cyst. The procedure involves your doctor making a tiny incision near your navel and then inserting a small instrument into your abdomen to remove the cyst.
Laparotomy
If you have a large cyst, your doctor can surgically remove the cyst through a large incision in your abdomen. They’ll conduct an immediate biopsy, and if they determine that the cyst is cancerous, they may perform a hysterectomy to remove your ovaries and uterus.
Ovarian Cysts Prevention
Ovarian cysts can’t be prevented. However, routine gynecologic examinations can detect ovarian cysts early. Benign ovarian cysts don’t become cancerous. However, symptoms of ovarian cancer can mimic symptoms of an ovarian cyst. Thus, it’s important to visit your doctor and receive a correct diagnosis. Alert your doctor to symptoms that may indicate a problem, such as:
- Changes in your menstrual cycle
- Ongoing pelvic pain
- Loss of appetite
- Unexplained weight loss
- Abdominal fullness
What’s the long-term outlook?
The outlook for premenopausal women with ovarian cysts is good. Most cysts disappear within a few months. However, recurrent ovarian cysts can occur in premenopausal women and women with hormone imbalances.
If left untreated, some cysts can decrease fertility. This is common with endometriomas and polycystic ovary syndrome. To improve fertility, your doctor can remove or shrink the cyst. Functional cysts, cystadenomas, and dermoid cysts do not affect fertility.
Although some doctors take a “wait and see” approach with ovarian cysts, your doctor may recommend surgery to remove and examine any cyst or growth that develops on the ovaries after menopause. This is because the risk of developing a cancerous cyst or ovarian cancer increases after menopause. However, ovarian cysts don’t increase the risk of ovarian cancer. Some doctors will remove a cyst if it’s larger than 5 centimeters in diameter.
Surgery
Surgery may be recommended if:
- There are symptoms
- The cyst is large or appears to be growing
- The cyst does not look like a functional cyst
- The cyst persists through 2 to 3 menstrual cycles.
Two types of surgery are:
- Laparoscopy, or keyhole surgery: The surgeon uses very small tools, to remove the cyst through a small incision. In most cases, the patient can go home the same day. This type of surgery does not usually affect fertility, and recovery times are fast.
- Laparotomy: This may be recommended if the cyst is cancerous. A longer cut is made across the top of the pubic hairline. The cyst is removed and sent to the lab for testing. The patient usually stays in the hospital for at least 2 days.
Frequently Asked Questions About Ovarian Cysts
What are ovarian cysts?
Ovarian cysts are closed, sac-like structures (more than 3 cm in diameter) within an ovary that contain a liquid, or semisolid substance. They may be single or multiple, unilateral or bilateral. They can vary in size from a few centimeters to the size of a large melon. They may be thin-walled and contain only fluid (simple cyst) or maybe more complex, containing thick fluid, blood, septa or solid areas.
Are all ovarian cysts the same?
No. There are many different types of ovarian cysts that can occur in women. Before menopause, most of them are “functional” cysts like follicular cyst and corpus luteum cyst. These resolve spontaneously within a few weeks or months.
Others are pathological, like serous and mucinous cystadenoma, endometrioma (chocolate cyst), dermoid cyst, etc.
How common are these cysts?
Ovarian cysts are common. Most women will be unaware that they have a cyst as they often cause no symptoms and disappear spontaneously with time. 1 in 10 women may need surgery for an ovarian cyst at some point in their lives.
What causes the pain to occur?
The pain can be caused by:
- Rupture of the cyst,
- Rapid growth and stretching,
- Bleeding into the cyst, or
- Twisting of the cyst around its blood supply (known as torsion)
What exactly are ovarian cysts?
Cysts are fluid or semi-solid filled sac. They are able to form anywhere in the body. Ovarian cysts form in or on the ovaries. The most typical type of ovarian cyst is a functional cyst that develops naturally in the ovary.
How are ovarian cysts diagnosed?
Sometimes ovarian cysts may be noticed by a doctor during a clinical examination of the pelvis. More commonly they are diagnosed during an ultrasound examination. A TVS ( transvaginal ultrasound) is better than an abdominal ultrasound for determining the size and appearance of ovarian cyst.
Cysts can also be detected with other imaging methods, such as CT scan or MRI scan (magnetic resonance imaging)
How can the physician decide if an ovarian cyst is dangerous?
If a woman is in her 40’s, or younger, and has regular menstrual periods, most ovarian masses are “functional ovarian cysts,” Example follicular cysts and corpus luteum cysts. These are related to the process of ovulation that happens with the menstrual cycle. They usually disappear on their own during a future menstrual cycle. These cysts are watched for a few menstrual cycles to verify that they disappear.
What other tests are usually done?
Besides routine tests to determine your baseline health status, blood tests like CA 125, HE 4, AFP, HCG may be offered.
Also imaging tests like Colour Doppler, CT scan or MRI may be suggested depending on the size and complexity of the cyst
Do all cysts require treatment?
Well, if your scan is reassuring and you have no symptoms, you may not need any treatment
If you have symptoms or if the ultrasound shows a large or complex cyst or one that is increasing in size, you need to be further investigated and treated.
What are the treatment options?
Depending on the symptoms, your age, size, and type of the cyst and desire for further childbearing, your doctor may either treat you conservatively or suggest surgery.
Surgery is done either by laparoscopy (keyhole) or laparotomy (open surgery) Laparotomy is usually recommended if the cyst is very large or rarely if there is a suspicion of cancer. Your gynecologist will discuss these procedures with you and advise you which procedure is best for your situation.
Does surgery for an ovarian cyst mean the removal of the whole ovary?
The ovaries produce important hormones before menopause and therefore in most cases, only the cyst is removed preserving the ovary. This is known as a cystectomy.
However, there are circumstances where one or both the ovaries may have to be removed. For example, if the cyst is very large and replaced the whole ovary or the cyst has twisted so much that the blood supply has been completely cut off, or, rarely, if there is a suspicion of cancer. Your surgeon may not know what surgery is to be done until the surgery begins.
Is there any role of combined oral contraceptive pills?
Taking combined oral contraceptive pills will not help a simple cyst disappear although taking the pill may stop further cyst developing in the future.
What if you are pregnant and your ultrasound shows that you have an ovarian cyst?
Well, ovarian cysts are often found on ultrasound scans during early pregnancy. Most of these disappear by 14-16 weeks of pregnancy. If the cyst is large or complex, you may be offered further scans during pregnancy and after your baby is born. An operation to remove the cyst during pregnancy would only be recommended if you have pain thought to be due to the cyst or very rarely if cancer is suspected.