Ovarian Cysts

The ovaries a part of the female reproductive system, also known as the female gonads, are located in the pelvis, one on each side of the uterus. Each ovary is about the size and shape of a walnut. The ovaries produce ova (eggs) and female hormones, which control the development of female body characteristic, menstrual cycle and pregnancy.

The number of ovarian cysts diagnosed has increased in recent years, with the wide spread use ultrasound .The discovery of cysts cause considerable anxiety in women owing to fear of malignancy, but the vast majority of them are benign and resolve even without treatment.

Here are some frequently asked questions about ovarian cysts.

1. 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 may be more complex, containing thick fluid, blood, septa or solid areas.

Q Are all ovarian cysts the same?

No. There are many different types of ovarian cyst 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.

Q 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 a surgery for an ovarian cyst at some point in their lives.

1. What symptoms may occur?

Most ovarian cysts in premenopausal women are asymptomatic and resolve without women ever realizing that they are there. When a cyst causes symptoms, pain in the lower abdomen or pelvis is the most common one.  Others are

• Painful periods or change in pattern of your periods
• Pain related to your bowels/ pressure on bowels,
• Pain during intercourse (dyspareunia)
• Increased frequency and urgency of urination
• A change in appetite or feeling full or a sense of bloating
• A distended or swollen abdomen
• Difficulty in conceiving (becoming pregnant) which may be linked to endometriosis.

Q What causes the pain to occur?

The pain can be caused from:

• Rupture of the cyst,
• Rapid growth and stretching,
• Bleeding into the cyst, or
• Twisting of the cyst around its blood supply (known as torsion)

1. 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)

Q 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.

Q 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

1. 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.

1. What are treatment options?

 Depending on the symptoms, your age, size and type of the cyst and desire for further child bearing, 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 advice you which procedure is best for your situation.

Q Does surgery for an ovarian cyst mean 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 cystectomy.

However, there are circumstances where one or both the ovaries may have to be removed. 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 till the surgery begins.

Q 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.

Q What if you are pregnant and your ultrasound shows that you have an ovarian cyst?

Well, ovarian cysts are often found on ultrasound scan 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.

KEY POINTS:-

• Ovarian cysts are common in women before menopause.
• Ovarian cancer is rare before menopause.
• An ultrasound scan should provide reassurance.
• Small simple ovarian cysts usually require no treatment
• If you have a surgery, this will usually be a keyhole surgery with removal of only the cyst

Dr Suili Chowdhary

Visiting Consultant,Obstetrics & Gynecology

Narayana Multispecialty Hospital, Barasat