“If you are distressed by anything external, the pain is not due to the thing itself but to your own estimate of it; and this you have the power to revoke at any moment.”
~ Marcus Aurelius
Ovarian Cysts
Ovarian cysts are fluid-filled sacs that develop in the ovary. They occur commonly in women of all ages, but in our practice we typically see ovarian cysts in women at the extremes of the reproductive ages: young women, within a few years of menarche and women in their mid to late 40s, approaching menopause.
In young women, ovarian cysts seem to cause the most significant pain, sending them to the emergency room, while others may have no symptoms.
Fortunately, most ovarian cysts do not require surgery and are not caused by cancer. Cysts vary in size from less than one centimeter (one-half inch) to greater than 10 centimeters (4 inches).
Causes
The most common causes of cysts depend upon whether you are still having menstrual periods (premenopausal) or have stopped menstruating for one year (postmenopausal).
In Young Women...
- Ovulation — "Functional" ovarian cysts (the most common) develop when a follicle (sac) grows, but does not rupture to release the egg, resulting in no ovulation that month. These cysts almost always resolve with supportive watchful waiting.
- Dermoid cysts — Dermoid cysts (teratomas) are one of the most common types of cysts found in women between age 20 and 40 years. A dermoid cyst is made up ovarian germ cells (germ cells are reproductive cells, eg, eggs) and can contain teeth, hair, or fat. Most dermoid cysts are benign, but extremely rarely, can be cancerous. They will need to be removed: typically, laparoscopically.
- Polycystic Ovarian Syndrome— Women with PCOS may have many small cysts. These cysts do not need to be removed or treated, but women with PCOS may need treatment for other PCOS problems, such as irregular periods, acne, excess hair...
- Endometriosis — Women with endometriosis can develop a type of ovarian cyst called an endometrioma, or "chocolate cyst". It is called "chocolate", because it is filled with old blood which turns brown, and when the cyst is punctured at removal during surgery, it looks like chocolate spilling out.
- Pregnancy — An ovarian cyst normally develops in early pregnancy, to help support the pregnancy until the placenta forms. In some cases, the cyst stays on the ovary until later in the pregnancy. As the pregnancy continues, these usually resolove.
- Severe pelvic infections — Severe pelvic infections may spread to involve the ovaries and fallopian tubes. This can result in pus-filled cysts forming close to the ovaries and fallopian tubes. While less common in healthy young women than in the past, we occasionally see this in young women who complain of fever, abdominal/pelvic pain and purulent vaginal discharge.
- Cancer is an uncommon cause of ovarian cysts in premenopausal women; < 1 percent of new growths on or near the ovary are related to ovarian cancer.
In Postmenopausal Women...
In women who have stopped having menstrual periods, the most common causes of ovarian cysts include:
- Fluid collection in the ovary: In postmenopausal women, new growths on or around the ovary are somewhat more likely to be caused by cancer than in premenopausal women.
- Ovarian cancer. Although ovarian cancer is not a common cause of ovarian cysts, many women who are diagnosed with a cyst are concerned that they could have cancer. Ovarian cancer is more likely in women who have: A genetic predisposition to ovarian cancer (eg, family history of ovarian or related cancers), A previous history of breast or gastrointestinal cancer, A cyst that appears complex (a cyst with solid areas, nodule on the surface, or multiple fluid-filled areas), A fluid collection (ascites) found in the pelvis or abdomen during the imaging test.
However, women without cancer may also have these characteristics. In most cases, further testing will be recommended to gauge the likelihood of cancer.
Diagnosing an Ovarian Cyst
Ovarian cysts can sometimes be detected during a pelvic examination, although an imaging test is generally necessary to confirm the diagnosis.
Pelvic sonogram/ultrasound: is the easiest, most accurate way to demonstrate a cyst on one's ovaries. The sonogram uses no radiation, is painless and quick and can identify most pelvic pathology well.
However, if you present to the emergency room with severe pelvic pain, you will likely undergo a CT scan, which is more sensitive for ruling out appendicitis. Either test can also provide information about the cyst's size, location, and other important characteristics.
Blood testing: One or more blood tests may be recommended if you are found to have an ovarian cyst. The blood test(s) can help to determine the nature of the cyst.
Pregnancy testing: A blood or urine pregnancy test is often performed in premenopausal women with an ovarian cyst. Ovarian cysts are common during pregnancy.
CA 125: CA 125 is a blood test that is sometimes drawn in women with ovarian cysts. However, ovarian cancer cannot be diagnosed based upon the results of a CA 125 test. Many women with early ovarian cancer will have a normal CA 125 level. CA 125 is abnormally elevated in about 80 percent of women with advanced ovarian cancer. Also, non-cancerous conditions can cause CA 125 to be elevated, including endometriosis, uterine fibroids, pelvic inflammatory disease, heart failure, and liver and kidney disease. As a result, measurement of the CA 125 is not recommended in every case.
Treatment
Ovarian cysts often do not require treatment. In young women, ovarian cysts often resolve on their own within one to two months, without treatment. In postmenopausal women, ovarian cysts are less likely to resolve.
If a cyst is large, causing persistent pain, or appears suspicious for cancer, treatment usually involves surgery to remove the cyst or the entire ovary.
Watchful Waiting
In young women, watchful waiting usually involves monitoring for symptoms of pelvic pain or bloating, and repeating the pelvic ultrasound after six to eight weeks.
If the ovarian cyst does not enlarge or if it resolves during the period of watchful waiting, it does not require surgical removal. Some premenopausal women may be offered a birth control pill during this time to help prevent new ovarian cysts from developing.
If a cyst decreases in size or does not change, the ultrasound is often repeated at regular intervals until it is determined that the cyst is not growing. If the cyst resolves, no further testing or follow up is needed.
In postmenopausal women, the decision to undergo watchful waiting depends upon the initial testing (ultrasound and CA 125). If the cyst does not appear to be cancerous, watchful waiting is usually the best option, and includes a pelvic ultrasound and measurement of CA 125 every three to six months for one year, or until the cyst resolves.
However, ovarian cysts do not always resolve in postmenopausal women. If the CA 125 levels increase or the cyst grows or changes in appearance, then surgery to remove the cyst may be recommended.
Surgery
Surgery may be recommended in the following situations:
- A cyst is causing persistent pain, or may rupture or twist on its vascular pedicle (ovarian torsion.)
- A cyst appears on ultrasound to be caused by endometriosis and is removed for fertility reasons.
- Large cysts (>5 to 10 cm) are more likely to require surgical removal compared to smaller cysts. However, a large size does not predict whether a cyst is cancerous.
- If the cyst appears suspicious for cancer. If you have risk factors for ovarian cancer or the cyst looks potentially cancerous on imaging studies.
If the suspicion for cancer is low but the cyst does not resolve after several ultrasounds, you may choose to have it removed after several discussions with us. However, surgical removal is not usually necessary in this case.
Follow Up/Risk of Recurrence?
After an ovarian cyst resolves, you will not need further imaging tests if you do not have symptoms.
Some types of ovarian cysts are more likely to recur than others. These include endometriomas and functional ovarian cysts. If you are premenopausal and are concerned about recurrent cysts, taking a birth control pill or other hormonal form of birth control may help to prevent ovarian cysts from developing.
"Pain is only valuable once you know that you've learned from it." ~ anon
