It is the goal of our staff to provide you with the latest women's healthcare innovations to address infertility and coexisting gynecologic problems. Backed by a superb laboratory team, CRH has enabled thousands of couples to conceive.  Contact us to schedule an appointment or have additional questions about infertility treatment at CRH.

 

 

Ovarian Cysts

In women who are having periods, functional cysts are normal. If you have a functional cyst, we may decide to do nothing except see you again in one to three months to make sure the cyst has disappeared. What we might decide to do after that depends on your age, the way the cyst looks on the sonogram and if you're having symptoms related to the cyst. Not to be confused with polycystic ovarian syndrome, an ovarian cyst is a small fluid-filled sac that grows in the ovary. Because the cyst usually resolves within one or two menstrual periods, it does not cause infertility. If the cyst does not disappear or respond to medical treatment, then rarely surgery might be considered, since a persistent cyst may be malignant, especially at an advanced reproductive age. In our center we have resorted to ultrasound-guided needle aspirations to rid off the cyst and to assess the nature of the cyst without invasive surgery. Finding a cyst in a young girl before she's begun menstruation is alarming and can be malignant 50% of the time. A functional cyst can be one of four types and are not malignant: follicular, corpus luteum, theca luteum, and polycystic ovaries. A follicular cyst occurs when the normal follicle, or sac that matured to release an egg, does not shrink after release of the egg. These can rupture, causing sudden, severe pain, which gradually goes away over several days. Theca luteum cysts, the least common of the functional cysts, are often associated with a twin pregnancy. Endometriosis can cause complex ovarian cysts or endometriomas, also commonly called chocolate cysts.

What are ovarian cysts?

There are many different types of ovarian cysts, and they are an extremely common gynecologic problem. Because of the fear of ovarian cancer, cysts are a common cause of concern among women. A cyst may cause discomfort or may be discovered at the time of a routine examination, when you are feeling absolutely fine. Every menstruating woman develops a small ovarian cyst (called follicle) each cycle. The menstrual cycle requires the coordinated functioning of the pituitary gland, ovary, uterus and the cervix. The pituitary gland in the head produces the hormones, Follicle Stimulating Hormone (FSH) and Luteinizing Hormone (LH). The maturing egg is in a follicle cyst that grows to about one half inch in diameter. The remnant of the follicle cyst is called the corpus luteum and makes the hormone progesterone. Progesterone converts the lining of the uterus to become a secretory lining that is prepared to accept a pregnancy. If you have a functional cyst, we may decide to do nothing except see you again in one to two months to make sure the cyst has disappeared. Or we may want you to take birth control pills to dissolve the ovarian cyst.

 

Women on birth control pills should not develop functional cysts. The function of the pill is to suppress ovulation, although some women ovulate on their pills. Premenarchal and postmenopausal women should not develop functional cysts. Women in these groups with a cyst as well as those with a complex or a solid cyst will have to be evaluated carefully to make sure that the cyst is not a cancer.

What causes cysts?

The most common cysts found are the functional cysts. A functional cyst can be one of four types and are not malignant: follicular, corpus luteum, theca luteum, and polycystic ovaries. A follicular cyst occurs when the normal follicle, or sac that matured to release an egg, does not shrink after release of the egg. These can rupture, causing sudden, severe pain, which gradually goes away over several days. Corpus luteum cysts are less common, but cause more symptoms and problems. They become larger than follicular cysts, thus causing more pelvic pain. Theca luteum cysts, the least common of the functional cysts, are often associated with an abnormal pregnancy. Polycystic ovaries are multiple clear fluid filled cysts in both ovaries and are associated with menstrual problems and hormone imbalances. Endometriosis can cause complex ovarian cysts or endometriomas, also commonly called chocolate cysts. When the egg is released, if the channel through which it has burst seals off very quickly, the corpus luteum (the hormone production center) underneath starts to expand into a cyst. For example, endometriosis, pelvic inflammatory disease, ectopic pregnancy, polycystic ovary syndrome, and ovarian cancer can lead to ovarian cysts.

What symptoms do cysts lead to?

Most cysts are silent and produce no symptoms. When cysts do lead to symptoms, these can include menstrual irregularities from a hormonal effect, pelvic or low back pain that can vary from mild, occasional pain to severe, persistent pain, pain during intercourse, a feeling of fullness or heaviness in the low abdomen or pelvis, and if the cyst is large enough, pressure on other organs like the bladder or bowel.

Occasionally, cysts can twist on their stalks or rupture leading to sudden severe pain that should be evaluated ASAP.

What can a sonogram show in patient with ovarian cysts?

This kind of sonogram can be done two ways, either through the abdomen or through the patient’s vagina. An abdominal sonogram requires a full bladder so everything in the abdomen shows up on the picture. If the ovarian cyst is small, the patient will probably have a sonogram per vagina. It will give the doctor valuable information about the size and the appearance of the cyst. This instrument bounces harmless sound waves off your uterus, fallopian tubes, and ovaries, forming a picture on a monitor. A sonogram allows the doctor to accurately determine the size of the cyst and to "see" inside it in order to detect whether it is filled with fluid or solid areas. Certain types of ovarian cysts, depending on which cells in the ovary is overgrowing, will make fairly reliable patterns on a sonogram. Abnormal cysts often will have an overgrowth of cells that stick out from the inside of the cyst wall, making the inside of the cyst appear jagged on the sonogram. Still, many of these irregularly shaped cysts are benign, but cancer can also appear this way. Unfortunately, the sonogram cannot make a definite diagnosis of benign vs. malignant cysts.

How can you tell if a cyst is benign or malignant?

When we feel a mass on the ovary, we will nearly always order a pelvic ultrasound examination to help define the lump. Ultrasound can help determine if a mass is solid or soft, if it's fluid-filled, its shape, its size, etc, all of which helps determine whether the cyst is benign and can be left alone to either regress or to be investigated some time on with another ultrasound, or whether it needs further inspection with a needle aspiration or laparoscopy, a "keyhole" look into the pelvis.

In analyzing cysts, the larger a cyst, the greater the likelihood it's malignant, although most large cysts are benign. The age of the patient is also important: an ovarian cyst that develops after menopause is much more likely to be malignant than a pre-menopausal cyst is.

Could it be endometriosis?

Endometriosis is a condition in which tissue similar to the lining of the uterus is located outside the uterus. When the lining of the uterus bleeds during the menstrual cycle, these implants also bleed. These are called endometriomas and are cysts in the ovary filled with old blood. If the symptoms persist during the menses then the pills can be taken in a continuous fashion and not interrupted for menses. Normally this occurs on the days when the empty pills are being taken. If the empty pills are ignored and an active pill is taken each day, then every day will be exactly the same. Continuous progesterone influences on the lining of the uterus produce thinning or atrophy of the uterine lining. This influence will also atrophy the endometrial implants. Hormonal suppression can also be accomplished by injection of long acting progesterone every 2 or 3 months. This drug is called Depo-Provera and can be continued indefinitely. There is also a monthly injection of a GnRH type hormone. It basically stops all pituitary and ovarian function. Pregnancy also has a beneficial effect on endometriosis because it is a time of high progesterone levels.

Are there any other tests I might have for an ovarian cyst?

We might test your CA-125 level. This test is done in women with an ovarian cyst, to see if their cyst could be cancerous. A normal CA-125 level is less than 35. However, this level can sometimes be high in women who have benign, or non-cancerous, conditions. This is particularly true in women who are still in their childbearing years.

How are cysts treated?

Most cysts are safely left alone, and are monitored with either follow-up pelvic examination or ultrasound. Some functional cysts can regress faster when a woman starts taking the birth control pill, and this will also lower the risk of getting more cysts. If, however, there is any question of malignancy, or if a cyst is causing problems such as irregular bleeding, a cyst will be either aspirated or removed for biopsy.

What type of surgery would I need?

The type of surgery you need depends on the size of your cyst, how your cyst looks on the sonogram, your CA-125 level, and if we thinks this might be cancer. If the cyst is small, about the size of a plum, if it looks benign on the sonogram and your CA-125 level is normal, we may decide to aspirate or remove by laparoscopy for biopsy.

Ultrasound-guided needle aspiration of ovarian cysts

At CRH we aspirate ovarian cysts with ultrasound guidance in women with simple ovarian cysts. The aspirations are carried out with either transabdominal or transvaginal ultrasonographic guidance with a needle visible to Doppler. All procedures take place on an outpatient basis in our ambulatory surgical center, with either anesthesia or sedation.

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