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.
