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.
Tell me more about...
