Ovarian Cysts -- What Are They, And What To Do About Them

Ovarian cysts are the cause of a great deal of anxiety and concern for many women, and much of the time they are not truly a problem. The first thing a patient needs to understand is "what is a cyst"??
By definition, a cyst is a fluid filled structure, and depending where it is located, and what type of fluid is contained within the cyst, it will have a special name. For example, a cystic structure in the labia (eg a Bartholin cyst) if infected and containing pus is called a Bartholin abscess . An infected hair follicle is called a carbuncle, or is more commonly known as a "boil".

Physiologic Ovarian Cysts:

In the ovary of a woman in the reproductive age group, who is not on the pill, there is constantly coming and going cystic structures that are essential for the development and release of an egg. Because they are part of normal ovarian function, and they come and go with the reproductive cycle, they are termed "physiologic".

In the first half of the common 28 day cycle, the maturing egg is carried to the surface of the ovary contained within a cystic structure called a "follicle". Not only does the follicle transport the egg but it also manufactures estrogen, the hormone that stimulates growth of the uterine lining, and the initiation of the intrauterine changes necessary for a fertilized egg to implant and develop the embryo. At the time of ovulation, the follicle is about the size of an olive, and when the follicle ruptures and thus releases the egg, the clear follicular fluid is replaced by blood that is released with the rupturing process. At this point our estrogen-manufacturing plant begins to additionally produce the second important reproductive hormone, progesterone. Because this new cystic structure has a yellowish appearance, it assumes a new name, the "corpus luteum" which in Latin means "yellow body". In the event that pregnancy does not occur, the corpus luteum for that cycle shrivels up about 2 weeks after ovulation, and becomes a little scarred structure called the corpus albicans, and then the process is repeated the next cycle. Both the follicle and the corpus luteum by definition are cystic structures because they contain a fluid. While normally their size is relatively small, occasionally the process gets carried away somewhat and these physiologic structures fill with either follicular fluid or blood, and may become the size of a small plum. The condition may or may not be painful, as severe stretching of the capsule of the ovary can be uncomfortable. Menstrual irregularity may often accompany these physiologic cysts. These structures can leak, or twist the ovary, and the patient often develops severe pain and tenderness. Ultrasound can be helpful in determining the size of the cyst, and maybe suggestive of its contents. There is not a direct relationship between the size of a cyst and the degree of pain. Large cysts can be silent, and small cysts exquisitely tender and painful . Unless the patient is having severe pain , enough to raise concern about possible twisting of the ovary, or possible hemorrhage from a ruptured cyst, gynecologists will tend to be conservative, and follow the patient. Because the cysts are physiologic, it is anticipated and usually is the case that the "cyst" goes away with nothing being done. Physiologic cysts are rarely bigger than a plum, and almost all will regress within a couple of cycles. If a cyst is diagnosed, some care should be taken with intercourse (or avoided altogether), as the cyst may be ruptured because of sexual trauma. Physiologic cysts of the ovary are very unusual in women on the birth control pill, because the pill suppresses ovulation. Thus, the above described events usually do not occur in terms of the ovulation process. Women past the menopause also do not ovulate, therefore they too do not develop physiologic cysts.

Pathologic Ovarian Cysts

Cystic structures that develop in the ovary that are not part of the ovulation cycle can be called "pathologic ovarian cysts". In other words, they are growths. Such growths are also called tumors, and tumors are divided into two categories, benign or malignant (Cancer). There are many different types of pathologic ovarian cysts… some contain mucous, others old blood, and fairly common in younger women a cystic tumor that contains a disorderly array of tissues found in the body such as teeth, bone, hair, fat, or even thyroid tissue. As with physiologic cysts, the size can vary, but because these cysts do not regress, fluid accumulation can occur tremendously. Further, because the cyst is filling with fluid, the cyst can grow fairly rapidly. Solid (ie non-cystic) ovarian tumors usually enlarge slowly over many months. Cystic tumors may enlarge rather dramatically over weeks or a few months.

A few years ago, I removed a benign ovarian cyst, that was the size of soccer ball, and weighed 10 pounds. The thin patient appeared as if she was about 6 months pregnant. That very day at Stanford University, the gynecologists removed a benign cyst that weighed an incredible 405 pounds!!! The larger cysts become, the more likely they are to so destroy adjacent healthy ovarian tissue, that salvaging the involved ovary may be impossible. Salvaging the ovary can only be accomplished if the gynecologist is sure that the tumor is benign.

Management of Ovarian Cysts

The following remarks are the usual approaches to cyst management:

1. In a woman in the reproductive age group, who is not on the pill ( or Depo provera), given a cystic structure smaller than a plum, and the absence of severe pain that would mandate surgical intervention, conservative observation is acceptable. Many physicians will perform an ultrasound to precisely measure the size of the cyst, and evaluate the contents. Pathologic cysts sometimes develop tissue partitions ( called septations) so that on ultrasound one can see many different fluid compartments. Also pathologic cysts may develop tissue growths into the cyst, so the wall is not smooth, and these are called "excrescences". Septations and excrescences are not seen in physiologic cysts thus surgical intervention may be warranted immediately
2. Conservative surgery may be undertaken if the cyst is not malignant, and the patient wishes to salvage the ovary if possible. This is called an ovarian cystectomy. Unfortunately, the ovary which is opened surgically has a propensity for the development of adhesions, which may result in pain, or tenderness with intercourse, or even infertilty. Surgical technique requires that tissue injury be minimal, that all bleeding is meticulously secured, and the use of adhesion barriers be considered. If the ovary is extensively involved in the cystic process, and the other ovary is normal, removal of the involved ovary may be indicated. The ovarian cystectomy may be performed laparoscopically ( through tiny incisions as an outpatient) or through a conventional incision. The former approach results in much less pain, less disfigurement, and faster recuperation.
3. Hysterectomy and removal of the ovaries may be the appropriate choice of therapy depending on the type of cyst, the age of the patient and possible other pelvic disease. A good example would be a woman who has had her family, the cyst proves to be a collection of very old blood that is seen with endometriosis (an endometrioma, also called a "chocolate cyst"), and endometriosis is found elsewhere in her pelvis. This more aggressive surgery is very likely to be definitive, and forever solve her problem. Ovarian cancer is obviously a condition that must be dealt with very aggressively, as it is associated with relatively low survival.

J. Glenn Bradley, MD
OBGYN.net Editorial Advisor

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