Ovarian Cysts

One of the most common and yet one of the most misunderstood problems in gynecology are ovarian cysts. I hope this pamphlet clears up any confusion.

INTRODUCTION

Ovarian cysts are extremely common. They are far more common than most people realize. Nonetheless, when I have to tell someone that they have an ovarian cyst, it is not uncommon for a sudden look of panic to cross their face. I hope this pamphlet helps to allay your anxieties.

I have had ultrasound machines in my office for twenty years. During that time, I have literally done thousands of ultrasounds and I can tell you that hardly a day goes by that I do not find a cyst that would otherwise have been missed had the ultrasound not been done.

My own personal experience as well as several research studies has clearly shown that pelvic exams are incredibly inaccurate. It is my opinion that an ultrasound is as important and as integral to a pelvic exam as a cardiogram would be if you went to a cardiologist. I firmly believe that every gynecologist should have an ultrasound machine in his or her office and that every patient should have an ultrasound done once a year just the same way they have a pap smear. Of course, the insurance companies would go ballistic over such a thought because it interferes with their profits but the evidence is overwhelming that it is important.

The ovary forms more cysts, tumors, and other abnormal structures than probably any other organ in the body. Ovarian cysts are extremely common, especially in women with the types of problems that I see such as Poly-Cystic Ovary Syndrome and other hormone problems, endometriosis, and chronic pelvic pain. Contrary to popular myth, the vast majority of ovarian cysts do not cause pain or other symptoms. If for no other reason, this is why many women are surprised to learn that they have a cyst. People have been led to believe that cysts cause pain - the vast majority do not.

The purpose of this pamphlet is to explain to you what a cyst is and how it develops. I hope that it gives you enough basic information so that we can then discuss whatever problem you may have more completely in the office.

A cyst, no matter where in the body it might be found, is simply any structure which contains fluid. It doesn't matter what type of fluid - only that it contains a fluid.

If there is an abnormal structure somewhere in the body that is solid, we call it a tumor. Tumors may be benign or they may be malignant.

To further confuse the situation, particularly in the ovary, some tumors may have fluid areas within them. These are termed "cystic tumors". Conversely, some cysts may have small solid areas contained within them as well.

It is critically important to understand that in a normally ovulating woman, the ovary forms a cyst every month. That cyst is called the follicle and it is the structure in the ovary in which the egg is growing.

As has been pointed out in other pamphlets, a woman is born with all the eggs she is going to have - one million at birth and around 400,000 at puberty. Once a woman goes through puberty, about 100 to 150 eggs begin to develop everyday. It does not matter whether you are pregnant, whether you are on birth control pills, whether your periods are regular or irregular, or just about anything else. Some of those eggs begin to develop.

The egg and the cells of the ovary that surround it is called the follicle. In its most basic inactive state, the follicle consists of the egg with a single layer of ovarian cells around it like a string of pearls. As the egg begins to develop, those cells around it multiply and the follicle grows in size. When it reaches a certain critical size, fluid begins to accumulate between the cells of the follicle. This fluid then begins to come together and a small cyst is formed.

In a normally menstruating woman, only one egg is selected each month to go on to full maturity and ovulation. No one knows the mechanism by which that one egg is selected but, nonetheless, all of the other eggs that had begun to develop die. They are eventually absorbed by the body. If those other eggs have reached a stage in their development where some fluid has begun to accumulate you would see multiple tiny cysts within the ovary. In fact, when you have an ultrasound, it is very normal and very common to see a number of these tiny cysts representing follicles in various stages of development. They are supposed to be there.

In a woman who is normally ovulating, the one egg that is going to go on to full maturity continues to develop. As it grows, more and more fluid is accumulated in the follicle and by the time the egg is fully mature, the follicle has reached a diameter of between 20 and 25 mm. This is easily seen on ultrasound.

Once the egg is fully mature, the wall of the follicle ruptures and the egg is expelled (ovulation). After ovulation, the follicle undergoes a transformation and becomes the corpus luteum. The corpus luteum is a solid structure and is normally not seen on ultrasound.

If something goes wrong with the ovulatory process, this orderly maturation of the follicle is disrupted. As a result, numerous problems can develop. Although the problems may appear different, they all share a common thread - something has thrown the normal ovulatory process off track. That something may be a one time episode - no woman ovulates normally every month. It may also be an indicator of some underlying chronic hormonal problem that requires further evaluation.

As a corollary to all this, I hope you can now understand that it is critically important to know where a woman is in her menstrual cycle when interpreting an ultrasound. If I see a cystic structure when a woman is presumably at mid-cycle, I am confident in calling it a follicle although I also run hormone levels to confirm.

However, if a cystic structure is seen at a time of the cycle when it should not be present, then it is a cyst and not normal.

If a woman does not ovulate at all or ovulates very infrequently, particularly if she is overweight; is making too much androgen (male hormone), etc., we say that she has Poly-Cystic Ovary Syndrome. This is a terrible term but it has been around for over 65 years and we are stuck with it.

In a woman who has Poly-Cystic Ovary Syndrome, the ovulatory process is never or infrequently completed. As a result, the ovary fills up with numerous follicles that have only begun to develop. Many of these follicles have accumulated small amounts of fluid - hence, the ovary has multiple tiny cysts within it. It is "Poly-Cystic".

This is a descriptive term only. You can get a "poly-cystic ovary" from many different causes. At the time the syndrome was named, people were confusing cause with effect.

On the other side of the coin, when the ovulatory process is disrupted for whatever reason, sometimes the follicle never develops properly, the egg never fully matures, and the follicle begins to accumulate more fluid than it should. It continues to grow beyond its normal size. It becomes a "follicle cyst".

In a normally menstruating woman, the follicle never gets bigger than 30 mm. in diameter. Any follicle that is larger than 30 mm. is termed a follicle cyst.

In some women, particularly those with endometriosis, sometimes the ovulatory process in disrupted such that the follicle wall never ruptures and the egg is never expelled. However, the hormonal changes are still occurring so that the follicle still undergoes a transformation to the corpus luteum. Because the egg is not expelled, the fluid is not expelled as well. It is retained within the ovary and is easily visible following the time that ovulation should have occurred. This is termed the "unruptured follicle syndrome" and is easily diagnosed when a woman is being tracked through a menstrual cycle if she is having a fertility problem.

In a normally ovulating woman, when ovulation occurs and the follicle is transformed into the corpus luteum, a small amount of bleeding occurs. Usually the amount of blood is very small and is of no significance. Occasionally, however, there can be more than the average amount of bleeding. This blood is then trapped inside the corpus luteum and because blood is a liquid, it becomes visible on ultrasound. If this should occur, we call it a hemorrhagic corpus luteum. If the hemorrhagic corpus luteum stays around for awhile, eventually the body will breakdown the red blood cells but the other liquid (the serum) remains. Eventually, the fluid inside the hemorrhagic corpus luteum is transformed from blood to a yellowish fluid. We call this a luteal cyst.

All of the problems that I have just discussed describe the cause of what are termed "functional cysts". By this term, we mean that they are cysts that develop as a result of the abnormal functioning of the ovary. They simply represent the ovulatory process that has been thrown off track for whatever reason.

Functional cysts will usually disappear with simple observation although it may take several months to do so.

All other types of cysts within the ovary represent true pathology. They are cystic tumors. These cystic tumors, particularly in younger women, are almost always benign.

There is one type of cyst that is not functional but is not, strictly speaking, a cystic tumor either. We are referring to endometriosis cysts of the ovary. Endometriosis cysts form when an implant of endometriosis on the surface of the ovary burrows its way into the ovarian tissue. As the endometrium in the endometriosis implant goes through a "menstrual cycle" each month and bleeding occurs, then that blood begins to accumulate within the ovary. As that blood persists for an extended period of time, it eventually turns brown and takes on an appearance that is almost identical to Hershey's chocolate syrup. As a result, these cysts are called "chocolate cysts".

They are cysts in the true definition of the term because they are a structure within the ovary that contains fluid. However, the way they got there is unique to endometriosis and they are, therefore, as we have mentioned, not strictly functional cysts but they are not really cystic tumors.

How does a woman know she has an ovarian cyst? The fact is, in the vast majority of cases, cysts produce no symptoms. We know this is contrary to what everyone believes. Nonetheless, the vast majority of cysts that we discover in our office are producing no symptoms whatsoever and the woman is completely unaware that she has them.

Sometimes the cyst may be indicative of other problems and may be causing indirect symptoms such as irregular bleeding, etc. However, usually attributed to a cyst such as pain are present only in the minority of instances.

When cysts do produce symptoms, pain is usually the principal one. The pain will be located on the side of the cyst and it may range in severity from a vague discomfort all the way up to very very severe pain. The later is very uncommon and usually indicates something far mare serious than just the presence of a cyst.

Cysts are not infrequently associated with menstrual abnormalities. Sometimes it is the problem causing the menstrual abnormality that interferes with normal ovulation and allows the development of a cyst. In other instances, a cyst may develop for a variety of reasons. Any foreign body in the ovary such as a cyst can and frequently does disrupt the normal functioning of that ovary. This then leads to irregular menstrual cycles which then brings the woman into the office for evaluation. Subsequently, a cyst may be found.

As we have noted, one of the most common myths is that cysts cause pain. Some do - most don't.

One of the most common stories we hear involves women who sought help because of pelvic pain. Very often these women are told that their pain is due to a cyst that burst. Right? WRONG.

The scenario usually goes something like this. The woman is experiencing pain and she either goes to a physician or to a hospital emergency room. An ultrasound is done and fluid is seen in the pelvis. The woman is told that she had a cyst that burst.

Everyone is happy with this explanation. It sounds very logical. It sounds very reasonable. The woman is happy because she has been given an explanation that makes sense to her. The doctors are happy because that woman is not bothering them anymore with questions. It all sounds very nice - it just doesn't happen to work that way.

The fact of the matter is, as we have already said, cysts do not usually cause pain. Even if you did have a cyst and it ruptured, the fluid that would spill into the abdomen would be a relatively small amount - not enough to show up on ultrasound. Furthermore, the fluid that might spill would be fairly rapidly absorbed.

A woman would have pain. She would then call her physician for an appointment - delay number one. Once she got to her physician, an ultrasound would be ordered. Since most Gynecologists do not have the ability to perform their own ultrasounds, you would have to call the hospital for an appointment - delay number two. By the time you actually got to the hospital for the ultrasound, several days would have elapsed. Therefore, any fluid that might be seen on the ultrasound had absolutely nothing to do with that cyst that was supposed to have ruptured.

Keep in mind that in normally ovulating women, an ovarian cyst ruptures every month. The follicle in which the egg develops is a cyst. The process of ovulation involves the rupture of the follicle wall followed by the expulsion of the egg. This does not cause pain. The pain that women experience at the time of ovulation is due to the rapid growth of the follicle with stretching of the follicle wall just prior to ovulation. Ovulation with collapse of the follicle actually relieves the pain.

In the vast majority of women that we see, the explanation for their pelvic pain is endometriosis. Some studies have shown that women with endometriosis have larger amounts of fluid in their pelvis than women who do not have endometriosis. This is the most logical explanation that we can think of to explain this common story.

There are only two treatment options available to deal with ovarian cysts - you can either watch them for awhile or you can operate on them. Sometimes the choice is quite simple and straightforward; sometimes it is not quite so easy.

There are numerous factors that must be evaluated before arriving at the best treatment choice. The age of the woman is obviously of considerable importance; the symptoms that the cyst might be producing is important; whether the cyst is solitary or one of many must be considered; and what other factors may also be present that might give you a clue as to what type of cyst it might be plays a role as well.

Perhaps the most important factor in the decision making process is the appearance of the cyst on ultrasound. Cysts can be separated into two principal categories - simple and complex. Clear fluid on an ultrasound is homogeneous and black. If the cyst is solidly black and the wall of the cyst is smooth and sharp, then the likelihood is that it is not anything of significance and can be watched for awhile. This is true even in a woman who is postmenopausal providing the cyst is less than 5 cm. in diameter and the CA-125 level is normal.

The other type of cyst that could be present is "complex". A complex cyst can have several features on ultrasound. First, there could be numerous echoes inside the cyst. The cyst could have internal walls; the margins of the cyst could be irregular; there could be evidence of small solid masses attached to the cyst wall; etc. Any of these features would immediately make the cyst somewhat more suspicious.

Another important factor, as I have mentioned, is the woman's age. The older the woman the more concerned one needs to be. The thing everyone worries about, of course, is cancer. Ovarian cancer in young women is rare.

If the decision is made to simply observe the cyst, then periodic ultrasounds, usually every month or so, are performed to make sure the cyst is not growing and, hopefully, shrinking and ultimately disappearing.

If the decision is made that surgery is the appropriate treatment, this is usually done through a laparoscope. Depending upon numerous factors, the cyst may simply be opened, drained, and a portion of the cyst wall taken for biopsy to establish its true nature. Unfortunately, with occasional exceptions, the appearance of the cyst on ultrasound only gives you a general idea of what type it is - it cannot tell you definitively.

Sometimes the entire cyst wall is removed - sometimes this is technically almost impossible without damaging the ovary significantly.

Occasionally, again depending upon the age of the woman and other factors, the entire ovary may be removed.

It is critically important to understand that there is nothing that can be done to make a cyst disappear without surgery. I know that women are frequently given birth control pills in an attempt to "dissolve" the cyst. This is useless therapy. Again, it is based upon erroneous assumptions. Women have frequently been given birth control pills and a certain number of cysts will disappear. It was, therefore, concluded that the pill made the cyst disappear. Very nice in theory - it just happens to be incorrect. All that taking birth control pills do is give the woman something to pass the time while the cyst is going away on its own.

In my experience, over 90% of cysts in pre-menopausal women will disappear, regardless of whether they are simple or complex. They will do this within 3-4 months without any hormonal therapy of any kind.

Some cysts (usually functional cysts) are going to go away on their own in the vast majority of instances without any specific treatment whatsoever. Other types of cysts are never going to go away on their own and require surgery.

Several studies have been done putting women on birth control pills and following their cysts. Those cysts that were going to go away on their own would do so whether the woman was taking the pill or not. Those cysts that were not going to go away on their own remain - again, regardless of whether the woman was taking the pill or not. All the pill really does is give you something to do everyday while you are waiting to see whether your cyst is going to disappear spontaneously. The pill may correct any irregular bleeding associated with the cyst but it is not going to make the cyst go away and it is certainly not going to make a cyst go away that would otherwise remain.

Symptoms

Treatment