What is Ovarian Cyst?
The adnexa refers to the areas near the uterus, including the ovaries and fallopian tubes. This text will mainly focus on the ovaries and the different types of cysts that can grow there. The ovaries are attached to the uterus and are covered by a structure called the mesovarium, which is part of the broad ligament – a major supportive tissue in the female reproductive system. The ovaries are also connected to the walls of the pelvis. The ovarian artery, directly branching off the main body artery called the aorta, delivers blood to the ovaries.
In women who are not yet menopausal, their ovaries produce multiple follicles, tiny sacs filled with fluid that could potentially house an egg, each month. Among these, one becomes the dominant follicle that matures and releases an egg in a process called ovulation.
As a result of ovulation, a fluid-filled sack, or otherwise known as an ovarian cyst, can form on one or both of the ovaries. Ovarian cysts or adnexal masses, are not rare; in fact, 20% of women will develop at least one pelvic mass during their lifetime. There are over thirty types of these masses, each of which may be managed differently depending on the mass characteristics, the age of the woman, and the risk factors for cancer. For women of child-bearing age, most ovarian cysts are functional (related to the menstrual cycle) and non-cancerous, and they do not need to be removed. However, complications can occur such as pelvic pain, rupture of the cyst, bleeding, and twisting of the ovary, all of which require quick medical attention.
What Causes Ovarian Cyst?
Ovarian cysts, or abnormal fluid-filled sacks in the ovaries, can develop because of various reasons. They go from natural bodily functions like menstrual cycle-related cysts, to more serious issues like ovarian cancer. While these cysts can appear at any age, they are typically more prevalent in women of reproductive age due to the hormones produced during menstruation. Simple cysts, which are filled with fluid, are the most common across all age groups.
However, mixed cysts (part solid, part fluid-filled) or entirely solid ovarian bumps are more closely linked with cancer than simple cysts. Even though the majority of ovarian cysts are harmless, age is a crucial factor. Especially after menopause, women with any type of cyst should be closely monitored and treated due to a heightened risk for cancer.
Several risk factors can increase the chance of ovarian cyst formation. These include infertility treatments where hormones or other agents that stimulate ovulation may lead to cyst formation as a side effect. Tamoxifen, a medicine used to treat breast cancer, is another risk factor. Pregnancy, specifically during the second trimester when the hormone hCG peaks, is also a time when ovarian cysts may form.
Furthermore, hypothyroidism (when the thyroid gland doesn’t produce enough hormones), is a risk factor too. Maternal hormones that cross the placenta can also cause cysts to form in a fetus. Smoking and having a procedure that closes off or removes the fallopian tubes (tubal ligation) have also been linked with functional cysts, which are cysts that appear during the menstrual cycle.
Risk Factors and Frequency for Ovarian Cyst
It is difficult to measure the real number of ovarian cysts as a lot of patients do not show symptoms and hence, remain undiagnosed. Also, the prevalence varies with the population studied. By the age of 65, roughly 4% of women are admitted to the hospital due to ovarian cysts. In a study of 335 women aged 24 to 40 without symptoms, nearly 8% had a type of ovarian lesion. A different study showed that 2.5% of postmenopausal women had a certain type of ovarian cyst. In a larger survey of almost 34,000 women (both pre and post-menopausal), just below half had a cyst on a specific ultrasound, with 63.2% of these showing improvements on later ultrasounds.
It is also seen that 18% of postmenopausal women can experience one or more Graffian follicles that show up as cysts on imaging, but most of these cysts are harmless. Over 10% of all ovarian growths are mature cystic teratomas or dermoids and ovarian cysts can be found in infants and fetuses being the most common tumor with a prevalence of over 30%. In terms of annual rates in the United States, ovarian carcinomas leading to 14,600 deaths are diagnosed in more than 21,000 women.
Signs and Symptoms of Ovarian Cyst
While ovarian cysts are often discovered during routine physical exams or pelvic imaging, a thorough review of each patient’s medical history, gynecological history, and family history is still necessary. Ovarian cysts can either produce symptoms or be symptom-free. Some women might feel one-sided lower abdominal pain or pressure, which can come and go or be constant. The pain might be piercing or dull. Acute severe pain can occur suddenly if an ovarian cyst bursts or if the ovary twists, a condition known as ovarian torsion. This severe pain could be accompanied by nausea and vomiting. Women may also notice an irregular menstrual cycle or unusual vaginal bleeding.
During an examination, the health professional may try to feel the ovaries through a bimanual exam, to check their location, shape, size, firmness, tenderness, and mobility. However, feeling the ovaries can be challenging depending on the woman’s body shape, the experience of the health provider, and the anatomy of the pelvis. Consequently, a pelvic examination may not be enough to diagnose ovarian cysts.
- One-sided lower abdominal pain or pressure
- Pain type: intermittent or constant, sharp or dull
- Sudden severe pain if a cyst ruptures or ovary twists
- Nausea and vomiting
- Irregular menstrual cycle
- Unusual vaginal bleeding
Testing for Ovarian Cyst
When a doctor suspects a growth on an ovary, they first need to figure out if the patient is pre or postmenopause, basically whether or not they still get periods. If the patient is premenopausal, the first step would be to take a pregnancy test via blood or urine. Once pregnancy has been ruled out, the doctor would then use imaging like ultrasound to get a better view of the ovaries.
The doctor would also order a blood test to measure levels of hematocrit and hemoglobin. These tests help to check if the patient has anemia, a condition where the body doesn’t produce enough healthy red blood cells, which can be caused by severe bleeding. They would also test the patient’s urine to check for any urinary tract infections or kidney stones. Additionally, a sample would be collected from the cervix to check for pelvic inflammatory disease, an infection of the female reproductive organs.
The doctor could also check for a protein called Cancer antigen 125 (CA125), which is found on the surface of both healthy and cancerous ovary cells. The normal level of this protein in the blood is less than 35U/ml. In 85% of cases where there’s ovarian cancer, CA125 levels are higher than normal. However, in cases where the cancer is at an early stage and has not spread beyond the ovary, only half of patients see an increase in their CA125 levels. This protein can give more helpful information when combined with an ultrasound scan.
Ultrasound is usually the first imaging test done when a doctor suspects an ovarian mass. It’s preferred because the probe can be placed very close to the ovaries, giving a clearer image. The doctor can use it to tell whether the growth is likely to be benign (non-cancerous) or malignant (cancerous). They’d also check whether one or both ovaries are affected, the size of the growth, its appearance (whether filled with fluid or solid, or a mix of both, whether it has partitions, outgrowths or nodules), whether there’s fluid in the pelvis and check the blood flow to the ovaries.
It’s also important to check that the ovary hasn’t twisted around itself, a condition known as ovarian torsion. This can block blood flow and cause the ovary to die. However, a normal blood flow detected via ultrasound does not necessarily rule out ovarian torsion.
Certain findings on ultrasound like a cyst larger than 10 cm, mass with multiple compartments, outgrowths or solid parts, irregular shape, thick partitions, evidence of fluid in the abdomen, and increased blood flow should raise concerns of cancer and further testing would be needed. In some cases, other imaging tests like MRI or CT scans could also be done, but they are not typically used initially. If there’s a strong suspicion of cancer, a specialist known as a gynecologic oncologist would be involved in the patient’s care.
Treatment Options for Ovarian Cyst
The best way to treat ovarian cysts depends on several factors including a person’s age, whether they have gone through menopause, the size of the cyst, and whether it’s suspected to be cancerous. Generally, cysts that are smaller than 10 cm are noncancerous, regardless of a person’s age. If you have such a cyst and don’t have any symptoms, monitoring the cyst with ultrasound is usually an option. Ultrasound is a medical test that uses sound waves to create a picture of the inside of the body. Doctors often take a “wait and see” approach because most cysts go away without any treatment. But if a cyst doesn’t go away after several menstrual periods, it’s probably not a “functional” cyst (which should disappear on its own), so more tests could be needed.
Fetal ovarian cysts, on the other hand, are caused by hormonal changes. These cysts have been associated with maternal diabetes and fetal hypothyroidism (an underactive thyroid gland in the baby). Most fetal ovarian cysts are small and go away during the first few months of life, so they aren’t usually a cause for concern. These cysts are typically found in the later stages of pregnancy and usually disappear between two and ten weeks after a baby is born.
While some ovarian cysts can develop during pregnancy, majority of them go away naturally by the 14 to 16 weeks of pregnancy. If a pregnant woman has a large cyst (bigger than 5 cm) or one with a complex shape, it might not go away naturally. If a cyst is less than 6 cm and simple in nature, the risk of it being cancerous is less than 1%.
Women with endometriomas, a type of cyst caused by endometriosis, or dermoid cysts, a type often present at birth, should have ultrasound scans every six to twelve months. These scans should continue until the cysts can be removed surgically.
Certain conditions may call for surgery, such as suspected condition where the ovary twists around the ligaments that hold it in place (ovarian torsion), persistent mass of the ovary or its surrounding structures (adnexal mass), severe abdominal pain, or a suspected cancerous cyst. When performing surgery on pre-menopausal women, the priority is to preserve fertility. As such, surgeons try to remove as little ovarian tissue as possible. Pregnant women too may have cysts needing surgery. While minimally invasive surgery (laparoscopy) can be safely done at any stage of pregnancy, it is preferably scheduled for the second trimester when possible.
What else can Ovarian Cyst be?
When a doctor thinks a patient might have an ovarian cyst, there are several other health conditions they must consider, or rule out, before making a diagnosis. These potential health issues are divided into two categories: gynecological and non-gynecological.
For gynecological conditions, these could include:
- Benign conditions such as a functional cyst, endometrioma, tubo-ovarian abscess, mature teratoma, serous cystadenoma, mucinous cystadenoma, paratubal cyst, hydrosalpinx, or leiomyomas
- Malignant conditions like epithelial carcinoma, germ cell tumor, sex cord or stromal tumor, or metastatic cancer
- Pelvic inflammatory disease
- Ectopic pregnancy
For non-gynecological conditions, these might include:
- Appendicitis
- Diverticulitis
- Pelvic kidney
- Gastrointestinal cancer
- Urinary Tract Infection (UTI)
- Kidney Stones (Nephrolithiasis)
- Psoas abscess or an abscess in the psoas muscle
It is important for the doctor to consider all of these possibilities and conduct the necessary tests to reach an accurate diagnosis.
What to expect with Ovarian Cyst
Most ovarian cysts are discovered by chance, usually don’t cause any symptoms, and are usually harmless. Some might disappear on their own, which brings a positive outlook for those who have them. In fact, between 70% to 80% of one type of ovarian cyst, called follicular cysts, go away without any treatment.
There has been a theory that a certain type of benign (non-cancerous) ovarian cyst, known as cystadenoma, might become cancerous, but this theory is not confirmed yet. Cysts that are less likely to become cancerous generally have a harmless course.
In such instances, the overall survival rate is usually 86.2% after five years. However, in rare cases, some types of cysts like dermoid cysts and those linked to a condition called endometriosis, can become cancerous, and this generally carries a poor outlook.
If a cyst is suspected to be cancerous, the outlook usually isn’t favorable since ovarian cancer is often detected in later stages. This makes it crucial to have regular check-ups to detect any changes as early as possible.
Possible Complications When Diagnosed with Ovarian Cyst
Ovarian cysts can lead to three typical complications that often result in emergency room visits:
- Rupture of ovarian cysts
- Bleeding from ovarian cysts
- Twisting of ovarian cysts, also known as torsion
The fifth most common gynecological emergency is ovarian torsion. It happens when the vessels in the ovary twist fully or partially, blocking blood flow to the ovary. Diagnosing this condition involves a mix of evaluating a patient’s medical history, a physical exam, lab tests, and medical imaging. The final confirmation usually happens through a diagnostic laparoscopy, a surgical procedure that allows doctors to view the area. Current best practices suggest a gentle approach during the laparoscopy and the untwisting of the ovary to save fertility, with or without cyst removal.
Ovarian cysts can also rupture or bleed, often from physiological causes. Most patients experience mild to moderate symptoms without complications, and they usually can be managed with a “wait and see” approach if their vital signs remain stable. However, in some cases, this can lead to significant blood loss, potentially causing instability in their blood pressure and heart rate, which may require hospital stay, surgery, and transfusion of blood.
Recovery from Ovarian Cyst
When a person needs surgery, two common methods are a laparoscopy and a laparotomy. Both procedures have their advantages and drawbacks. A laparotomy, which involves larger incisions, is often chosen if the patient’s vital signs like blood pressure and heart rate are unstable. This is because it allows the surgeon to quickly access and visually examine the problem area. However, the larger incision often results in more severe post-surgery pain, a longer hospital stay, and a longer recovery period.
On the other hand, laparoscopies involve smaller incisions and are more time-consuming procedures. The benefits include a lower risk of infection and less blood loss compared to laparotomies. The downside is that because the surgery takes longer, the patient is exposed to general anesthesia for a longer period of time, which can increase the risk of damage to internal organs and blood vessels.
If a laparoscopy is performed and the patient’s vital signs are stable, they often are able to go home on the day of the surgery itself. Doctors would, of course, provide post-surgery guidelines and schedule proper follow-up checks to monitor recovery.
Preventing Ovarian Cyst
Ovarian cysts are little pouches filled with fluid that can sometimes form in the ovary. Most of the time, they’re harmless and go away on their own. They’re often discovered by accident during check-ups or other imaging procedures. However, sometimes, these cysts can grow too big. When that happens, they can make the ovary turn in on itself, cutting off its own blood supply. This situation, known as ovarian torsion, is a serious medical emergency which needs to be fixed with surgery.
Additionally, ovarian cysts can sometimes burst which can lead to dangerous bleeding. It’s typically best to remove larger cysts to prevent complications like these. If anyone suddenly starts feeling sharp pain on one side of their lower belly, especially if it’s linked with feelings of nausea or vomiting or following intense activities like sex or exercise, they should seek medical help urgently.