Ovarian Cysts

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Ovarian Cysts Quick Overview

  • Ovarian cysts are fairly common. They are fluid-filled sacs that form in or on a woman's ovaries.
  • Symptoms of ovarian cysts depend to a large extent on the size of the cyst. Many ovarian cysts produce no symptoms. Large or ruptured ovarian cysts can cause symptoms including pain, pelvic pressure or discomfort.
  • Vaginal (pelvic) ultrasound can be used to reveal the presence of ovarian cysts.
  • Ovarian cysts can vary in size. Many are very small, while cysts associated with ovarian tumors may be 12 inches or more in diameter.
  • In some cases ovarian cysts can cause problems with menstrual periods such as abnormal or irregular bleeding. Spotting (light bleeding) from the vagina can also occur due to some ovarian cysts.
  • Very rarely, cysts on the ovaries are part of ovarian cancers. Benign functional ovarian cysts do not cause cancer, and the vast majority of ovarian cysts are benign.
  • Some types of ovarian cysts (polycystic ovary syndrome and cysts related to endometriosis) may make it more difficult for a woman to get pregnant.
  • Simple ovarian cysts (functional cysts) can sometimes be seen during pregnancy. Dermoid cysts and other types of cysts can also occur in pregnant women.
  • The sudden onset of severe pain is the characteristic symptom of a ruptured (burst) ovarian cyst.
  • Treatment of ruptured ovarian cysts involves medications for pain control. Ruptured dermoid cysts may require surgery due to irritation of the internal organs from the contents of the cyst.
  • Larger cysts may require surgery to remove the cyst or a biopsy to rule out cancer.

What Are Ovarian Cysts?

Ovarian cysts are small fluid-filled sacs that develop in a woman's ovaries. Most cysts are harmless, but some may cause problems such as rupture, bleeding, or pain. Moreover, surgery may be required in certain situations to remove the cyst(s). It is important to understand the function of the ovaries and how these cysts develop.

What are the ovaries and what is their function?

Women normally have two ovaries that store and release eggs. Each ovary is about the size of a walnut, and one ovary is located on each side of the uterus. One ovary releases an egg each month, and this process is called ovulation. Ovulation occurs in roughly the middle of a woman's monthly menstrual cycle. The egg is enclosed in a sac called a follicle. An egg grows inside the ovary while estrogen (a hormone released by the ovary) prepares the uterus for a developing pregnancy. Estrogen causes the lining of the uterus to grow and thicken so as to prepare for implantation of the fertilized egg resulting in a pregnancy. This cycle occurs each month. If the egg is not fertilized, the contents of the uterus are then expelled resulting in the onset of a menstrual period. The first day of bleeding is considered the first day of the ensuing menstrual cycle.

Who Gets Ovarian Cysts?

Ovarian cysts are common and affect women of all ages. The vast majority of ovarian cysts are functional (i.e. they are a by-product of hormonal fluctuations that occur during a menstrual cycle). Although they may become problematic they do not indicate a specific disease process. Most ovarian cysts are not cancerous (benign), and many disappear on their own without treatment over the course of several weeks. While malignant cysts may be found in conjunction with ovarian cancer, ovarian cysts are typically not cancerous. Ovarian cysts most commonly occur during a woman's childbearing years.

What Are the Signs and Symptoms of Ovarian Cysts?

Usually ovarian cysts do not produce symptoms, and are found during a routine physical exam. They also may be seen as an incidental finding on an ultrasound performed for other reasons. However, symptoms can be present, especially with large cysts or ruptured cysts. These are variable and may include:

  • Pain with sexual intercourse, especially with deep penetration
  •  Lower abdominal or pelvic pain. This may be intermittent, or can be severe, sudden, and sharp
  • Irregular menstrual periods
  • A feeling of lower abdominal or pelvic pressure or fullness
  • Chronic pelvic pain or low back pain throughout the menstrual cycle
  • Pelvic pain following exercise or vigorous activity
  • Pain or pressure with urination or bowel movement
  • Nausea and vomiting
  • Vaginal pain or spotty bleeding from the vagina
  • Infertility
  • Problems having bowel movements
  • Feeling pressure to have a bowel movement
  • Abdominal tenderness
  • Abdominal distension
  • Bloating
  • Feeling of abdominal fullness
  • Heartburn
  • Indigestion
  • Feeling full early when eating
  • Problems with the control of urination

A ruptured ovarian cyst typically causes severe pain that comes on suddenly. This most commonly occurs in the mid-menstrual cycle and often happens following sexual intercourse or exercise.

What Do Ovarian Cysts Look Like (Pictures)?

On an ultrasound image, ovarian cysts may resemble bubbles. The cyst usually contains only fluid, and it is surrounded by a very thin wall. This appearance on ultrasound identifies what is called a simple cyst. If a follicle fails to rupture and release an egg, the fluid remains and can form a cyst in the ovary. This usually affects one of the ovaries. Small cysts (smaller than one-half inch) may be present in a normal ovary while follicles are being formed.

An ovary containing small cysts on endovaginal ultrasound (looks similar to a chocolate chip cookie).
An ovary containing small cysts on endovaginal ultrasound (looks similar to a chocolate chip cookie). Click to view larger image.

An ultrasound image of a functional ovarian cyst. The round, dark, bubblelike structure is a cyst present on the ovary.
An ultrasound image of a functional ovarian cyst. The round, dark, bubble-like structure is a cyst present on the ovary. Click to view larger image.

How Big Is an Ovarian Cyst(s)?

The size of ovarian cysts is variable, ranging from less than one inch up to 4 inches. Uncommonly, ovarian cysts can form extremely large masses that measure 12 inches or more in diameter.

What Are the Types of Ovarian Cysts?

The most common types of ovarian cysts are:

Follicular cyst: A follicular cyst is simple cyst can form when ovulation does not occur or when a mature follicle involutes (collapses on itself). A follicular cyst usually forms at the time of ovulation, and can grow to about 2-3 inches in diameter. The rupture of this type of cyst can create sharp severe pain on the side of the involved ovary. This sharp pain (sometimes called mittelschmerz) occurs in the middle of the menstrual cycle, during ovulation. About one-fourth of women with this type of cyst experience pain. Usually, these cysts produce no symptoms and disappear by themselves within a few weeks or months.

Corpus luteum cyst: A corpus luteum cyst is a functional ovarian cyst that occurs after an egg has been released from a follicle. Following ovulation, the follicle becomes what is known as a corpus luteum. If a pregnancy doesn't occur, the corpus luteum usually breaks down and disappears. It may, however, fill with fluid or blood and persist on the ovary. Usually, this cyst is found on only one side and produces no symptoms.

Hemorrhagic cyst: A hemorrhagic cyst is a functional cyst that occurs when bleeding occurs within a cyst. Symptoms of this type of cyst is abdominal pain on one side of the body.

Dermoid cyst: A dermoid cyst is a benign tumor sometimes referred to as mature cystic teratoma. It is an abnormal cyst that usually affects younger women and may grow to 6 inches in diameter. A dermoid cyst can contain other types of body tissues such as fat and occasionally bone, hair, and cartilage.

The ultrasound appearance of this type of cyst can vary because of the spectrum of its contents, but a CT scan and magnetic resonance imaging (MRI) can show the presence of fat and/or dense calcifications. These cysts can become inflamed. They can also cause the ovary to twist on a stalk (a condition known as ovarian torsion), compromising the blood supply and causing severe abdominal pain.

Endometriomas or endometrioid cysts: Endometriomas or endometrioid cysts are a manifestation of the condition known as endometriosis, this type of cyst is formed when endometrial tissue (the lining tissue of the uterus) is present on the ovaries. It affects women during the reproductive years and may cause chronic pelvic pain both associated with, and remote from, menstruation.

Endometriosis is the presence of endometrial glands and tissue outside the uterus. Women with endometriosis may have problems becoming pregnant. Endometrioid cysts, often filled with dark, reddish-brown blood, may range in size from 0.75-8 inches. Due to the color of the old blood frequently found within the cysts, they have been referred to as "chocolate cysts."

Polycystic ovaries: A polycystic ovary is diagnosed based on its enlarged size - usually twice that of normal - with many small cysts underlying the surface of the ovary. This condition can be found in healthy women and in women with hormonal (endocrine) disorders. An ultrasound may be helpful in diagnosing this condition.

Polycystic ovary is different from the polycystic ovarian syndrome (PCOS), which includes other symptoms and physiological abnormalities in addition to the presence of ovarian cysts. Polycystic ovarian syndrome involves metabolic and cardiovascular risks linked to insulin resistance. These risks include impaired glucose tolerance, type 2 diabetes, and high blood pressure.

Polycystic ovarian syndrome is associated with infertility, abnormal bleeding, increased incidences of miscarriage, and pregnancy-related complications. Polycystic ovarian syndrome is extremely common and is thought to occur in 4%-7% of reproductive age women. PCOS also is associated with an increased risk for endometrial cancer. Other tests other than ultrasound are required to diagnose polycystic ovarian syndrome.

Cystadenoma: A cystadenoma is a type of benign tumor that develops from ovarian tissue. They may be filled with a mucous-type fluid material. Cystadenomas can become very large and may measure 12 inches or more in diameter.

Ovarian cancers: Most ovarian cysts are benign (non-cancerous); however, rarely, ovarian cysts may be related to ovarian cancers.

What About Ovarian Cysts Diagnosed During Pregnancy?

Sometimes, ultrasound evaluations of the fetus during pregnancy reveal an ovarian cyst. In most cases, these have been found to be non-cancerous, simple cysts that are small in size (less than 2 inches or 5 cm in diameter). Ovarian cysts during pregnancy are usually functional ovarian cysts as described previously. Most of these ovarian cysts that are detected in the first trimester spontaneously resolve by the early part of the second trimester. The corpus luteum that develops in the ovary to sustain a normal early pregnancy may persist as a corpus luteum cyst later in the pregnancy.

Larger cysts in pregnant women are often dermoid cysts. Ovarian cancers are a very rare cause of large ovarian cysts in pregnancy.

What Causes Ovarian Cysts?

The following are risk factors for developing ovarian cysts:

  • History of previous ovarian cysts
  • Irregular menstrual cycles
  • Obesity
  • Early menstruation (11 years or younger)
  • Infertility
  • Infertility treatment with gonadotropin medications
  • Hypothyroidism
  • Tamoxifen (Soltamox) therapy for breast cancer

Oral contraceptive/birth control pill usage decreases the risk of developing ovarian cysts, because they prevent ovulation.

When to Seek Medical Care

A health-care professional should be contacted if the following symptoms occur:

  • Fever
  • Abnormal pain or tenderness in the abdominal or pelvic area
  • Nausea or vomiting
  • Weakness, dizziness, or fainting
  • Pallor or anemia (possibly from loss of blood)
  • Abnormally heavy or irregular menstruation
  • Abdominal swelling or unusual increased abdominal girth
  • Abdominal pain in patient's taking blood thinners such as warfarin (Coumadin)
  • Increased facial hair
  • Excessive thirst or urination
  • Unexplained weight loss
  • A noticeable abdominal or pelvic mass

A woman with the following symptoms should go immediately to a hospital's emergency department:

  • Weakness, dizziness, or feeling faint, especially from standing
  • Fainting
  • Persistent fever
  • Severe lower abdominal or pelvic pain
  • High or low blood pressure unrelated to medications
  • Excessive thirst or urination
  • Unexplained shoulder pain combined with abdominal pain
  • Persistent nausea and vomiting

What Kind of Doctor Treats Ovarian Cysts?

A gynecologist is the type of doctor who specializes in conditions affecting the female genital organs, including ovarian cysts. In some cases, primary care providers including family medicine specialists or internists may treat mild cases of ovarian cysts.

How Are Ovarian Cysts Diagnosed?

A health-care professional may perform the following tests to determine if a woman has an ovarian cyst or to help characterize the type of cyst that is present:

Vaginal (pelvic) ultrasound: Vaginal (pelvic) ultrasound is a type of imaging, and is a special form of ultrasound developed to examine the pelvic organs. Pelvic ultrasound is the best test for diagnosing an ovarian cyst. A cyst can be diagnosed based on its appearance on the ultrasound.

An endovaginal ultrasound is a painless procedure that resembles a pelvic exam. A thin, covered wand or probe is placed into the vagina, and the examiner directs the probe toward the uterus and ovaries. This type of ultrasound produces a better image than a scan through the abdominal wall because the probe can be positioned closer to the ovaries. While performing an endovaginal ultrasound, the internal cystic structure may be categorized as simple (just fluid filled), complex (with areas of fluid mixed with solid material), or completely solid (with no obvious fluid).

Other imaging: Under special circumstances, CT or MRI scanning may aid be necessary.

Laparoscopic surgery: With this procedure the surgeon makes small incisions through which a thin scope (laparoscope) can be passed into the abdomen. The surgeon identifies the cyst through the scope and may remove the cyst or take a biopsy of it.

Serum CA-125 assay: This blood test checks for a substance called CA-125, which is associated with the most common type of ovarian cancer (the CA stands for cancer antigen). This test is used in the assessment of epithelial ovarian cancer and may help determine if an ovarian mass is harmless or cancerous. However, sometimes non-cancerous conditions such as endometriosis or uterine fibroids may result in the elevated levels of CA-125 in the blood. Thus, the test is not diagnostic of ovarian cancer.

Hormone levels: A blood test to check LH, FSH, estradiol, and testosterone levels may indicate problems concerning these hormone levels. These tests are especially helpful in establishing the diagnosis of polycystic ovarian syndrome.

Pregnancy testing: The treatment of ovarian cysts may be different for a pregnant woman. When considering the diagnosis of an ovarian cyst, a pregnancy test should be performed in order to rule out an ectopic pregnancy. Many of the signs and symptoms of an ovarian cyst are also seen with an ectopic pregnancy.

Culdocentesis: This test involves taking a fluid sample from the pelvis with a needle inserted through the vaginal wall behind the uterine cervix. This may occasionally be necessary to rule out active bleeding into the abdominal cavity.

What Is the Treatment for Ovarian Cysts?

Ovarian cysts do not always require a specific treatment, particularly if they are not causing symptoms. Often a pelvic ultrasound will be repeated after a period of months to see if the cyst has resolved. In premenopausal women, ovarian cysts often resolve on their own within one to two months, without treatment. In postmenopausal women, ovarian cysts are less likely to resolve. Treatment may involve other tests (as described previously) to determine the likelihood that cancer is present. Larger cysts may require surgery to remove the cyst or to take a tissue sample (biopsy) to rule out cancer.

A ruptured ovarian cyst is typically treated with pain medications and does not require surgery. Ruptured dermoid cysts may require surgery because the contents of these cysts are very irritating to the internal organs. Moreover, surgery may be necessary for ruptures of cysts that cause internal bleeding or are suspicious for cancer.

What Medications Treat Ovarian Cysts?

Oral contraceptives: Birth control suppresses ovulation and ovarian hormone production. The uterine lining grows and is shed in direct response to the hormonal content in the pills. Without ovulation and ovarian hormone production, functional cysts are rarely seen.

Pain relievers: Anti-inflammatory medication such as ibuprofen (for example, Advil) may help reduce pelvic pain. Narcotic pain medications by prescription may relieve severe pain caused by ovarian cysts. However, these medications do nothing to speed the resolution of the cyst.

What About Surgery for Ovarian Cysts?

Surgery may be needed to remove very large cysts or to take a tissue sampling (biopsy) of a cyst to be sure that the cyst is not cancerous.

  • Laparoscopic surgery: The surgeon makes small incisions through which a thin scope (laparoscope) can pass into the abdomen. The surgeon identifies the cyst through the scope and may remove the cyst or take a sample from it.
  • Laparotomy: This is a more invasive surgery in which a large incision is made through the abdominal wall in order to remove a cyst.
  • Surgery for ovarian torsion: An ovarian cyst may twist and cause severe abdominal pain, as well as nausea and vomiting. As the blood supply to the ovary on the involved side is compromised, emergency surgery is necessary for this complication.

Can Ovarian Cysts be Prevented?

Little medical information is available on the prevention of ovarian cysts. Some risk factors for the development of ovarian cysts have been identified (see Causes section). Taking oral contraceptives (birth control pills) prevents ovulation and therefore reduces the chance of developing functional ovarian cysts.

What Is the Prognosis for a Female with Ovarian Cyst(s)?

The outlook for a woman with an ovarian cyst depends on the type and size of cyst, as well as her age. Noncancerous (benign) masses or cysts greatly outnumber cancerous (malignant) ones.

Age

The development of a functional ovarian cyst depends on hormonal stimulation of the ovary. A woman is more likely to develop a cyst if she is still menstruating and her body is producing the hormone estrogen. Postmenopausal women have a lower risk for developing ovarian cysts as they no longer ovulate or produce significant amounts of ovarian hormones. For this reason, many doctors recommend removal or biopsy of ovarian cysts in postmenopausal women, particularly if the cysts are larger than 1-2 inches in diameter.

Cyst size

The size of the ovarian cyst relates directly to the rate at which they shrink. As a rule, functional cysts are 2 inches in diameter or smaller and usually have one fluid-filled area or bubble. The cyst wall is usually thin, and the inner side of the wall is smooth. An endovaginal ultrasound can reveal these features. Most cysts smaller than 2 inches in diameter are functional cysts. Surgery will likely be necessary to remove cysts larger than 4 inches.

Reviewed on 8/30/2017

REFERENCE: Helm, W., et al. "Ovarian Cysts." Medscape. Updated Feb 12, 2015.
<http://emedicine.medscape.com/article/255865-overview>

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