Dealing with ovarian cysts

By Dr Brigid Monda

Every woman is born with a pair of ovaries each about the size and shape of an almond, located in the pelvis. During menstrual cycle, ovaries grow tiny cyst-like structures called ovarian follicles which produce Estrogen and Progesterone hormones that regulate menstration and pregnancy.

Each follicle also contains an egg, which matures and breaks free from the follicle (ovulation) and travels through the fallopian tube to meet with a sperm for fertilisation. The follicle left behind dissolves.

Sometimes the ovaries may form a different type of cyst. The commonest are the functional cysts — the Follicular cysts which form in the first two weeks of the cycle and Corpus Luteam cysts in the later half of the cycle after ovulation. A follicular cyst will form if a follicle keeps growing without breaking open to release the egg. Because ovulation fails to occur, the cycle becomes irregular, and causes pain if the cyst ruptures.

Corpus Luteum cyst

A Corpus Luteum cyst is less common and forms if the follicular sac left behind after ovulation does not dissolve but seals off and fluid builds up within it. It grows larger than follicular cysts and can twist the ovary or fill up with blood and rupture, causing bleeding and sudden, sharp pelvic pain or missed periods. Both Follicular and Corpus Luteum cysts are entirely filled with fluid hence the name ‘simple cysts’. They are not cancerous and usually disappear within three months. Other types of ovarian cysts are called ‘Complex cysts’. Thankfully most are harmless. Examples are:

Endometriomas: Also called ‘chocolate cysts’ because of their appearance, they develop in women who have endometriosis — when tissue from the lining of the uterus grows outside the uterus, like on the ovaries and because it responds to hormonal stimulation during the menstrual cycle as it normally would if it were in the uterus, it also bleeds cyclically filling the affected ovary with dark, reddish-brown blood forming a cyst.

Cystadenomas: They grow from cells on the outer surface of the ovary and are filled with a thick sticky ‘gel’. They can become large —up to 12 inches or more.

Nature of cyst

Dermoid cysts: May contain hair, skin or teeth, are rarely cancerous, but can become large and also cause painful twisting of the ovary.

Many ovarian cysts have no symptoms. Some cause heaviness in your abdomen, a constant dull ache radiating to the lower back and thighs, frequent urination, pain during intercourse, spotting, irregular or unusually painful menstrual periods, nausea, vomiting or breast tenderness.

Once a cyst is discovered, a pregnancy test and ultrasound are carried out to reveal the cyst’s shape, size and location and whether it is fluid-filled, solid or mixed. Your doctor may also do hormone levels and blood test to measure protein in the blood, called CA-125 whose levels are high if a woman has ovarian cancer.

Treatment depends on how the cyst appears on the scan, your symptoms and age. A cyst in a girl who has not begun menstruation and in a woman after her menopause is cause for alarm because these are often cancerous.

Family history also plays a part in how aggressive a doctor may be in treating an ovarian cyst. If a woman’s mother or sister had cancer of the ovary, her doctor will worry about any cyst she may have, functional or not.

Treatment

This depends on the size and type of cyst, its symptoms and the woman’s age and future pregnancy plans.

Watchful waiting: If a scan reveals a functional cyst in a woman of child bearing age, you can wait two or three months because these cysts are common and ovarian cancer is rare in this age group. The scan is then repeated to see if the cyst will have dissolved on its own or become bigger. If the cyst doesn’t go away after several menstrual periods or gets larger, your doctor will want you to have an operation to remove it.

Also, if the woman doesn’t want to wait, she can be put on the pill, which makes the cysts disappear. If the cyst is pre-cancerous or cancerous it won’t go away with the pills meaning there’s something more dangerous than a functional cyst.

Hormonal contraception: This can be used in women who are not planning to get pregnant soon and frequently develop functional cysts. The pill, injection or implants can be used to suppress ovulation and thus prevent formation of new cysts as well as reduce the risk of ovarian cancer.

Surgery: If the cyst does not disappear after several menstrual periods, becomes larger, looks unusual on the ultrasound, causes pain, or you are postmenopausal, your doctor can remove it. It can be done in one of two ways:

Laparoscopy — a very small nick is made below the navel and a lighted telescopic-like instrument is inserted into the abdomen to remove the cyst. The tissue removed is sent to the laboratory for tests to find out if it is cancerous or not. This is done for small cysts, about the size of a plum or smaller, and does not look cancerous on the ultrasound.

Laparotomy — If the cyst is too big to remove laparoscopically, the doctor performs a laparotomy where the abdomen is opened to remove the cyst. If all is well with the other ovary, fertility should not be affected and periods should continue after the operation. The tissue removed is also sent to the laboratory for tests to find out if the tissue is cancerous. If cancerous, the doctor removes the other ovary, the uterus and lymph nodes.