Ovarian Cysts

Many women have questions about ovarian cysts, and wonder if ovarian cysts are the same thing as ovarian cancer (they are not), or if having a cyst puts them at risk for ovarian cancer (in most cases, it doesn’t).  Read more about ovarian cysts below.

Ovarian Cysts vs. Ovarian Cancer

Having an ovarian cyst does not mean you have ovarian cancer.  Ovarian cysts can be fairly common, while ovarian tumors are quite rare; ovarian cysts are fluid-filled while ovarian tumors are solid masses. Most ovarian cysts are not harmful, don’t cause symptoms and are not indicative of risk for future ovarian cancer, though some complex ovarian cysts may raise the risk.  Ovarian cysts are common in women with regular menstrual cycles, and less common in post-menopausal women.  Approximately 8% of pre-menopausal women develop large ovarian cysts that require treatment.    Cysts can come and go with a woman’s menstrual cycle (functional ovarian cysts), and may not cause symptoms unless they twist or rupture, or become large enough that a woman can feel the cyst.  While many ovarian cysts go away without treatment, some may require surgery to remove.

Though ovarian cysts often produce no symptoms, when they do these can include some symptoms similar to ovarian cancer, such as:  abdominal pain or ache, bloating, pain during intercourse, menstrual irregularities, and more rarely in ovarian cysts, frequent urination.  More specific to ovarian cysts, unusual growth of facial and body hair may occur due to an increase in production of male hormones called androgens.  And in rare cases, sudden sharp abdominal pain, fever and nausea may indicate a cyst has twisted or ruptured, and requires immediate medical attention and likely emergency surgery.

Possible Causes of Ovarian Cysts

  • Hormonal problems. Functional cysts usually go away on their own, and may be caused by hormonal problems or drugs that promote ovulation.
  • In women with endometriosis, a condition in which the lining of the uterus (womb) grows outside of the uterus, sometimes the endometriosis tissue attaches to the ovary and forms an endometrioma, a type of ovarian cyst. These cysts can be painful both during your period and during sex.
  • Severe pelvic infections. Infections can spread to the Fallopian tubes and the ovaries, and can cause cysts to form.
  • In early pregnancy, an ovarian cyst normally develops until the placenta forms to support the pregnancy. At times, the cyst remains on the ovary later into the pregnancy and requires removal.
  • Polycystic ovary syndrome (PCOS). Women with PCOS often have many small cysts on their ovaries; it is one of the leading causes of infertility.

Types of Ovarian Cysts

Functional cysts, the most common types of ovarian cysts, form during the menstrual cycle. They are usually benign (not cancerous).

The two most common types of functional cysts are:

  • Follicle cysts. In a normal menstrual cycle, an ovary releases an egg each month. The egg grows inside a tiny sac called a follicle. When the egg matures, the follicle breaks open to release the egg. Follicle cysts form when the follicle doesn’t break open to release the egg. This causes the follicle to continue growing into a cyst. Follicle cysts often have no symptoms and go away in one to three months.
  • Corpus luteum cysts. Once the follicle breaks open and releases the egg, the empty follicle sac shrinks into a mass of cells called corpus luteum. Corpus luteum makes hormones to prepare for the next egg for the next menstrual cycle. Corpus luteum cysts form if the sac doesn’t shrink. Instead, the sac reseals itself after the egg is released, and then fluid builds up inside. Most corpus luteum cysts go away after a few weeks. But, they can grow to almost four inches wide. They also may bleed or twist the ovary and cause pain. Some medicines used to cause ovulation can raise the risk of getting these cysts.

Other types of benign ovarian cysts are less common:

  • Cystadenomas: cysts filled with watery fluid, which can sometimes grow large.
  • Dermoids: derive from cells present from birth and typically do not cause symptoms.
  • Endometriomas: caused by endometriosis, these cysts occur when the lining of the uterus (womb) grows outside of the uterus.
  • Polycystic Ovary Syndrome (PCOS): in which the ovaries make many small cysts.

Malignant (cancerous) cysts are rare and are more common in older women. Cancerous cysts, or tumors, are ovarian cancer, though most ovarian cysts are not cancerous.

Identification of Ovarian Cysts

Cysts may initially be identified through pelvic exams.

Various tests may be used to determine the type of cyst and whether treatment is needed.  These may include:

  • pregnancy test (a positive result when not pregnant may indicate corpus luteum cysts);
  • transvaginal ultrasound (allows doctor to see size, shape, type of mass and location):

Various factors help the doctor determine if further follow-up is needed, including whether the mass looks solid or is fluid-filled (cysts are fluid-filled), as well as whether the shape appears simple or more complex (a tumor would likely be more complex), and if there is an increased blood supply flowing to it as there would be to a tumor;

  • laparoscopy surgery (see Surgery below);
  • CA125 blood test:

A protein in the blood known as cancer antigen 125 (CA 125) is often elevated in women with ovarian cancer. Your doctor may utilize this test if your cyst has characteristics of a tumor or if you’re at high risk of ovarian cancer.  Note:  CA 125 levels can also be elevated in noncancerous conditions, including endometriosis, uterine fibroids and pelvic inflammatory disease.

If the gynecologist believes the cyst is benign, he or she may suggest watching the cyst through continued ultrasound over a period of months, or could opt to surgically remove it.

Your doctor may decide to refer you to a gynecologic oncologist for examination and consultation based on the factors outlined above.  The gynecologic oncologist may or may not recommend surgery to determine if the mass is cancerous.  And if it is determined to be a cyst, and not a tumor, you will likely be referred back to your gynecologist.

Treatment

Often, your doctor may suggest waiting and re-examining the cyst to see if it goes away within a few months. Regardless of your age, this is typically an option if you have no symptoms and an ultrasound reveals a simple, small, fluid-filled cyst.

If your cyst does not require surgery, your doctor may talk to you about pain medicine such as over-the-counter medicine or stronger prescription medicine for pain relief if you are experiencing symptoms.  He or she may recommend hormonal birth control if you tend to have cysts often to help prevent ovulation, which can lower your chances of getting more cysts (but will not shrink existing cysts).

Your doctor will likely recommend that you get follow-up pelvic ultrasounds at intervals to see if your cyst changes in size.

Surgery

Some women have surgery to remove cysts (called cystectomy), and only a small percentage of these cysts are cancerous.  Surgery may be used to rule out ovarian cancer, confirm the diagnosis of an ovarian cyst, or remove a cyst that is causing symptoms and/or is very large.  It may be utilized if an ovarian mass that has been watched through ultrasound for several months does not go away; if there are masses on both ovaries; if an ovarian mass is present and you have never had a period, have gone through menopause, or use birth control pills (excepting low-dose progestin-only pills or if you have missed a pill, which would make an ovulation-related functional cyst more likely), or if the cyst is causing pain.

Laparoscopy vs. Laparotomy

If surgery is recommended to get a closer look at the mass, the surgeon may use laparoscopy for smaller cysts that look benign or not cancerous.  A small incision is made above or below your belly button to offer a view of your pelvic area and allow for possible removal of the cyst.   Or he or she may use laparotomy, which is a larger abdominal incision to remove the cyst, which may be used if the cyst is large and may possibly be cancerous. The cyst is then tested for cancer. If it is thought the mass might be cancerous, it is best to see a gynecologic oncologist, who may need to remove the ovary and other tissues, like the uterus.

Either surgery can be used to diagnose ovarian cysts, adhesions, pelvic infections or fibroids.  A laparotomy offers the best view of the abdominal organs and the female pelvic organs. Then, if ovarian cancer is found, the gynecologic oncologist may remove it at the same time. If a noncancerous cyst is causing symptoms, it can be removed during surgery , while leaving the ovary intact. In some cases, the entire ovary or both ovaries are removed, particularly when cancer is found.

An ovarian cyst can be removed from an ovary , preserving the ovary and your fertility. But it is possible for a new cyst to form on the same or opposite ovary after a cystectomy. New cysts can only be completely prevented by removing the ovaries (oophorectomy), so it is important to discuss any concerns and recommended options with your doctor.

Surgery Recovery Time

If it is recommended that you have surgery, you will likely be given general anesthesia.  If you have laparoscopy, you can usually resume normal activities within a day, but will likely be advised to avoid strenuous activity or exercise for a period of time, usually around a week.  After a laparotomy, you may stay in the hospital from 2 to 4 days and return to your usual activities in 4 to 6 weeks, pending your surgeon’s recommendation.

If your doctor suggests you see a gynecologic oncologist, click here (link) to see a list of questions you may wish to ask.

Questions

What did you see on the ultrasound results to refer me to a gynecologic oncologist?

What factors were present?  For example, was the mass solid and not fluid-filled?  Was it more complex than cysts usually are?  Does there appear to be a blood supply flowing to it?

Which type of surgery will you do initially?