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WHAT ARE OVARIAN CYSTS?
An ovarian cyst is simply a collection of fluid within the normally solid ovary. There are many different types of ovarian cysts, and they are an extremely common gynecologic problem. Because of the fear of ovarian cancer, cysts are a common cause of concern among women. But, it is important to know that the vast majority of ovarian cysts are not cancer. However, some benign cysts will require treatment in that they do not go away by themselves, and in quite rare cases, others may be cancerous. The good news is that almost all ovarian cysts will go away by themselves without any treatment.

CAN A CYST CAUSE PAIN?
Although many cysts cause no symptoms at all, pressure or pain in the pelvic area is a common problem that may cause a woman with an ovarian cyst to see her doctor. As fluid collects in a cyst and can weigh the ovary down, causing a pulling sensation when a woman moves. In very rare cases, the covering of the ovary tears opens, or ruptures, releasing the cyst fluid into the abdominal cavity. This ruptured ovarian cyst usually results in the sudden onset of pain.

 

HOW ARE OVARIAN CYSTS DIAGNOSED?
At the time of a pelvic exam, your doctor will feel off to the sides of the uterus, where the ovaries are located. The ovaries are normally no larger than a small walnut. But if a cyst forms, the ovary can swell to a few inches or more. The doctor is often able to feel a cyst as a soft, movable lump.

If you are not menopausal and the cyst is not bothersome, a repeat examination can be scheduled in two or three weeks to make sure that the cyst is going away. If the cyst has dissolved by that time, no further treatment or follow-up is needed. If the cyst is still present at the follow-up visit, I will usually order a pelvic sonogram.

WHAT CAN A SONOGRAM SHOW?
The most accurate way to get a picture of the ovary and cyst is with a vaginal sonogram. This test uses a small instrument, which is comfortably passed into the vagina. This instrument bounces harmless sound waves off your uterus, fallopian tubes, and ovaries, forming a picture on a monitor. A sonogram allows the doctor to accurately determine the size of the cyst and to "see" inside it in order to detect whether it is filled with fluid or solid areas. Certain types of ovarian cysts, depending on which cells in the ovary are overgrowing, will make fairly reliable patterns on a sonogram.

Figure 1: Clear functional cyst

 

Figure 2: Speckled blood with endometrioma

 

Figure 3: Fat cells floating at the top of cyst

 

Figure 4: Blood clot within hemorrhagic cyst

 

Figure 5: Irregular shape of ovarian cancer

WHAT ARE THE DIFFERENT TYPES OF OVARIAN CYSTS?
Ovarian cysts can be divided in two ways - those that go away by themselves vs. those that need treatment, and those that are benign vs. those that are cancer. Most cysts are benign and will go away by themselves. The distinction that is most important to your health and well-being is whether the cyst is cancerous or benign. Cancerous cysts should, obviously, be removed as soon as possible. However, some benign cysts are of the type that will not go away by themselves and may also need to be removed to prevent further problems. The following chart may be helpful.

USUALLY GO AWAY BY THEMSELVES
BENIGN CYSTS
CANCEROUS CYSTS
follicular cysts
none
corpus luteum cysts
 
hemorrhagic cyst
 

 

DO NOT GO AWAY BY THEMSELVES
BENIGN CYSTS
CANCEROUS CYSTS
endometriomas
epithelial cancers
epithelial cysts-serous, mucinous
germ cell cancers
dermoid cysts
 

DO BENIGN OVARIAN CYSTS BECOME CANCEROUS?
Research shows that benign cysts do not turn into cancerous cysts, so if you have an ovarian cyst that seems to be benign upon exam and on a sonogram, waiting for it to go away for two months or so is not risky. Research also shows that women who form benign ovarian cysts are not any more likely to develop ovarian cancer than women who have not had cysts.

HOW ARE OVARIAN CYSTS TREATED?
The appropriate treatment for an ovarian cyst depends on the type of cyst present, the symptoms you have, and whether you are premenopausal or postmenopausal. If you are premenopausal, if you are not having bothersome symptoms, and if your cyst appears benign on sonogram, watchful waiting will often allow the cyst to dissolve by itself within 4-10 weeks. If, however, your symptoms are very bothersome, or the cyst appears suspicious for malignancy, then it should be removed.

WHEN IS SURGERY NEEDED FOR AN OVARIAN CYST?
Surgery may be considered necessary if a cyst appears suspicious for cancer on the sonogram, if it causes severe pain, if it continues to grow, or if it does not go away in 8 weeks. A number of studies show that cysts that persist longer than eight weeks without decreasing in size have a greater likelihood of being abnormal. This does not mean cancer, but rather an abnormal growth of cells within the ovary that will never go away. If left in place, these cysts may continue to grow and cause discomfort or twist the ovary around and destroy it. Also, in very rare instances (less than 5%), these cysts may be cancerous, and early detection and removal are important.

CAN LAPAROSCOPIC SURGERY BE USED TO TREAT AN OVARIAN CYST?
Instruments are now available that enable the gynecologist to remove a cyst through small incisions in the abdomen , while preserving the normal, healthy ovary . The type of procedure, known as laparoscopic surgery, provides the benefits of outpatient surgery and a quick recovery.

Removing a cyst, called a cystectomy, is like taking a clam out of the shell. The thinned out ovarian tissue is cut open, and the cyst is gently peeled away from inside the ovary. The cyst fluid is then removed with a suction device. The cyst now looks like a deflated balloon and can easily be removed through the small laparoscopy incision.

Rarely, if a cyst has destroyed all the normal ovarian tissue, it may be necessary to remove the entire ovary and it is possible to do this, as well, with the laparoscope.

For more information about laparoscopic surgery, as well as photographs of the procedure, please visit http://www.parkermd.com/oc-treatment.htm

WHEN IS MAJOR SURGERY NEEDED FOR AN OVARIAN CYST?
If a cyst is suspicious for being a cancer based on the exam and the sonogram, there is no reason to subject a woman to the added time, risk and expense of a laparoscopy only to find that it is necessary for the doctor to switch, while the patient is asleep, to the standard abdominal surgery. Therefore, if there is a possibility that a cyst is cancer based on the examination and sonogram, abdominal surgery should be performed.

IF YOU ARE PREMENOPAUSAL, DO YOU NEED TO HAVE YOUR ENTIRE OVARY REMOVED IF YOU HAVE AN OVARIAN CYST?
Almost always, the answer is no. If you are premenopausal, the ovary contains eggs that make the female hormones estrogen, progesterone and testosterone and also allow you to get pregnant. So, as long as there is healthy ovarian tissue remaining, it is a good idea to leave the ovary in place and just remove the benign cyst. In very rare instances, the cyst destroys all the normal ovarian tissue, and there is nothing left to save and removing the entire ovary is necessary.

CAN AN OVARIAN CYST FORM AFTER MENOPAUSE?
The ovary no longer produces eggs after menopause, but benign ovarian cysts can still occur after menopause. In fact, after menopause the most likely types of ovarian cysts are still benign cysts. However, because the incidence of ovarian cancer increases with age, any cyst or growth in the ovary after the menopause should be evaluated right away with a sonogram. Once again, the sonogram can be helpful in predicting whether the cyst is benign, or if it is suspicious for cancer. In addition, if you have a cyst after menopause, the blood test CA-125 should be done. As previously noted, the test is inaccurate in pre-menopausal women, but it is more accurate in postmenopausal women. If the sonogram shows a benign pattern and the CA-125 test is normal, then the ovarian cyst is probably benign.

A very interesting recent study found benign ovarian cysts to be much more common in post-menopausal women than anyone had realized. Ultrasounds were performed on 7,700 healthy post-menopausal women as part of a study designed to find early ovarian cancers. Small ovarian cysts, 2-inches or less, were unexpectedly found in 450 of these women. Because these cysts were benign-appearing on ultrasound, and CA-125 tests were normal, the women had the ultrasound repeated in two months. Surprisingly, half of the cysts had already disappeared by that time.

Half of the women with persistent cysts chose surgery and NONE of them had cancer found at the time of surgery. Also, NONE of the women who had repeated ultrasounds and were followed over the next few years were found to have ovarian cancer. Women and doctors still have varying degrees of comfort about not removing an ovarian cyst. But, based on this study and others, a discussion about options should take place. Some women may choose surgery and others may choose careful follow-up. At this point, both options are reasonable.

IS A HYSTERECTOMY NEEDED IF YOU HAVE AN OVARIAN CYST?
In the past, if a woman had completed her family and had a benign cyst that needed to be removed surgically, a hysterectomy was routinely performed at the same time. This practice has recently been questioned by a scientific study that showed the risks of surgery were greater if, in addition to removing the ovary, a hysterectomy was also performed to remove a normal uterus. This only makes sense - more surgery leads to more risk of blood loss, more risk of injury to other organs, and more time under anesthesia. Hopefully the idea of limiting surgery to just the problem area will be adopted by more gynecologists. If you have an ovarian cyst and your doctor is recommending hysterectomy, ask why they think that it is necessary. If you are not satisfied with the answer, you should consider getting a second opinion.

 

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