Types of ovarian cyst and management
Ovarian cysts are closed, sac-like structures within the ovary that are filled with a liquid or semisolid substance. Ovarian cysts are very common. They can occur during the childbearing years or after menopause. Most ovarian cysts are benign (Non-neoplastic) (not cancer) and go away on their own without treatment. Rarely, a cyst may be malignant (Neoplastic)
Non-neoplastic cysts of the ovary : An ovarian cyst is a sac filled with liquid or semi-liquid material arising in an ovary. The number of diagnoses of ovarian cysts has increased with the widespread implementation of regular physical examinations and ultrasound technology.The finding of an ovarian cyst causes considerable anxiety for women because of the fear of malignancy, but the vast majority of ovarian cysts are benign.
TYPES OF OVARIAN CYSTS.
- POLYSTIC OVARIAN SYNDROME (PCOS)
- ENDOMETRIOMATOUS CYSTS
- FUNCTIONAL CYSTS (commonest) –Follicular cysts –Theca lutein cysts –Corpus luteum cysts.
FUNCTIONAL CYSTS Ovarian cysts arising in the normal process of ovulation .They may be follicular ,theca-lutein or corpus luteum cysts.These cysts can be stimulated by gonadotropins, including follicle-stimulating hormone (FSH) and human chorionic gonadotropin (hCG).
Multiple functional cysts can occur as a result of excessive gonadotropin stimulation or sensitivity This stimulation may occur in cases of Ø GTDs (hydatiform mole and choriocarcinoma) Ø multiple pregnancy. In patients being treated for infertility, ovulation induction with gonadotropins (FSH and luteinizing hormone [LH]), and clomiphene citrate, may lead to ovarian hyperstimulation syndrome, especially if accompanied by hCG administration
ENDOMETRIOMATIC CYSTS OF THE OVARY : Cysts filled with blood arising from the ectopic endometrium. They usually enlarge pre and during menses and slightly shrink there after. The ovary is the commonest site of pelvic endometriosis.
POLYCYSTIC OVARIAN SYNDROME (PCOS)
- Rotterdam criteria for diagnosis of PCOS 1. Menstrual irregularities. Most patients with PCOS have menstrual irregularities that begin during adolescence. –Oligomenorrhea: less than nine menses per year –Amenorrhea: no menses for 6 months or three or more skipped cycles vDifficulty in conceiving is present in many women with PCOS
- . Hyperandrogenism. Patients may either show signs of clinical hyperandrogenism or have biochemical hyperandrogenism: –Clinical hyperandrogenism: e.g hirsutism, acne, or male pattern hair loss. –Biochemical hyperandrogenism: Up to 90% of women with PCOS have elevated serum androgen concentration. However, the androgen levels may be normal.
- Polycystic ovaries. A diagnosis of polycystic- appearing ovaries can be made using pelvic ultrasound. –PCOS by ultrasound criteria is defined as 12 or more antral follicles between 2 and 9 mm in size and peripheral in location in at least one ovary –Transvaginal ultrasound is more sensitive, but may not be appropriate to perform in a young female
RISK FACTORS OF OVARIAN CYSTS 1. Hypothyroidism 2. Infertility or women who are on treatment for infertility 3. Those taking tamoxifen, a drug to combat breast cancer 4. Irregular periods 5. Early periods (before 11 years) 6. Previous history of ovarian cysts. 7. A drug called clomiphene may lead to formation of corpus luteum cyst.
CLINICAL PRESENTATION OF OVARIAN CYSTS
History: The majority of ovarian cysts are asymptomatic. Pain or discomfort may occur in the lower abdomen. Torsion (twisting) or rupture may lead to more severe pain. Patients may experience discomfort with intercourse, particularly deep penetration. Having bowel movements may be difficult, or pressure may develop, leading to a desire to defecate.
Micturition may occur frequently and is due to pressure on the bladder.Patients may experience abdominal fullness and bloating. Endometriomas are associated with endometriosis, which causes a classic triad of painful and heavy periods and dyspareunia. Patients with polycystic ovary syndrome presents hirsutism, infertility, oligomenorrhea, obesity, and acne. ØInfertility is not a rule.
Physical findings : A large cyst may be palpable during the abdominal examination . Sometimes, discerning the cystic nature of an ovarian cyst may be possible, and it may be tender to palpation. If a cyst is huge ,The cervix and uterus may be pushed to one side.
Laboratory Studies: • No laboratory tests are diagnostic for ovarian cysts except for PCOS for which hormone assays are done: ØFSH ØLH ØTestosterone ØOestradiol
Imaging Studies: •Ultrasonography •Doppler flow studies •MRI •CT scan
Blood test – if there is a tumor present blood levels of CA125 (a protein) will be elevated. • High CA125 levels could also mean the patient has ovarian cancer. If a woman develops an ovarian cyst that is partially solid she may have ovarian cancer. • High CA125 levels may also be present in other conditions, including endometriosis, uterine fibroids or pelvic inflammatory disease.
Laparoscopy – a thin, lighted instrument (laparoscope) is inserted into the patient’s abdomen through a small incision (skin cut). If the doctor spots an ovarian cyst he/she may also remove it there and then.
Pregnancy test – a positive result may suggest the patient has a corpus luteum cyst
Complications of ovarian cysts • Torsion • Rupture • Hemorrhage • ?Malignant change :remains unproven
Several factors are taken into account when deciding on the type of treatment for ovarian cysts; and whether to treat at all. The main factors are:
- The patient’s age
- Whether the patient is pre- or postmenopausal
- The appearance of the cyst
- The size of the cyst
- Whether or not there are any symptoms
Watchful waiting (observation) – sometimes watchful waiting, also known as observation is recommended, especially if the woman is pre-menopausal and she has a small functional cyst (2cm to 5cm). An ultrasound scan will be carried out about a month or so later to check it, and to see whether it has gone.
Birth control pills – to reduce the risk of new cysts developing in future menstrual cycles, the doctor may recommend birth control pills. Oral contraceptives also reduce the risk of developing ovarian cancer.
Surgery – if there are symptoms, the cyst is large, does not look like a functional cyst, is growing, or persists through two or three menstrual cycles, the doctor may recommend that the patient have it surgically removed. Laparoscopy (key hole surgery) – two small cuts are made in the lower abdomen and one in the belly button. Gas is blown into the pelvis to raise the wall of the abdomen, away from the internal organs. A small tube with a light on the end (a laparoscope) is inserted into the abdomen. The surgeon can see the internal organs. With very small tools the surgeon is able to remove the cyst through the small incisions. In some cases a sample (biopsy) of the cyst is taken to determine what type it is. In most cases the patient can go home the same day. This type of surgery does not usually affect a woman’s fertility, and recovery times are much faster.
Laparotomy – this is a more serious operation and may be recommended if the cyst is cancerous. A longer cut is made across the top of the pubic hairline, giving the surgeon better access to the cyst. The cyst is removed and sent to the lab. The patient usually has to remain in hospital for at least a couple of days.
There is no definite way of preventing ovarian cyst growth. However, regular pelvic examinations, which allow for early treatment if needed, usually protect the woman from complications. Although most cysts are harmless and go away on their own, health care provider will want to keep track of any cyst to be sure that it does not grow and cause problems.
Dr. Ira Biswas