THE OVARY’S JOB IS TO MAKE CYSTS
While the above comment may be somewhat of an exaggeration, it is closer to the truth than most people realize. One of the most common and yet one of the most misunderstood problems in gynecology are ovarian cysts. I hope this pamphlet clears up any confusion.
Ovarian cysts are extremely common. They are far more common than most people realize. Nonetheless, when I have to tell someone that they have an ovarian cyst, it is not uncommon for a sudden look of panic to cross their face. I hope this pamphlet helps to allay your anxieties.
I have had ultrasound machines in my office for over twenty years. During that time, I have literally done thousands of ultrasounds and I can tell you that hardly a day goes by that I do not find a cyst that would otherwise have been missed had the ultrasound not been done.
My own personal experience as well as several research studies have clearly shown that pelvic exams are incredibly inaccurate. People do not realize how much is missed by just doing a pelvic exam without an ultrasound. Conversely, unresolved issues can also be cleared up. I have seen many patients who were told they had fibroids when the ultrasound clearly showed they did not. It is my opinion that an ultrasound is as important and as integral to a pelvic exam as a cardiogram would be if you went to a cardiologist. I firmly believe that every gynecologist should have an ultrasound machine in his or her office and that every patient should have a routine ultrasound just the same way they have a pap smear. Of course, the insurance companies would go ballistic over such a thought because it interferes with their profits but the evidence is overwhelming that it is important.
The ovary forms more cysts, tumors, and other abnormal structures than probably any other organ in the body. Ovarian cysts are extremely common, especially in women with the types of problems that I see such as Poly-Cystic Ovary Syndrome and other hormone problems, endometriosis, and chronic pelvic pain.
Contrary to popular myth, the vast majority of ovarian cysts do not cause pain or other symptoms. If for no other reason, this is why many women are surprised to learn that they have a cyst. People have been led to believe that cysts cause pain – the vast majority do not.
On the other hand, most women with pelvic pain do not have ovarian cysts. Yet this is what they have been told.
The purpose of this pamphlet is to explain to you what a cyst is and how it develops. I hope that it gives you enough basic information so that we can then discuss whatever problem you may have more completely in the office.
A cyst, no matter where in the body it might be found, is simply any structure which contains fluid. It doesn’t matter what type of fluid – only that it contains a fluid.
If there is an abnormal structure somewhere in the body that is solid, we call it a tumor. Tumors may be benign or they may be malignant.
To further confuse the situation, particularly in the ovary, some tumors may have fluid areas within them. We would call these “cystic tumors”. Conversely, some cysts may have small solid areas contained within them as well.
It is critically important to understand that in a normally ovulating woman, the ovary forms a cyst every month. That cyst is called the follicle and it is the structure in the ovary in which the egg is growing.
As has been pointed out in other pamphlets, a woman is born with all the eggs she is ever going to have – 2 million when you are a 20 week fetus, one million at birth and around 400,000 at puberty. Once a woman goes through puberty, about 100 to 150 eggs begin to develop everyday. It does not matter whether you are pregnant, whether you are on birth control pills, whether your periods are regular or irregular, or just about anything else. Those eggs begin to develop.
The egg and the cells of the ovary that surround it is called the follicle. In its most basic inactive state, the follicle consists of the egg with a single layer of ovarian cells around it like a string of pearls. As the egg begins to develop, those cells around it multiply and the follicle grows in size. When it reaches a certain critical size, fluid begins to accumulate between the cells of the follicle. This fluid then begins to come together and a small cyst is formed.
In a normally menstruating woman, only one egg is selected each month to go on to full maturity and ovulation. No one knows the mechanism by which that one egg is selected but, nonetheless, all of the other eggs that had begun to develop die. They are eventually absorbed by the body. If those other eggs have reached a stage in their development where some fluid has begun to accumulate you would see multiple tiny cysts within the ovary. When you have an ultrasound, it is very normal, very common, and in fact, we expect to see a number of these tiny cysts representing follicles in various stages of development. They are supposed to be there. In a younger woman, the number of these tiny immature follicles is very important in assessing her “ovarian reserve”. If the woman has too few immature follicles, it raises a big red flag that she may have difficulty becoming pregnant.
In a woman who is normally ovulating, the one egg that is going to go on to full maturity continues to develop. As it grows, more and more fluid is accumulated in the follicle and by the time the egg is fully mature, the follicle has reached a diameter of between 20 and 25 mm (1 inch). This is easily seen on ultrasound.
Once the egg is fully mature, the wall of the follicle ruptures and the egg is expelled (ovulation). After ovulation, the follicle undergoes a transformation and becomes the corpus luteum. The corpus luteum is a solid structure and is normally not seen on ultrasound.
If something goes wrong with the ovulatory process, this orderly maturation of the follicle is disrupted. As a result, numerous problems can develop. Although the problems may appear different, they all share a common thread – something has thrown the normal ovulatory process off track. That “something” may be a one time blip – no woman ovulates normally every month. It may also be an indicator of some underlying chronic hormonal problem that requires further evaluation.
If a woman does not ovulate at all or ovulates very infrequently, particularly if she is overweight; is making too much androgen (male hormone), etc., we say that she has Poly-Cystic Ovary Syndrome. This is a terrible term but it has been around for over 70 years and we are stuck with it.
In a woman who has Poly-Cystic Ovary Syndrome, the ovulatory process is never or infrequently completed. As a result, the ovary fills up with numerous follicles that have only begun to develop. Many of these follicles have accumulated small amounts of fluid – hence, the ovary has multiple tiny cysts within it. It is “Poly-Cystic”.
This is a descriptive term only. You can get a Poly-Cystic Ovary from many different causes. At the time the syndrome was named, people were confusing cause with effect.
On the other side of the coin, when the ovulatory process is disrupted for whatever reason, sometimes the follicle never develops properly, the egg never fully matures, and the follicle accumulates more fluid than it should. It continues to grow beyond its normal size. It becomes a “follicle cyst”.
In a normally menstruating woman, the follicle never gets bigger than 30 mm. in diameter. Any follicle that is larger than 30 mm. is termed a follicle cyst.
In some women, particularly those with endometriosis, sometimes the ovulatory process in disrupted such that the follicle wall never ruptures and the egg is never expelled. However, the hormonal changes are still occurring so that the follicle still undergoes a transformation to the corpus luteum. Because the egg is not expelled, the fluid is not expelled as well. It is retained within the ovary and is easily visible following the time that ovulation should have occurred. This is termed the “Unruptured Follicle Syndrome” and is easily diagnosed when a woman is being tracked through a menstrual cycle if she is having a fertility problem.
In a normally ovulating woman, when ovulation occurs and the follicle is transformed into the corpus luteum, a small amount of bleeding occurs. Usually the amount of blood is very small and is of no significance. Occasionally, however, there can be more than the average amount of bleeding. This blood is then trapped inside the corpus luteum and because blood is a liquid, it becomes visible on ultrasound. If this should occur, we call it a hemorrhagic corpus luteum. If the hemorrhagic corpus luteum stays around for awhile, eventually the body will breakdown the red blood cells but the other liquid (the serum) remains. Eventually, the fluid inside the hemorrhagic corpus luteum is transformed from blood to a yellowish fluid. We call this a luteal cyst.
All of the problems that I have just discussed describe the cause of what we call “functional cysts”. By this term, we mean that they are cysts that develop as a result of the abnormal functioning of the ovary. They simply represent the ovulatory process that has been thrown off track for whatever reason.
Functional cysts will usually disappear with simple observation although it may take several months to do so.
All other types of cysts within the ovary represent true pathology. They are cystic tumors. These cystic tumors, particularly in younger women, are almost always benign.
There is one type of cyst that is not functional but is not, strictly speaking, a cystic tumor either. I am referring to endometriosis cysts of the ovary. Endometriosis cysts form when an implant of endometriosis on the surface of the ovary burrows its way into the ovarian tissue. As the endometrium in the endometriosis implant goes through a “menstrual cycle” each month and bleeding occurs, then that blood begins to accumulate within the ovary. As that blood persists for an extended period of time, it eventually turns brown and takes on an appearance that is almost identical to Hershey’s chocolate syrup. As a result, these cysts are called “chocolate cysts”.
They are cysts in the true definition of the term because they are a structure within the ovary that contains fluid. However, the way they got there is unique to endometriosis and they are, therefore, as we have mentioned, not strictly functional cysts but they are not really cystic tumors.
How does a woman know she has an ovarian cyst? The fact is, in the vast majority of cases, cysts produce no symptoms. I know this is contrary to what everyone believes. Nonetheless, the vast majority of cysts that I discover in my office are producing no symptoms whatsoever and the woman is completely unaware that she has them.
Sometimes the cyst may be indicative of other problems and may be causing indirect symptoms such as irregular bleeding, etc. However, usually attributed to a cyst such as pain are present only in the minority of instances.
When cysts do produce symptoms, pain is usually the principal one. The pain will be located on the side of the cyst and it may range in severity from a vague discomfort all the way up to very very severe pain. The latter is very uncommon and usually indicates something far mare serious than just the presence of a cyst.
Cysts are not infrequently associated with menstrual abnormalities. Sometimes it is the problem causing the menstrual abnormality that interferes with normal ovulation and allows the development of a cyst. In other instances, a cyst may develop for a variety of reasons. Any foreign body in the ovary such as a cyst can and frequently does disrupt the normal functioning of that ovary. This then leads to irregular menstrual cycles which then brings the woman into the office for evaluation. Subsequently, a cyst may be found.
As I have noted, one of the most common myths is that cysts cause pain. Some do – most don’t.
One of the most common stories I hear involves women who sought help because of pelvic pain. Very often these women are told that their pain is due to a cyst that burst. Right? WRONG.
The scenario usually goes something like this. The woman is experiencing pain and she either goes to a physician or to a hospital emergency room. An ultrasound is done and fluid is seen in the pelvis. The woman is told that she had a cyst that burst.
Everyone is happy with this explanation. It sounds very logical. It sounds very reasonable. The woman is happy because she has been given an explanation that makes sense to her. The doctors are happy because that woman is not bothering them anymore with questions. It all sounds very nice – it just doesn’t happen to work that way.
The fact of the matter is, as I have already said, cysts do not usually cause pain. Even if you did have a cyst and it ruptured, the fluid that would spill into the abdomen would be a relatively small amount - not enough to show up on ultrasound. Furthermore, the fluid that might spill would be fairly rapidly absorbed.
The sequence of events would most likely be as follows:
A woman would have pain. She would then call her physician for an appointment – delay number one. Once she got to her physician, an ultrasound would be ordered. Since most Gynecologists do not have the ability to perform their own ultrasounds, you would have to call the hospital for an appointment – delay number two. By the time you actually got to the hospital for the ultrasound, several days may have elapsed. Therefore, any fluid that might be seen on the ultrasound had absolutely nothing to do with that cyst that was supposed to have ruptured.
Keep in mind that in normally ovulating women, an ovarian cyst ruptures every month. The follicle in which the egg develops is a cyst. The process of ovulation involves the rupture of the follicle wall followed by the expulsion of the egg. This does not cause pain. The pain that women experience at the time of ovulation is due to the rapid growth of the follicle with stretching of the follicle wall just prior to ovulation. Ovulation with collapse of the follicle actually relieves the pain.
In the vast majority of women that we see, the explanation for their pelvic pain is endometriosis. Some studies have shown that women with endometriosis have larger amounts of fluid in their pelvis than women who do not have endometriosis. This is the most logical explanation that we can think of to explain this common story.
SIMPLE VERSUS COMPLEX
Today are many different ways you can categorize cysts. One way is their appearance on ultrasound – they can be either simple or complex.
A simple cyst is one where the margins of the cyst are smooth and the interior of the cyst is filled with clear fluid. Clear fluid on ultrasound appears black and it is homogeneously black.
Complex cysts can have several different appearances. One relates to the wall of the cyst where you may see irregularities or small projections.
Another appearance is one in which there may be walls inside the cyst. This tends to divide the cyst into several compartments.
Another appearance is when the fluid inside the cyst has irregular echoes-it is not homogeneously black.
One question I have been asked is whether or not there are different degrees of complexity. While there is certainly can be, this is all of little clinical significance. Most importantly is whether or not the cyst is either simple or complex.
Although there is almost certainly going to be an exception to everything in medicine., as a general rule, simple cysts are almost always benign. Most complex cysts are also going to be benign although if a cyst represents a malignancy, it will almost always be complex.
Sometimes you can tell what type of the cyst it may be simply by its appearance on ultrasound. One common type of cyst that is seen in women who do not ovulate properly is a hemorrhagic corpus luteum. These have a very distinctive appearance on ultrasound. Endometriosis cysts also have a very typical appearance on ultrasound. Sometimes you can tell if a dermoid cyst is present but many times you can’t. Trying to guess the nature of a cyst based upon its ultrasound appearance is usually not going to work.
There are only two treatment options available to deal with ovarian cysts – you can either watch them or you can operate on them. Sometimes the choice is quite simple and straightforward; sometimes it is not quite so easy.
There are numerous factors that must be evaluated before arriving at the best treatment choice. The age of the woman is obviously of considerable importance; the symptoms that the cyst might be producing is important; whether the cyst is solitary or one of many must be considered; and what other factors may also be present that might give you a clue as to what type of cyst it might be plays a role as well.
Perhaps the most important factor in the decision making process is the appearance of the cyst on ultrasound. Cysts can be separated into two principal categories – simple and complex. Fluid on an ultrasound is black. If the cyst is solid and black and the wall of the cyst is smooth and sharp, then the likelihood is that it is not anything of significance and can be watched. This is true even in a woman who is postmenopausal providing the cyst is less than 5 cm. in diameter and the CA-125 level is normal.
The other type of cyst that could be present is “complex”. A complex cyst can have several features on ultrasound. First, there could be numerous echoes inside the cyst. The cyst could have internal walls; the margins of the cyst could be irregular; there could be evidence of small solid masses attached to the cyst wall; etc. Any of these features would immediately make the cyst somewhat more suspicious.
Another important factor, as I have mentioned, is the woman’s age. The older the woman the more concerned one needs to be. The thing everyone worries about, of course, is cancer. Ovarian cancer in young women is rare.
If the decision is made to simply observe the cyst, then periodic ultrasounds, usually every month or so, are performed to make sure the cyst is not growing and, hopefully, shrinking and ultimately disappearing.
If the decision is made that surgery is the appropriate treatment, this is usually done through a laparoscope. Depending upon numerous factors, the cyst may simply be opened, drained, and a portion of the cyst wall taken for biopsy to establish its true nature. Unfortunately, with occasional exceptions, the appearance of the cyst on ultrasound only gives you a general idea of what type it is – it cannot tell you definitively.
Sometimes the entire cyst wall is removed – sometimes this is technically almost impossible without damaging the ovary significantly.
Occasionally, again depending upon the age of the woman and other factors, the entire ovary may be removed.
It is critically important to understand that there is nothing that can be done to make a cyst disappear without surgery.
I know that women are frequently given birth control pills in an attempt to “dissolve” the cyst. This is useless therapy. Again, it is based upon erroneous assumptions. Women have frequently been given birth control pills and a certain number of cysts will disappear. It was, therefore, concluded that the pill made the cyst disappear. Very nice in theory – it just happens to be incorrect.
Some cysts (usually functional cysts) are going to go away on their own in the vast majority of instances without any specific treatment whatsoever. Other types of cysts are never going to go away on their own and require surgery.
Studies have been done putting women on birth control pills and following their cysts. Those cysts that were going to go away on their own would do so whether the woman was taking the pill or not. Those cysts that were not going to go away on their own remain – again, regardless of whether the woman was taking the pill or not. All the pill really does is give you something to do everyday while you are waiting to see whether your cyst is going to disappear spontaneously. The pill may correct any irregular bleeding associated with the cyst but it is not going to make the cyst go away and it is certainly not going to make a cyst go away that would otherwise remain.
POST-MENOPAUSAL OVARIAN CYSTS
Although they are not very common, ovarian cysts do occur in women after menopause. Since ovarian cancer is predominantly a disease of postmenopausal women, the presence of an ovarian cyst in this age group is naturally a cause for concern.
Not that long ago, in the days before we had ultrasound and a better understanding of this entire problem, an ovarian cyst in a postmenopausal woman was an automatic indication for surgery. There was even a name attached to it – “PPMO” – the Palpable Post-Menopausal Ovary.
With the development of good ultrasound equipment and a better understanding of this issue, we now know that every enlarged ovary in a postmenopausal woman does not always require immediate surgery.
How can we determine which ovarian cysts can be watched and which ovarian cysts require surgery? There are several factors that must be taken into consideration.
The first is the size of the cyst. The evidence is that any cyst that is 5 cm in diameter or less can be watched. As a point of reference, a ping-pong ball is 4 cm.
Another criteria is that the cyst must be simple – not complex. This has already been discussed earlier in this pamphlet.
Another criteria is the CA-125 level. While this is not an absolute guarantee that a cyst is benign, a normal level is very reassuring.
Last is what happens to that cyst over time. Ultrasounds are done at regular intervals to make sure the cyst is not enlarging. A cyst requires surgery if it is over 5 cm in diameter (some will watch a cyst up to 10 cm but I personally don’t feel comfortable with that philosophy).
A cyst requires surgery if it is complex, if the CA-125 level is elevated, or if the cyst is enlarging. Per her
A newer test has replaced the CA-125. It is called the “OVA-1″ and gives somewhat more reliable information than just the CA-125.
Family history should also be taken into consideration. If there is a strong family history of breast cancer and/or ovarian cancer this would tend to push me toward surgery sooner rather than later.
Another factor would be whether the cyst is single or whether there are many cysts in the ovary. A solitary simple cyst is most likely going to be benign. However, in a postmenopausal woman, an ovary with multiple cysts is a cause for concern.
Endometriosis cysts are fairly common. The official term for an endometriosis cyst is an “endometrioma”.
Although they are officially cysts, endometriomas are different than other types of ovarian cysts and therefore deserve some special comments and explanations.
Keep in mind that a cyst is any structure in the body that is not supposed to be there and is filled with fluid. What type of fluid is unimportant.
Most ovarian cysts are either functional or they are cystic tumors as described elsewhere in this pamphlet. As such, these types of cysts have walls that are distinct and usually easily identifiable membranes that surround the cyst and enclose it.
I have tried to think of a way of explaining this in simple, easy to understand terms. One way to imagine this would be to take a large container of ice cream, put a balloon into the ice cream, and then slowly blow up the balloon. The balloon represents a cyst and the wall of the balloon represents the cyst wall. You can appreciate that removing this is usually relatively easy. It is usually possible to find a “plane” – a thin area of separation between the wall of the cyst and the surrounding ovarian tissue.
Endometriomas are different. Based upon everything that we have learned about this crazy disease over the past hundred years, it appears that endometriomas begin as an implant of endometriosis on the surface of the ovary which then, at least in part, burrows into the ovary.
Keep in mind that implants of endometriosis, at least to a certain degree, go through the same sort of cyclic changes during your menstrual cycle as does the normal endometrium inside the uterus. When you are having your period, these implants are also bleeding although obviously not to the same degree.
Nonetheless, if you have some implants of endometriosis that have other at the Patel is you you are were one actually grown into the ovary, any blood that they release has nowhere to go and it begins to accumulate. Eventually, it forms an endometrioma – a cystic structure within the ovary that is filled with blood. As that blood remains in the ovary, over time it goes through various changes and ultimately turns brown. If the endometrioma has been there for a considerable period of time, this old blood looks identical to Hershey’s syrup and we called them “chocolate cysts”.
Again go back to the analogy of the container of ice cream. Now however imagine if you will that we simply take a hose, placed it into the ice cream and turned on the water. As the water begins to accumulate, it has nowhere to go to, just as in the case of an endometrioma and the blood that accumulates. However, although the increasing pressure of the water compresses the ice cream around the pocket, there is no wall – no balloon.
The same thing is happening in the ovary when the endometrioma is formed – there is no wall around it – only compressed ovarian tissue.
This difference between an endometrioma and other types of ovarian cysts is not just of academic interest. It has very serious implications for how endometriomas should be treated.
Over the years, arguments have raged back in for among various physicians as to the best way of treating endometriomas. One segment thought that you should treat an endometrioma like other ovarian cysts, removing the cyst wall, conveniently forgetting that there is no true cyst wall. Therefore, what you are really doing is a removing the compressed ovarian tissue around the endometrioma which means you are really removing normal ovarian tissue that contains eggs.
Others say that you should simply open the endometrioma, drain out the old blood that is in there, clean out the endometrioma as much as possible and then, either using a laser or cautery or whatever, destroy the surface of the endometrioma inside the ovary to destroy any implants of endometriosis that might be present. Doing it this way significantly reduces the damage to the ovary that is left behind.
This is of critical importance because studies have now clearly shown that if you treat an endometrioma by stripping what amounts to a pseudo-wall, and if you are overly zealous, you can easily remove excessive amounts of ovarian tissue and significantly impair that women’s future fertility.
Therefore, based upon the evidence that has accumulated, I personally think that in today’s world, it is not appropriate to try to treat an endometriosis cyst by “stripping” a wall that does not really exist. I can tell you that I have treated endometriomas both ways. I can tell you that for a long time, even before we had good hard data, I was very uncomfortable trying to remove endometriomas by stripping because very often, when I got finished, I could tell there wasn’t much normal ovary left. Therefore, for many years, it has been my practice to simply open the endometrioma, drain it, destroy the interior of the endometrioma and then, if the woman is not interested in becoming pregnant, put her on hormonal suppression the to minimize the reformation of the endometrioma. I can tell you that I have never regretted doing it this way and the data now available shows that this approach is the best way to make sure that the woman’s future fertility is not impaired to any greater degree than it otherwise might be.