It is important to know that in every menstrual cycle, the ovaries go through cystic changes. As menstruation progresses in the ovaries, a signal to the brain causes a series of eggs to be selected for ovulation—only one of which will hatch. Prior to hatching, a follicle develops, and the size of this follicle is about 2-3 centimeters. This follicle is called a physiological ovarian cyst, and it is a natural phenomenon in the menstrual cycle for every woman. Beyond this, any pouch or sac filled with fluid or other tissue that formed on the ovary is also called an ovarian cyst. In general, an enlargement of the ovary cyst beyond 4 centimeters can cause persistent discomfort and would alert a patient and their doctor to an abnormal cyst. It is critical to follow these ovarian cysts in early diagnosis in order to rule such possible conditions as endometriosis or even ovarian cancer. Nevertheless, cysts are most often benign and even when they are abnormal, rarely do they require removal of the ovaries, also called an oophorectomy .
The ovaries are responsible for producing healthy eggs for fertilization. However, sometimes cysts form within or on the surface of the ovaries. These fluid-filled sacs are called ovarian cysts. While small (2-3 centimeters) ovarian cysts will not present harmful symptoms and only need to be managed by observation, there are many other forms of cysts generated under pathological conditions. These cysts either have a bigger size and/or produce painful symptoms, and can have a detrimental impact on a woman’s reproductive system.
Just as men have two testicles in the reproductive system, females have two ovaries, which is the site of possible ovarian cyst development. However, while men have the luxury of being able to clearly visualize such key reproductive organs, female anatomy presents a much more difficult challenge as the ovaries are within the pelvic cavity. On top of this, typical ovarian cysts are a normal part of a woman's ovulation cycle. Thus, the distinction between physiological cysts versus harmful cysts must be made. Because of these facts, women can be much trickier to diagnose when it comes to ovarian diseases such as ovarian cysts. Nevertheless, painless imaging techniques such as sonography can be used to help provide a presumable diagnosis of the type of ovarian cyst a patient may have.
In order to understand how ovarian cysts can commonly form, it is first important to know how a healthy egg is released upon ovulation. Before an egg can be released from the ovaries, a follicle must form. Follicles are small, fluid-filled sacs that can be thought of as healthy, normal cysts. They create a protective environment in which an egg can properly develop. Upon ovulation, the follicle breaks and a mature egg is released into the fallopian tubes, and the remaining hemorrhagic fluid leaks out of the ovary. This leakage, along with follicle development and breakage, is a normal process in the production of healthy eggs in the female reproductive system, but it does present one area where abnormal ovarian cysts can arise.
Follicle abnormalities can occur in several different ways. First, there are cases where the follicle does not break, and in turn, the fluid remains in the tightly packed sac, forming what is referred to as a follicular ovarian cyst. Ovarian cysts can also arise after ovulation, when the egg is released and the follicular breakage reforms to make the corpus luteum forms. The normal lifespan of this structure is 14 days following ovulation, but there are situations when the corpus luteum does not dissolve and in turn a corpus luteal cysts arise. Blood and other forms of bodily debris such as ectopic endometrium or even neoplastic tissue also plays a role in the formation of several other forms of ovarian cysts. The female reproductive system is incredibly complex, and it is crucial for each coordinated step to occur as intended.
PCOS is a hormonal disorder that causes small, benign cysts to arise throughout the ovaries. While these cysts may not be harmful, they often lead to further hormonal imbalances. This can cause such symptoms as irregular periods, acne, and even infertility issues.
As noted above, there are many different forms of ovarian cysts that can arise, both physiologically and pathologically. Below are a few of the most common forms of ovarian cysts:
When ovarian masses arise, such as abnormal ovarian cysts, one of the common complications that can occur is ovarian torsion. When the ovarian cyst is large enough in size, it causes the ovary to rotate and twist around its root, ultimately cutting off the ovarian blood cell line. Fallopian tube torsion can also arise in congruence with ovarian torsion. This is one of the primary reasons why abnormal ovarian cysts can cause such symptoms as pelvic and lower abdomen pain, along with nausea and vomiting. However, in cases of ovarian torsion causing a lack of blood supply to the ovaries, the pain experienced will be excruciating, as the ovaries are at risk of “dying.” Cases of severe ovarian torsion are considered medical emergencies due to excruciating pain and the possible loss in ovarian function. In the emergency department, laparoscopic detorsion is used, which has a success rate of saving ovarian function in 90% of cases. It is highly encouraged to rush to the hospital if you have a history of pathological ovarian cysts and your symptoms become agonizingly painful.
Pelvic masses are defined as abnormal growths in the pelvic cavity. They can be a growth or tumor in the ovaries, uterus or any pelvic organ. Many ovarian cysts such as cystadenomas, dermoid cysts, and endometriomas are all examples of pelvic masses that can arise in the ovaries. However, fibroids can also be considered pelvic masses, and they are normally found in the uterus. Thus, ovarian cysts can usually be classified as pelvic masses, but the same cannot be said vice-versa.
Endometriosis is one known cause of abnormal ovarian cysts, specifically endometriomas. One of the most common locations for ectopic endometrial cells to grow are the ovaries . This occurs when menstrual blood carrying sloughed off endometrial tissue moves backward through the fallopian tubes to the ovaries. The endometriosis tissue then accumulates and grows inside the ovary, eventually forming an endometrioma. This newly implanted endometriosis scar tissue will then be able to have its own “mini periods,” in which the said lesion will begin to bleed and possibly slough off even more endometriosis tissue. The combination of these fragments of endometrial tissue, old thickened blood, and inflammatory enzymes combine together within the ovary to create an endometrioma or chocolate cyst.
As noted above, the endometriosis scar tissue that makes up a chocolate cyst will have its own “mini period,” causing blood and additional endometrium to slough off from the cyst. For this reason, endometriomas are likely to leak into other areas within the pelvic and abdominal cavity. This is one of the primary ways in which deep infiltrating endometriosis develops. When this occurs, adhesions can form in areas outside of the ovaries and spread in such diffuse areas as the peritoneum, cul-de-sac, intestines, and more. When this occurs, symptoms of pelvic pain, heavy bleeding, painful sex, nausea, vomiting, and cramping can often worsen. In rarer cases, the chocolate cysts can even rupture, causing the contents to spill out and lead to such severe, deep infiltrating endometriosis that frozen pelvis develops. This is why it is important to seek an endometriosis specialist who can surgically remove endometriomas in order to ensure that the disease does not spread and worsen.
While the average ovarian cyst does not need much more than routine check-ups, a patient should definitely consider an endometrioma with concern. This is primarily for four reasons. First and foremost, there is a high possibility that endometriosis is spreading if the cyst is indeed an endometrioma. As noted above, endometriomas will often leak into the pelvic cavity and cause deep infiltrating endometriosis to occur, which can then spread to the rectum, bladder, and bowels. Ovarian endometriomas thus appear to be markers for more extensive pelvic and intestinal disease. Exclusive endometriomas are found only in 1% of endometriosis cases, while remaining patients have extensive pelvic or intestinal endometriosis along with ovarian endometriosis . An endometrioma can also rupture, causing its contents, including both endometriosis scar tissue and old degenerative blood, to spill into the pelvic cavity. This can cause aggravated symptoms and can lead to the most serious classification of endometriosis: stage IV endometriosis with a frozen pelvis. Frozen pelvis is when the pelvic cavity is so extensively covered in endometriosis adhesions that the surrounding organs “glue” together, causing the pelvic anatomy to be “frozen” in place. Thus a ruptured endometrioma is a huge concern and is why a patient should consider surgery if they are in fact diagnosed with an endometrioma. Another concern with endometriomas is the risk of ovarian torsion. If the ovary gets large enough due to inflammation and growth of the cyst, it will begin to turn on itself. It is believed that an ovarian cyst larger than 4 cm in diameter has a greater chance for torsion than those that are smaller. This torsion can lead to a loss of blood supply to the ovaries, resulting in tissue death. While rare, these occurrences are medical emergencies and should be a great cause for concern. Last but not least, research has shown that patients with ovarian endometriosis or endometrioma have a greater risk of developing certain types of ovarian cancer, including clear cell ovarian cancer, low-grade serous ovarian cancer, and endometrioid invasive ovarian cancer . It is crucial for patients to seek an early diagnosis if they are concerned of endometrioma development.
Endometriomas can be as small as a quarter or as large as a watermelon. When endometriomas and adhesions continue to grow and involve both ovaries, the ovaries can become so large and inflamed that they nearly touch each other. Endometriomas with such a close proximity to one another are termed "kissing ovaries." This condition is easily visualized through vaginal sonography and is usually used as an indicator as to whether or not the patient has a mild to severe case of endometrioma development.
While endometriosis can be the cause for developing ovarian cysts, it is important to note that not all ovarian cysts are caused by endometriosis. As stated above, there are several classifications of ovarian cysts, and an endometrioma is just one of them. Nevertheless, this is an important distinction to make as oftentimes a doctor may diagnose their patient with an ovarian cyst, which is actually a very vague diagnosis to make. Keep in mind that an ovarian cyst can mean anything from a benign follicular cyst to a highly concerning and still developing endometrioma. For these reasons, it is very important to consult a gynecological specialist who can differentiate between these nuances that ultimately call for a completely different plan as to whether or not to monitor the cyst itself. This distinction can be the difference between a presumptive misdiagnosis of a benign follicular cyst, which can resolve on its own, versus a growing endometrioma, which is an indicator for endometriosis and possible deep infiltration of endometriosis that requires surgery.
It is important to note that most often, ovarian cysts will present no symptoms as they are small and benign. Symptoms can also vary depending on the type of ovarian cyst. Nevertheless, in cases of abnormal and potentially harmful ovarian cysts, the following symptoms can arise:
There are multiple ways in which an ovarian cyst can be diagnosed, but the best way to presumptively diagnose an ovarian cyst is through sonography, which is ideally performed through the vagina as opposed to via the abdomen.
Blood testing: Cancer antigen (CA) 125 is a protein that is often measured in blood tests for cases of ovarian cancer. It has been found that CA 125 levels are significantly elevated in moderate or severe endometriosis compared to women with minimal or mild disease . However, the low sensitivity of this test poses the limitation in its clinical use for endometriosis . Serial CA125 determinations may be useful to predict the recurrence of endometriosis after therapy .
Medication: One of the first measures doctors will take in attempting to treat abnormal ovarian cysts is to prescribe medication. Of these recommendations, birth control is the most common. By prescribing oral contraceptives, the doctor is attempting to prevent ovulation, and thus further development of ovarian cysts. While oral contraceptives are useful in relieving a patient’s symptoms, it is important to note that they do not cause pre-existing dangerous ovarian cysts, such as endometriomas or cystadenomas, to disappear. In other words, medication will not remove the abnormal cyst itself. Medication does aid in relieving the symptoms that the cyst causes.
Ovarian cystectomy is the surgical removal of ovarian cysts where the function of the ovaries is preserved. This is made possible by laparoscopic surgery, which is considered the "gold standard" for both visualizing and treating abnormal ovarian cysts. By making several small incisions into the abdomen and pelvis, a surgeon is able to insert a laparoscope in order to clearly visualize and operate on a patient’s ovaries, fallopian tubes, and surrounding reproductive organs. However, when it comes to ovarian cysts, it is important to find a surgeon who will not only perform minimally invasive laparoscopic surgery in order to properly remove an ovarian endometrioma, cystadenoma, etc., but will also carefully preserve ovary functionality, and will only remove the ovaries if necessary.
Because ovarian cysts can range from such classifications as completely benign follicular cysts to large ovarian endometriomas and cystadenomas (which present a high risk for deep infiltrating endometriosis and ovarian cancer), we strongly believe that diagnosing and treating ovarian cysts must be handled with great care.
We believe the most important element of a successful ovarian surgery is ensuring the patient that removal of the ovaries will only be conducted if absolutely necessary, which is rare. Second, the ovarian cortex, which houses a healthy woman’s developing eggs, must be preserved. In order to preserve the ovarian cortex, we conduct our surgeries very meticulously by adhering to the principles of microsurgery, which clearly state the great need for fine tissue handling. This means not using electricity or cauterizing the ovary, a term that is sometimes referred to as “cooking” the ovaries. This can be very harmful to a patient’s ovarian reserve and can even have detrimental effects for patients looking to preserve their fertility. Our goal is to ensure that our patients have as few complications and risks as possible. This is why we abide by the technique of "cold" excision, meaning surgical removal of your abnormal cysts without electricity.
We also ensure the preservation of ovarian functionality following the removal of ovarian cysts by conducting ovarian reconstruction surgery. Just as a plastic surgeon reformats and recreates tissue, we look to do the same with the ovaries in order to preserve their functionality. Finally, we will also suspend the ovary from the pelvic wall in order to ensure that the ovary does not "get stuck" to other tissue, or even the other ovary, following surgery.
By conducting a very precise, careful ovarian laparoscopic surgery technique, on top of assessing patients pre-surgery through transvaginal ultrasonography and often MRI, we ensure that every case is handled with the care and patience that it deserves. Proper diagnosis and classification of ovarian cysts is a very tricky subject and should only be taken up by the most experienced ovarian cyst specialists. We like to combine our world-renowned expertise with our unique philosophy of personal care. Not every case is the same and, therefore, every patient must be heard .
Candie, an actress and musician, was found to have abnormal ovarian cysts in each of her ovaries after suffering such horrible symptoms as killer cramps, painful ovulation, back pain, constipation, nausea, and vomiting. Initially told that her symptoms were "in her head," Candie went on to seek surgery—only to be poorly operated on by a proclaimed “endometriosis specialist.” Candie was able to find us and receive the surgery that she needed. Learn about Candie and her story and her successful endometrioma and surrounding endometriosis removal surgery, and remember her triumph can be yours too.
You can read more stories of patients with ovarian cysts, at varying stages, in our testimonial section.
Medically reviewed by Tamer Seckin, MD on October 30, 2019
I’ve seen many obgyns over the years explaining my monthly symptoms during my period...but eventually it became a daily struggle with these pain. It feels like a poke here and there near my right pelvic region. I was given birth control pills for the past ten years but honestly, it didn’t help at all. I was in bed whenever I had my period. I was previously sent to GI doctors for possible appendicitis but it was ruled out from imagings…
Dr.Seckin is so much more than a surgeon. His passion for helping endometriosis sufferers and determination to improve the quality of life in all of his patients is undeniable. I remember when my gynecologist first told me I needed a laparoscopy. Her exact words were "I can do the surgery, but if you were MY daughter- I'd send you to him." From the first day I met him he took the time to explain endometriosis to me since I knew…
I was there for hysterectomy but then I found out that I also had endometriosis.My both surgeries went excellent and I feel great!.I am so thankful to Dr.Seckin and all his team for making my journey smooth!
I am a physician who suffered from deep infiltrative endometriosis. I needed laparoscopic surgery, so I went to see my former gynaecologist and he performed the procedure (a surgery which he supposedly does hundreds of times a year) last November. I had severe pain again when I had my period in January and was advised to go on taking a low hormone dose anticoncipient pill. My symptoms came back quickly and got worse in a few months’ time. I went…
After years of excessively painful periods, a serious loss of quality of life, and a series of uninformed and uninterested doctors, Dr. Seckin and Dr. Goldstein turned my life around. I was told I woke up from my surgery almost a year ago with a smile on my face, and I haven't stopped since. Before I heard of Dr. Seckin, I was experiencing almost daily terrible pain to the point where I had difficulty walking, inability to eat, inexplicable weight…
Dr Seckin and his team gave me back my life! Tomorrow will be 1 month since my surgery and I feel great. Dr. Seckin, Dr Liu, and Dr Goldstein are not only beyond words talented and amazing Doctors, but they are also genuinely wonderful and caring people. I cannot say enough great things about Holly, Asiye and Kim as well. They were all caring, kind, patient, and took the time to listen to me and explain anything I needed to…
Dr. Seckin and his staff spared me from years and years of heavy periods and unbearable endometriosis pain. After having surgery with him (my first) I can now function like a regular human. No more eating NSAIDs like candy and calling out sick from work. Thank you, Dr. Seckin!