Overview of Ovarian Cysts
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 concern a patient and their doctor of 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.
What are ovarian cysts?
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) simple 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 hold a bigger size, produce painful symptoms and can have a detrimental impact on a woman’s reproductive function.
Why are ovarian cysts difficult to identify?
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, the 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, such painless imaging techniques as sonography can be used to help provide a presumable diagnosis of the type of ovarian cyst a patient may have.
Causes of ovarian cysts
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 first 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 is leaked out of the ovary. This leakage, along with follicle development and breakage, is all a normal process in the production of healthy eggs in the female reproductive system, but it does present one area in which abnormal ovarian cysts can arise from.
There are several ways in which follicle abnormalities can occur. First, there are cases when 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. Another way in which ovarian cysts can arise, is after ovulation upon the egg being released, 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. Thus, we can once again see how complex the female reproductive system is, as well as how crucial it is for each coordinated step to occur as intended.
What is Polycystic Ovarian Syndrome (PCOS)?
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.
Classification of Ovarian Cysts
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:
- Follicular cysts: An ovarian cyst that forms when the follicle containing a developing egg does not break. They are most often painless, harmless and resolve after a few menstrual cycles.
- Corpus Luteal cysts: When the corpus luteum does not dissolve according to the designed time line, which is 14 days after ovulation without fertilization or 14 weeks in the presence of pregnancy, a corpus luteal cyst will occur. Often times, the internal tissue of this cysts undergoes necrosis, uncontrolled cell death, causing bleeding to be contained within the cyst itself. When this happens the cyst is termed a hemorrhagic corpus luteal cyst. These cysts can easily be confused with an endometrioma, which is detrimental mistake. Usually hemorrhagic cysts are benign cysts that will go away on their own within a few weeks, with no treatment needed. However, endometriomas can be highly dangerous as they can lead to spreading of endometriosis tissue, as well such emergencies as ovarian torsion. Thus it is invaluable for you to know the distinction between these two forms of cysts, as a patient should feel comfortable to speak up to their provider in order to ensure an endometrioma does not go misdiagnosed as a benign hemorrhagic corpus luteal cyst.
- Endometriomas: Also known as “chocolate cysts,” these ovarian cysts will contain fragments of endometriosis tissue and possible retrograde menstruation blood that ultimately pools together and degenerates, making a chocolatey brown serous fluid.
- Dermoid ovarian cysts (teratomas): These cysts will typically develop while a female is at her most fertile, and will contain hair, fat or any other form of abnormal tissue. They can usually take on both a solid and cystic form and can cause pain, infection, rupture and even cancer in some cases. About 15-20% of dermoid cysts are bilateral, meaning they grow on both ovaries, with less than 3% being malignant (cancerous). It is thus highly advised to surgically remove a dermoid ovarian cyst. Ovarian surgery for dermoid cysts must be performed by an experienced laparoscopic surgeon with a meticulous technique to avoid spilling the dermoid contents into the peritoneal cavity. Depending on the size, ovaries need to be reconstructed skillfully, without resorting to using electrosurgery which can affect ovarian blood supply and eliminates ovarian reserve by coagulating healthy eggs.
- Cystadenomas: This benign ovarian tumor usually develops on the outside of the ovary, and it can be mucous filled (mucinous cystadenoma) or filled with a clear yellow serum (serous cystadenoma). They can grow to be very large, but once again, are most often not harmful. However, it has been found that serous cystadenomas have more of a tendency to develop into cancer.
What is ovarian torsion?
When ovarian masses arise, such as abnormal ovarian cysts, one of the common complications that can occur is ovarian torsion. This is when the ovarian cyst is large enough in size that 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 bloody supply to the ovaries, the pain experienced will be excruciating, as the ovaries at risk of “dying.” Thus cases of severe ovarian torsion are considered medical emergencies due to the concern of a loss in ovarian function and the excruciating pain caused by it. In the emergency department laparoscopic detorsion is used, which has a success rate of saving ovarian function in 90% of cases. That is why it is highly encouraged to rush to the hospital if you have a history of pathological ovarian cysts and your symptoms become agonizingly painful.
Are ovarian cysts and pelvic masses the same?
Pelvic masses are defined as any abnormal growth in the pelvic cavity. This 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.
Ovarian cysts and endometriosis
How can Endometriosis lead to ovarian cyst development?
Endometriosis is one known cause of abnormal ovarian cysts, specifically endometriomas. One of the most common locations for ectopic endometrial cells to seed is the ovaries . This occurs when menstrual blood carrying sloughed off endometrial tissue moves backward through the fallopian tubes to the ovaries. Once there, the endometriosis tissue 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 it is often termed due to its brown serous appearance.
How can endometriosis in the form of an endometrioma spread?
As noted above, the endometriosis scar tissue that makes up a chocolate cyst will have their own “mini periods,” 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 happens, symptoms of pelvic pain, heavy bleeding, painful sex, nausea, vomiting and cramping can often be found to worsen. In more rare 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 the disease does not spread and worsen.
Why are endometriomas of a patient's concern?
While the average ovarian cyst does not need much more than routinely check ups, an endometrioma should certainly be of a patient’s concern. This primarily is for four reasons. First and foremost, there is a high possibility of endometriosis 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 such organs as 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, with the remaining patients having extensive pelvic or intestinal endometriosis along with ovarian endometriosis . Even worse, an endometrioma can also rupture. When this happens, all of its contents, including both endometriosis scar tissue and old degenerative blood, will spill into the pelvic cavity. This can cause symptoms to be aggravated and lead to the worse classification of endometriosis, stage IV endometriosis with frozen pelvis. This is when the pelvic cavity is covered in endometriosis adhesions so extensively that it causes surround organs to “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 to be had when diagnosed with an endometrioma, is the risk of ovarian torsion. Remember, 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 smaller. This torsion can lead to a loss of blood supply to the ovaries and thus tissue death.These occurrences while rare, are medical emergencies and should thus be a great cause for concern. Last but not least, research has showed 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 . Therefore it is crucial for patients to seek an early diagnosis if they are concerned for endometrioma development.
What are "kissing ovaries?"
Endometriomas can be as small as a quarter to 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.
Are ovarian cysts and endometriomas the same?
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 often a doctor may diagnose their patient with an ovarian cyst, which is 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 make for a completely different plan as to whether or not monitor the cyst itself. This distinction can be the difference between a presumptive misdiagnoses of a benign follicular cyst that is fine to be left, versus a growing endometrioma, which is an indicator for endometriosis and possible deep infiltration of endometriosis that requires surgery either way.
Symptoms of Ovarian Cysts
It is important to note that most often, ovarian cysts will present no symptoms at all 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:
- Irregular and painful menstrual bleeding and periods (dysmenorrhea)
- Pelvic pain, especially during period
- Pain with intercourse (dyspareunia)
- Nausea, vomiting, diarrhea or bloating
- Bladder and bowel dysfunction and pain
- Lower back pain that can radiate to thighs and legs
- No symptoms at all, unless a cyst ruptures or ovarian torsion occurs
Diagnosis of Ovarian Cysts
There are multiple ways in which an ovarian cyst can be diagnosed, but perhaps 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.
- Transvaginal ultrasonography: This diagnostic tool is inserted into the vagina in order to produce real-time images on a monitor. Through these images, your doctor will not only be able to assess whether or not you have any ovarian cysts, but they also can exam the shape, size, location and components that make up the cyst itself. This is key in determining if the cyst is fluid-filled, solid or a mix of the two. These key distinctions will ultimately determine whether or not your surgeon will operate on you, or if the ovarian cyst is even harmful in the first place.
- MRI: Magnetic resonance imaging (MRI) is a key diagnostic tool used to evaluate pelvic pathology. Therefore, before any surgery is conducted, a physician may ask their patient to receive an MRI in order to obtain clear imaging of the ovaries, providing the doctor with a greater understanding of the size, severity and extent of the ovarian cyst.
- CAT Scan: Using computerized axial tomography, this x-ray imaging can be highly useful in determining whether an ovarian cyst is abnormal or not. It is primarily used to detect suspicion of malignancy and abnormal ovarian growth causing invasion to adjacent organs, lymph and blood vessels. Thus, a CAT scan is often used to rule out any immediate emergency, or need for surgery, when it comes to ovarian cysts.
- Laparoscopy: Laparoscopy is a minimally invasive technique that uses a laparoscope in order to clearly visualize the ovaries and any cysts that may be present. This technique is performed in the operating room while the patient is under anesthesia. It is often referred to as “almost scarless surgery” and minimally invasive surgery (MIS), and the number of incisions and incision sizes can vary from one surgeon to another depending on their experience, skill and method. An ideal example would be in the new implementation of robotic surgery, which requires a minimum of 5 larger incisions, compared to the 3 smaller, near-invisible incisions made when done by an expert laparoscopic surgeon. Robotic assistance does not make an average surgeon a better one.
once it is confirmed through ultrasound that a patient has an ovarian cyst. It is both a diagnostic and treatment tool as it produces the best real-time images of the ovaries, and is thus prime for use in the surgical removal of any harmful cysts that may be present.
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 limitation in its clinical use for endometriosis . Serial CA125 determinations may be useful to predict the recurrence of endometriosis after therapy .
Treatment for Ovarian Cysts
Ovarian Cyst Medication
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 perhaps the most common. By prescribing oral contraceptives, the doctor is attempting to prevent ovulation, and thus further development of ovarian cysts. While this is one common method of pain control, it is important to note that it does not cause pre-existing dangerous ovarian cysts, such as endometriomas or cystadenomas, to disappear but rather it is useful in relieving a patient’s symptoms. In other words, no medication will remove the abnormal cyst itself. It will aid in treating the symptoms that the cyst causes. Therefore, medication should not be considered a definite treatment for endometriomas, but more of a pain reliever for the symptoms that arise from said disorders.
Ovarian Cyst Surgery:
Laparoscopy: This is the surgical removal of ovarian cysts, while preserving the function of the ovaries. This is made possible, by what is the "gold standard" for both visualizing and treating abnormal ovarian cysts, laparoscopic surgery. 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. When handled with such care, ovarian laparoscopic surgery can be an extremely critical surgery to treat a patient’s symptoms and future medical complications.
First of all, 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 in order to adhere 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 in terms of 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 preservation of ovarian functionality following removal of your ovarian cysts by conducting ovarian reconstruction surgery. Just as a plastic surgeon reformats and recreates tissue, we look to do the same with your ovaries in order to preserve their functionality. Finally, we will also suspend the ovary from the pelvic wall in order to ensure 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 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 .
You may call us at 212-988-1444 or have your case reviewed by clicking here.
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 being told that her symptoms were "in her head" Candie now seeked surgery, only to poorly operated on by a proclaimed “endometriosis specialist.” Finally, Candie was able to find us and receive the surgery that she needed. Learn about Candie and her story following up to her successful endometrioma and surrounding endometriosis removal surgery, and remember her triumph can be yours too.
- Endometriosis Fundation of America https://www.endofound.org/endometriomas-what-you-need-to-know.
- D'Hooghe, T.M. and J.A. Hill, Killer cell activity, statistics, and endometriosis. Fertil Steril, 1995. 64(1): p. 226-8.
- Redwine, D.B., Ovarian endometriosis: a marker for more extensive pelvic and intestinal disease. Fertil Steril, 1999. 72(2): p. 310-5.
- Pearce, C.L., et al., Association between endometriosis and risk of histological subtypes of ovarian cancer: a pooled analysis of case-control studies. Lancet Oncol, 2012. 13(4): p. 385-94.
- Pittaway, D.E., The use of serial CA 125 concentrations to monitor endometriosis in infertile women. Am J Obstet Gynecol, 1990. 163(3): p. 1032-5; discussion 1035-7.
- Novak, E., Berek & Novak's gynecology. J. S. Berek (Ed.). Lippincott Williams & Wilkins. 2012.
- Pittaway, D.E. and J.A. Fayez, The use of CA-125 in the diagnosis and management of endometriosis. Fertil Steril, 1986. 46(5): p. 790-5.
- Seckin, T., The Doctor Will See You Now: Recognizing and Treating Endometriosis. 2016.
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