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The ovaries are a pair of small-sized organs that are shaped like almonds and play a central role in the female reproductive system.
Also referred to as the female gonads, these glands are responsible for releasing the ova, or egg, during the menstrual cycle as well as the production of the female sex hormones, namely, progesterone and estrogen.
With the onset of the menstrual period, a few eggs begin to grow. As the eggs grow, fluid accumulates in the egg and it begins to make estrogen.
It is normal for women to develop a small blister-like growth filled with fluid or semisolid tissue either inside the ovary or on its surface. This fluid filled space is called a cyst. The term “cyst” is descriptive, it is not a diagnosis. There are many causes for cysts on the ovary.
Ovarian cysts are usually small-sized structures that rarely present any symptoms and usually resolve on their own. In fact, most women go about their daily lives without even knowing that they are harboring an ovarian cyst.
Since the ovaries are pain sensitive, cysts can be associated with usually mild pain. Ovarian cysts that are more than 5 cm in diameter may need to be removed surgically.
Types of Ovarian Cysts
Ovarian cysts are classified into two major categories:
- Functional cysts
- Pathological cysts
a. Functional cysts
The most common types of ovarian cysts develop routinely as part of the growth and ovulation of ovarian eggs during the monthly menstrual cycle and disappear in a matter of 2–8 weeks without any treatment.
1. Follicular cyst
The female egg grows within a fluid-filled sac present inside the ovary called a follicle.
At the beginning of the menstrual cycle, the egg is the size of a pinhead. By the time of ovulation, the egg increases to 2.5 cm and is released when the follicle breaks open.
Fertilization occurs at the end of the tube, near the ovary, called the fimbriae. The fertilized egg then travels through the tube for 6–7 days before implanting in the uterus.
Once the egg moves out of the follicle, it discharges the fluid contained within it and shrinks. However, if the ovulation fails to materialize, the fluid remains inside the follicle and persists until this follicular cyst gradually disappears.
2. Corpus luteum cyst
A corpus luteum is the tissue that remains after ovulation. It produces the hormone progesterone.
Fluid can accumulate in the corpus luteum leading to the development of a corpus luteum cyst. In some women, bleeding into the ovary after ovulation results in a hemorrhagic cyst.
Sometimes, the follicle may fail to ovulate. The egg remains in the ovary, and the corpus luteum produces progesterone. This type of cyst is called a luteinized unruptured follicle. These types of cysts are also categorized as functional cysts.
Both these cysts result from a functional process rather than a disease process and are benign.
b. Pathological cyst
Unlike functional cysts, the menstrual cycle has no involvement in the formation of pathological cysts. These cysts are the result of excessive growth of ovarian cells and can occur both inside or outside the ovaries.
While most pathological cysts are found to be noncancerous, the risk of malignancy is possible and therefore cannot be completely ruled out. Pathological cysts can affect women of all ages, which includes both reproductive as well as post-menopausal women.
1. Dermoid cysts
Dermoid cysts, also known as cystic teratomas, are the most commonly-occurring pathological cysts in women who are still in the reproductive age (below 30 years).
A dermoid cyst is made up of those ovarian cells that are used to form the ova or egg. This kind of cyst may also contain traces of hair, dermal tissue, fat, teeth, or bone within it.
Despite the threatening appearance, these cysts are usually benign. These tumors can become quite large and typically require surgical removal.
Ovarian cystadenomas differ from dermoid cysts both in terms of their composition and location.
Cystadenomas are largely benign tumors that develop from the abnormal growth of those ovarian cells that cover the surface epithelium of the ovaries. Cystadenomas are relatively bigger than regular teratomas and can grow large enough to obstruct blood flow to the ovaries.
On average, cystadenoma tends to be at least 10 cm wide but can expand to a much greater size. These cysts tend to have a smooth outer and inner surface and are usually filled with a translucent and runny substance.
Women above the age of 40 are more prone to developing cystadenomas. These cysts require surgical removal.
Causes of Ovarian Cyst
Ovarian cysts can develop due to a number of causes, but some of the prime culprits include:
1. Hormonal issues
Ovarian cysts can often be traced back to some kind of hormonal dysfunction or imbalance in the female body. Women who face fertility problems and take hormone-based medicines to stimulate ovulation are particularly prone to this type of cyst formation.
It is normal for a woman to develop an ovarian cyst soon after conceiving, which serves the purpose of supporting the embryo until the placenta forms. It is also common for childbearing women to retain the ovarian cyst formed during their last phase of ovulation throughout the course of their pregnancy.
It refers to a condition characterized by the abnormal growth of endometrial cells that form the uterine lining in places outside the womb.
The ovaries are often affected by this kind of endometrial tissue growth, which results in the formation of cyst-like mass that is prone to bleeding.
This brown-colored cyst is known as endometrioma, or chocolate cyst in more general terms. Women with endometriosis are, therefore, at an increased risk of developing ovarian cysts.
4. Pelvic infections
Pelvic infection can spread to the ovaries, resulting in the formation of cysts called ovarian abscesses, which are purulent, or pus-filled, cysts.
5. Polycystic ovary syndrome
PCOS is a common hormonal disorder afflicting up to 20% of women all over the world. This condition is characterized by the development of multiple tiny cysts in and on the ovaries. It is a common cause of female infertility.
Signs and Symptoms
Most ovarian cysts are small-sized benign growths that do not exhibit any noticeable symptoms. However, if the cyst becomes unusually large or ruptures, it may give rise to some degree of pelvic discomfort.
Some of the commonly reported symptoms associated with large ovarian cysts include:
- Bloating, swelling, or pressure in the lower abdomen
- Painful bowel movements
- Irregular periods
- Unusually heavy or light menstrual flow with cramps
- Pain in the pelvic area before or during the menstrual cycle, which can range from a dull, heavy ache to a sudden, piercing pain
- Pain that spreads from the pelvis to the lower back or thighs
- Feeling of heaviness even after eating very little
- Frequent need to pass a stool or urinate
- Difficulty in emptying the bladder fully
- Feeling of pressure in the bladder or rectum
- Nausea and vomiting
- Pain during sex
- Rare instances of hormonal fluctuations, which can have a bearing on your breast development and excessive hair growth
- Painful tenderness in the breasts
If an ovarian cyst ruptures, you may experience a sharp pain that comes on suddenly and can be felt only on one side of the abdomen. Women with severe pain or progressively worsening pain should seek immediate medical attention.
The pain associated with a ruptured cyst usually gets aggravated or triggered by any kind of intensive physical activity, such as exercise or sexual intercourse. Some degree of internal bleeding may be present as well.
However, a lot of women do not feel a thing when their ovarian cyst ruptures, especially if it is small in size.
Standard Medical Treatment
While it is true that most ovarian cysts tend to clear on their own within a few weeks or months, some may require medical treatment. In any case, your doctor will ask you to keep a check on your symptoms once you are diagnosed with a functional cyst.
A follow-up ultrasound may be conducted to see if the cyst has shrunk or dissolved completely. If the cyst shows no sign of resolving or increases in size, your doctor will further care based on the type and size of the cyst, your age, and your overall medical history.
Women who are prone to developing functional ovarian cysts may be prescribed oral contraceptives and other types of hormonal birth control or hormonal therapy to temporarily reduce the occurrence of these cysts.
Your doctor may consider surgery for cysts that are extremely painful, persists for more than 3 months, are over 8 cm in size, or increasing in size. Any concern for a benign or cancerous tumor of the ovary may also require surgery for biopsy.
Laparoscopy is one of the less invasive surgical interventions intended for cyst removal and it is usually recommended if the mass appears small and benign. This technique involves the use of an instrument called a laparoscope, a slender telescope. The doctor will make a small incision just above or below your belly button and insert the laparoscope through it. (1)
The laparoscope is equipped with a light source to help the doctor see your internal organs and evaluate the cyst for biopsy or surgical removal. Once excised the cyst is usually drawn out through small cuts at the pubic hairline.
Laparoscopic surgery is quite popular among young women for the simple reason that it leads to minimal scarring and usually performed as an outpatient, or same-day procedure.
Laparoscopy may not work for removing large cysts or those that may pose a cancer risk In these cases, a laparotomy may be performed. This surgical technique will require your doctor to make relatively bigger incisions to withdraw the large-sized cyst.
The extracted mass will then be tested for the presence of cancer cells and to make a final diagnosis. If the test results are positive for cancer, it is highly likely that your doctor will remove the affected ovary and surrounding tissue as well.
Women who have tumors that are high risk for cancer may need to seek consultation with a gynecologic oncologist, a specialist in female genital cancers.
If the doctor suspects that cancer has metastasized to the fallopian tubes, the other ovary, or the entire uterus, all affected tissue may have to be removed.
Your doctor can help dispel any doubts that you may have regarding the surgery and can help you prepare for the procedure by telling you just what to expect.
Diagnosing Ovarian Cyst
The diagnosis of an ovarian cyst typically involves a series of tests. These tests may include:
- An ultrasound exam to determine the exact location and size of the cyst and to see if it is a solid mass or a fluid-containing cyst.
- Blood tests to evaluate the level of CA 125, a substance which, if found in higher levels, can signal the risk of cancer, especially in post-menopausal women. The CA-125 test can also be increased in benign conditions associated with ovarian cysts, such as endometriosis and pelvic infections.
- A pregnancy test to check if the cyst is the outcome of early-stage gestation.
- Hormone level tests to identify possible hormonal factors that may contribute to the occurrence of ovarian cysts.
- Magnetic resonance imaging (MRI) to analyze ovarian growth in greater detail.
- Biopsy, wherein a sample of the ovarian tissue is tested in a lab for the presence of cancer cells.
Pediatric Ovarian Cysts
In a 2017 study conducted on 1009 girls of different ages, it was observed that the frequency of ovarian cyst formation tends to increase with age once the female child enters into adolescence. It is at its highest when the girl turns 15. (2)
The children between the ages of 5 and 9 years were most likely to develop small-sized cysts in an infrequent manner.
Whereas, the teenagers with cysts larger than 5 cm in diameter were found to exhibit the most significant cyst-related significant ovarian pathologies.
Difference Between PCOS and Ovarian Cyst
It is a general misconception to equate ovarian cysts with PCOS. An ovarian cyst is a broad term that refers to different types of cysts that can develop due to a number of factors.
PCOS is a metabolic disorder that is characterized by an excess of male like hormones. These hormones are normal but their levels are often increased in women with PCOS. It is extremely prevalent among women of childbearing age.
As the name suggests, most women with PCOS often develop a large number of small cysts in their ovaries. So, it is wrong to assume that just because you have multiple ovarian cysts, you will inadvertently have PCOS.
Simply put, not everyone with PCOS is bound to have polycystic ovaries, and not everyone with multiple ovarian cysts will necessarily be diagnosed with PCOS.
Does an Ovarian Cyst Affect Pregnancy?
Pregnant women have an increased tendency to developing ovarian cysts, particularly during the early months. Ovarian cysts are important to a healthy pregnancy.
The corpus luteum produces progesterone, essential to an early pregnancy until the placenta begins to produce progesterone at about 9 weeks gestation.
Ovarian cysts such as these are just as benign but they can complicate matters if they continue to become bigger over the course of the pregnancy.
With or without an ovarian cyst, every childbearing woman must remain under the constant care of an ob-gyn. This kind of expert supervision just becomes more pertinent when you have a mass growing on your ovaries.
Women with PCOS require special attention as they are generally at a greater risk of certain pregnancy-related complications, such as:
- Gestational diabetes
- Pregnancy-induced hypertension
- Premature delivery
Myths Related to Ovarian Cyst
1. Ovarian cysts need to be surgically removed
Over 98% of ovarian cysts are fairly small, benign, and harmless, and they tend to go away within a few months without any medical or surgical intervention. Surgery is needed only if the cyst:
- Becomes progressively large
- Is accompanied by fever
- Results in unmanageable pain and discomfort in the lower pelvis and abdomen
- Poses a threat of infection or possible malignancy
2. Ovarian cysts cause infertility
A lot of women with ovarian cysts worry that the condition will make it harder for them to conceive a pregnancy but this is rarely the case. In fact, most ovarian cysts are functional cysts and are related to the growth of an egg and ovulation. These processes are necessary for pregnancy to occur.
Ovarian cysts are also more likely to cause fertility-related problems in women who suffer from endometriosis.
3. Ovarian cysts only affect older women
Another misconception regarding ovarian cysts is that only women who are past the menopausal age are affected by this condition. This is entirely untrue, as women of all ages can develop ovarian cysts at any point their life. Some might get them pretty early on before they have even entered puberty.
However, it is worth noting that cysts that form after menopause are more likely to be cancerous than those that occur during the reproductive years. It is, therefore, mandatory for older women to get their ovarian cysts medically examined to eliminate the risk of ovarian cancer. However, even in menopause, many ovarian cysts are benign and can be safely monitored.
4. Ovarian cysts are cancerous
It is easy to get worked up about any abnormal growth in your body due to the fear that it may be cancerous. The same holds true for ovarian cysts, but you can rest easy knowing that most cases are benign. Thus, the commonly held concern that a cyst on your ovary is the first sign of ovarian cancer is exaggerated.
1. Cancerous (malignant) cyst
Functional ovarian cysts and benign ovarian tumors do not become cancerous. However, differentiating a cancerous cyst from a functional cyst or benign tumor is difficult in some cases.
Physical examination, blood tests, ultrasounds, X-rays, and MRIs are all descriptive, not diagnostic. These tests help your doctor to estimate your risk of an ovarian cyst being cancer. However, if you and your doctor are concerned about cancer, surgical biopsy is the only definitive test to either prove or disprove cancer.
International guidelines have been developed to help women and their doctors decide when surgery is most appropriate. Women and/or their doctors may find a consultation with a gynecologic oncologist helpful, particularly if there is a risk of cancer.
Women who are past the menopausal age are more likely to have ovarian cancer as a cause of an ovarian cyst.
2. Ruptured cyst
Although the development of these fluid-filled sacs in or on your ovary should rarely be a cause of concern, sometimes the cystic ovarian mass can grow to a large size and even rupture, leading to pain, internal bleeding, and other discomforts.
3. Ovarian torsion (adnexal torsion)
Any ovarian cyst can cause the ovary to twist around its blood supply resulting in pelvic pain. Pelvic ultrasound can often diagnose adnexal torsion.
Once diagnosed, surgery to untwist the ovary may allow preservation of the tube and/or ovary. Though this condition is rare, it is accompanied by pelvic pain. If left untreated, it may also restrict the blood flow to the ovary.
When to See a Doctor
Ovarian cysts do not qualify as a serious health concern, but you may require medical assistance by an ob-gyn if:
- You start experiencing several symptoms associated with an ovarian cyst.
- You suffer from unmanageable pain in and around the abdomen.
- Your period flow becomes abnormally heavy or light.
It becomes even more crucial to seek medical help if the following symptoms persist for more than 2 weeks:
- Feeling of fullness despite eating very little
- Loss of appetite
- Unexplained or unintentional weight loss
Expert Answers (Q&A)
Answered by Dr. Masahide Kanayama, MD (Gynecologist)
Possible consequences of a ruptured ovarian cyst are acute pelvic pain (likely on the side of ruptured ovarian cyst), acute hemorrhage and possible anemia, nausea and vomiting, dizziness, lower back pain, and groin pain.
Ovarian cysts may rupture because they have reached a certain size and cyst walls cannot hold the pressure inside anymore.
Only a very small percentage of ovarian cysts (usually less than 1%) may develop into ovarian cancer.
But the risk of developing into ovarian cancer increase with advanced ages, especially after 60. And with complex cysts, with septations and nodules, the chance of cancer is higher.
It depends on the type of ovarian cysts. If the cyst is endometrioma or chocolate cyst, fertility is significantly compromised by the presence of chocolate cysts. If it is just a simple follicular cyst, there is no effect on fertility.
It again depends on the type of cyst. If it is a follicular ovulation cyst, it is best to leave it untreated since these cysts disappear over time.
But other pathological cysts like a chocolate cyst, dermoid cyst, and the complex cyst may need to be treated depending on the size, appearance, and symptoms.
As in the case of any other tumorous growth, there is always the possibility that the cyst may be malignant or cancerous. However, the chances of that happening are fairly slim considering the present data.
Women who are past the menopausal age are more likely to develop a malignant cyst as opposed to those who are still in the reproductive age.
Ovarian cysts need to be quickly diagnosed and evaluated. Treatment approaches are entirely different, depending on the type of cyst. Some cysts like follicular cysts and corpus luteum cysts most likely disappear by themselves. On the other hand, endometriosis cysts like chocolate cysts cause infertility and pain, and they need to be addressed by specialists.
Any cyst of complex type with nodules and septation raises chances of malignancy, and they need to be monitored and treated accordingly.