Ovarian Cysts

I got a phone call last night from a good friend from college, who has just recently been diagnosed with an ovarian cyst, and had been told by her doctor not to worry too much about it and was prescribed birth-control pills to help manage the symptoms. She wanted a second opinion, and I told her what I knew about ovarian cysts (i.e. that they’re very common, usually benign, usually do not affect fertility, and usually spontaneously resolve in a few months without incident), but I did promise that I’d do some more research on the subject for her. So here you go: more than you probably ever wanted to know about ovarian cysts!

An ovarian cyst is a fluid-filled sac that forms on the ovary. The majority of ovarian cysts are benign, and are classified as either functional or organic. We’ll start with functional cysts, because they are simpler and easier to understand.

Functional cysts are fluid-filled sacs which most often form during a normal menstrual cycle—either during the follicular phase or the luteal phase. Follicular cysts are more common and are often undiagnosed because they are usually asymptomatic. During the follicular phase of the menstrual cycle, the follicle ripens while the egg matures and becomes a small, fluid-filled sac in the process. During normal ovulation, when the egg is released the sac breaks open, the fluid is released along with the egg, and the remnants of the sac are eventually re-absorbed. If for some reason the egg is not released (i.e. there is no ovulation), the ripened follicle can remain as a cyst, and may continue to grow through the next menstrual cycle. Follicular cysts can occassionally grow quite large, and the risk of torsion or rupture increases the larger the cyst becomes. However, the majority of follicular cysts usually spontaneously disappear within one to three months.

Luteal ovarian cysts, or corpus luteum cysts, occur during the second half of the menstrual cycle, after ovulation has occurred. Once the follicle has ruptured and the egg has been released, the remaining follicle sac becomes the corpus luteum, which produces progesterone and maintains the endometrial lining of the uterus. If the egg is not fertilized and pregnancy does not occur, the corpus luteum normally disappears through a process called luteolysis, which occurs with the onset of menses. In some cases, though, the corpus luteum does not disappear, and instead seals off after ovulation, fills with fluid and forms a cyst. Luteal cysts are less common than follicular cysts and usually disappear on their own within a few weeks. However, they can sometimes grow up to four inches and may cause bleeding, torsion, or pain.

If a small blood vessel ruptures inside a functional cyst, the cyst fills with blood instead of clear fluid, and is then called a hemorrhagic cyst. However, like follicular and luteal cysts, hemorrhagic cysts rarely rupture, are often self-limiting, and will most likely spontaneously resolve on their own.

Organic cysts are the second type of ovarian cyst, and are much less common than functional cysts. They’re referred to as complex cycts because of how they appear on ultrasound, and may contain blood, serous or solid material inside them. The type of cyst that forms depends on the type of ovarian tissue the cyst arises from. “Mucinous or serous cysts arise from mucinous or secretory ovarian glandular cells and can become very large, though they usually grow slowly.” (Schuiling & Likis, 2006). Another type of organic cyst known as a dermoid cyst arises from ovarian germ cells. Because germ cells have the capability of forming any material in the body, dermoid cysts sometimes contain unusual substances such as hair cells, skin cells, bone cells, tooth enamel or other body material. Dermoid cysts tend to grow rapidly and can become very large. They are rarely malignant, however, because they don’t spontaneously regress and there is some (albeit small) chance of malignancy, dermoid cysts are most often surgically removed . Another kind of organic cyst is known as a cystadenoma, which forms in the stromal tissue on the outside of the ovary, and can also grow quite large and cause a fair amount of pain.

Ovarian cysts can also be caused by other illnesses. Endometrial tissue begins to grow outside the uterus in women with endometriosis, and can sometimes attach itself to the ovary, forming an endometrioma, which is a solid cyst. Women with polycystic ovarian syndrome (PCOS) form multiple functional cysts within their ovaries from repetitive anovulatory cycles, and are often infertile. While neither of these kinds of cysts are malignant, managing these types of cysts requires dealing with the underlying etiology—either endometriosis or PCOS—and these cysts usually do not resolve on their own without assistance.

Because ovarian cysts are usually asymptomatic, many women have them without realizing that they do, and they often resolve on their own without the woman even being aware. Otherwise, the woman may experience pressure or fullness in the abdomen, pain during intercourse, persistent low-back ache, urinary frequency, chronic pelvic pain or pain during menstruation. Ovarian cysts are sometimes detected during a routine pelvic exam if a large mass or fullness is felt around the ovaries. However, diagnosis is most often made by ultrasound (either abdominal or transvaginal ultrasound), and management depends in part on the size of the cyst.

For most functional cysts, nothing needs to be done. Simple cysts don’t require therapy unless they’re larger than 8 cms, rupture or lead to ovarian torsion. The “watch and wait” approach is most often used, since these cysts usually spontaneously resolve on their own. If there is minor pain associated with the cyst, medication like Motrin or Tylenol is usually enough to manage the pain while waiting for the cyst to disappear. Follow-up ultrasounds at 1-3 months after diagnoses are sometimes performed, but aren’t mandatory unless the symptoms persist or worsen. If the cyst is between 5-8 cm, repeat visits to your doctor or midwife may be needed to follow the growth of the cyst. Surgery may be required to drain and remove larger cysts (anything greater than 8 cm), and is usually done either through laparoscopy or laparotomy. Other tests, such as a blood test to check for CA-125, a tumor marker which can indicate malignant growth, may also be performed for larger cysts just to rule out cancer. Oral contraceptive pills can be prescribed to help reduce the likelihood of repeat cyst formation, and may be especially helpful in women who keep having ovarian cysts. Since ovulation and the ripening of a follicle are often the causes of functional cyst formation, birth control prevents this from happening by preventing ovulation.

Organic cysts are generally more complex and usually require medical treatment. An MRI or cat-scan may be used in addition to ultrasound in order to diagnose the exact type of cyst (dermoid, cystadenoma, endomerioma etc.) The tumor marker CA-125 will most likely be checked to rule out cancer, and larger cysts greater than 8 cm will most likely be removed via surgery.

Warning signs for the rupture of an ovarian cyst include nausea and vomiting, fever, sudden, severe abdominal pain, fainting, dizziness, weakness or rapid breathing. In the case of very large cysts, rupture can be quite dangerous, so emergency care should be sought immediately if any of the warning signs appear. Otherwise, as in the case of my friend, who has some type of functional cyst by the sound of it, I’d agree with her doctor’s assessment that she shouldn’t worry too much about it. The cysts will probably go away on their own, and using oral contraceptives will make the likelihood of future cyst formation very, very slim.

References and further resources:

Shuiling & Likis (2006) Chapter 22: Benign Gynecologic Conditions. Women’s Gynecologic Health, pp. 584-587, Boston, MA: Jones and Bartlett.

Varney, H. et. al. (2004) Chapter 14: Common Diagnoses in Women’s Gynecological Health. Varney’s Midwifery: Fourth Edition, p. 406, Boston, MA: Jones and Bartlett.

Women’s Health.gov: Ovarian Cysts

Emedicine: Ovarian Cysts

This entry was posted in Gynecology, Primary Care, Questions, Research, Women's Health. Bookmark the permalink. Trackbacks are closed, but you can post a comment.

8 Comments

  1. Posted October 11, 2007 at 11:48 am | Permalink

    Hey girlfriend! Congrats on starting the job!!

    A data point to add: I had a big cyst (probably functional) my senior year in college, which almost required surgery — from the ultrasound they said it got twisted at the point of connection to the ovary so it couldn’t be re-absorbed as they usually would be? I had the SEVERE abdominal pain experience. Doctor thought it was appendicitis at first, but somehow I knew that was my ovary, not my appendix. Fortunately, they waited overnight to see what it would do, and it resolved itself…

    Here’s what I don’t get, though. If almost all cysts resolve themselves on their own, what’s the benefit of putting a woman on oral contraceptives for this?

  2. The Midwife
    Posted October 13, 2007 at 6:23 pm | Permalink

    Hi, Becca:

    As far as I can tell, the benefit of using oral contraception is that it can help prevent future cyst development, and is especially useful in women who’ve been having recurrent cysts. There might have been other factors involved in my friend’s decision to start OCPs, too (like, the birth control factor) which may also have played a part. I didn’t ask her, to be honest.

    The twisting of the ovary is called torsion. I think that it’s rare for torsion to resolve on its own, but I’m really glad to hear that yours did! Glad that they waited an extra night, too, instead of opening you up immediately.

  3. Posted October 22, 2007 at 10:51 am | Permalink

    You were v lucky that the torsion resolved itself, mine was left & I lost an ovary to torsion & a ruptured cyst about grape-fruit size.

    A rupture is terrifying.

  4. Roxxy
    Posted December 16, 2007 at 3:31 am | Permalink

    Hi there!

    Well, let me tell you something. When I was 15, I scheduled a regular physical with my GP. At the end of the exam, she felt my belly and she said she felt something hard and she thought I was pregnant for sure.

    Me being 15 and being quite aware that I still had not had my first sexual intercourse experience told her she was insane and that I could never be pregnant.
    She was still sure of it, she even got a radio ultrasound machine to hear for a heart beat. She made me take a urine test. She said she thought I could be anywhere from 6-8 months pregnant.

    She asked me if I had regular periodes. I told her I did not, they were spurratic, ranging on and off for months at a time.

    When the pregnancy test came back negative, my GP ordered an ultrasound. I went to a low profile place, where their equipement was standard. The ultrasound operator would not tell me any information on what she saw. She called the doctor in and he too would not discuss it with me. They took about 50 photos of what they could not tell me.

    I was sent to a high profile hospital, and there, finally, I was told I had a cyst. This was followed by a visit to a gyno, who explained to me what was in my body.

    A brief explaination followed: Apparently I had a cyst on my right ovary that would need operating. This is because the size of my cyst was not one that could be resolved by the pill or by itself…my cyst was massive. On screen it mesured 42cm in diametre. After the surgery, the weight of the cyst removed was 11.3pounds.

    The surgery left me with an incision scar that mesured 12inch long. From my pubic hair to my belly button.

    Thankfully I did not lose my right ovary, the gyno said she removed 75% of the ovary, but when I had my 1 year checkup, a vaginal ultrasound showed both ovaries about the same size and everything was there!
    Crazy!

    Thought I’d share my story with you :)

  5. mish
    Posted January 1, 2008 at 6:21 pm | Permalink

    Hi – I just got back from the hospital and am so confused about what is wrong with me and am just trying to find some answers. I went to the ER after experiencing severe abdominal pain for over 24 hours without relief and a fever between 101 and 102…no vomiting and no diarrhea….just severe pain in the midsection of my abdomen and downward. The pain I experienced this time felt very much like the 3 other times I went to the ER in the past 10-15 years of my life…I am 32 now…always leaving with a possible diagnosis of a ruptured cyst…but never with clear evidence. I went on a bcp (Loestrin) 2 months ago…and am expecting my period this week…I also had spotting in the middle of this cycle but not during the 1st month.

    This time my bloodwork was normal as was my urine sample. The ER was going to send me home with a diagnosis of a stomach virus…which I knew this was not. I requested an abdominal and transvaginal ultrasound since my obgyn suggested I have these done anyway to explore the presence of endometriosis. The transvaginal ultrasound showed 1 cyst on each ovary approx 2-3cms in size…1 of them being a hemorrhagic cyst. She thought this was enough to be causing the pain but not severe enough to treat further.

    The ER Dr. thought that my symptoms were perhaps a combo of the cyst issue and a stomach virus…basically because she could not explain why I had a fever. I was discharged from the hospital with paperwork that indicated I had a stomach virus and pain killers to manage the pain of the cysts. I will be scheduling an appt with my obgyn this week so he can see the ultrasound results as well.

    So I told you want I know…but this is what I am confused about. Is it normal that I had so much pain from these types of cysts? Is it normal that I experienced this type of pain right before getting my period versus in the middle of the cycle? Is it common to have a fever with these symptoms? Does a hemorrhagic cyst tend to be more painful then a regular cyst? Would these symptoms support a diagnosis of endometriosis? Why might the doctor have insisted I have a stomach virus when I am pretty sure I know the difference between stomach/digestive pain versus abdominal pain? I just hate leaving the ER after having been there for 8 hours on new years day feeling as if I still don’t know what’s wrong with me…or what the ultrasound results really mean. I am home now and still in pain…but the pain meds are helping at least.

    Thank you for any responses, thoughts, and/or advise given. I appreciate it…happy new year!

  6. The Midwife
    Posted February 23, 2008 at 9:05 pm | Permalink

    I’m sorry it’s taken me so long to respond to this. To be honest, I don’t have much to add to this. I don’t have a lot of experience with ovarian cysts–everything I know is from text books, and is pretty much written above. I do know that women with endometriosis tend to experience severe pain with menstruation, which may begin a few days before menses and continue a few days afterwards. From what you’re saying, it does sound like it may be more like endometriosis than the cysts alone. I’m not sure if a hemorrhagic cyst is more painful than a functional cyst. I wish I could be more help, but I am at the limit of my knowledge! I hope you’re feeling better by now, though, and all I can advise is that you continue to follow-up on this with your gynecologist to try to figure out what’s going on. If you do get to the bottom of it, please let me know! I’d ve very interested to hear an update. Take care.

  7. Posted March 19, 2008 at 1:22 am | Permalink

    I’m only fourteen and today the doctor told me that I have ovarian cysts.
    I thought my appendix had ruptured, but it wasn’t my appendix.

  8. M
    Posted March 9, 2013 at 2:02 pm | Permalink

    Hi everyone, thanks very much for the extremely helpful article and comments. I’ve just been diagnosed as having an organic cyst and am waiting for a date to get it off.. Every bit of info I can get my hands on is like a Godsend! I hope everyone’s health is much better my now and wish everyone a healthy and happy weekend.

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