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

“I came across your website when I was google searching the words “Ina May” and hyperthyroidism. Reading a bit on your blog, I saw that you did a monstrous report on the condition. I have a ten month old baby girl (my first) and was recently diagnosed with hyperthyroidism (my TSH was .004) but have not yet been to an endocrinologist. My physician put me on atenolol, but I am still breastfeeding so I’m not taking it. Anyway, I was wondering what your report was about, and if you might have any suggestions that you could share. Many thanks in advance.”

Funny that you should ask about this, because we actually had our lecture on thyroid conditions during pregnancy today. My earlier report was on different thryoid conditions which are often seen during primary care of women (not necessarily during pregnancy), although today’s lecture focused only on pregnancy. My first suggestion would be to go to an endocrinologist as soon as possible. There are many different causes of hyperthyroidism, the most common cause being Grave’s Disease, which is an autoimmune disorder caused by thyroid stimulating antibodies. However, there are many other different causes of hyperthyroidism, running the gamut from pituitary tumors (very rare) to iodine-induced hyperthyroidism. This is why you’ll really need an endocrinologist to help figure all of this out; it’s complicated stuff, with many different etiologies.

Another thing to think about is when your symptoms first began. Was it before your pregnancy, during your pregnancy, or has it been only during the postpartum period? If only during the postpartum period, there might be another cause for the hyperthyroidism: postpartum thyroid dysfunction (also called lymphocytic thyroiditis or postpartum thyroiditis), which occurs in about 5-10% of all pregnancies. With this disorder, usually hyperthyroidism develops first, about 2-3 months postpartum, and will continue for up to 4 months postpartum, followed by a hypothyroid phase lasting 1-3 months. In 70-90% of all cases, this will usually resolve spontaneously without treatment, usually within 6 months. However, 10-30% of women with postpartum thyroiditis may have permanent hypothyroidism, so again, it would be a good idea to have an endocrinologist following this in order to determine the true cause of your hyperthyroidism, and whether it will resolve or not.

Treatments for hyperthyroidism usually include either PTU (Propylthiouricil) or Methimazole (Tapazole), both of which interfere with the synthesis of thyroid hormones by preventing iodine uptake. Both of these medications can be used during pregnancy AND are safe for breastfeeding. Atenolol (a beta blocker) was also listed in our lecture as one of the drugs used to help control the severe hypermetabolic symptoms of hyperthyroidism, such as tachycardia (fast pulse), tremors, palpitations and heat intolerance. Beta blockers are actually the treatment of choice for thyroiditis, and are safe to use during pregnancy. There is no contraindications to using beta blockers while breastfeeding. I just visited the website forum of Dr. Thomas Hale, one of the leading experts on pharmacology during breastfeeding, and looked up Atenolol. In this post, as you can see, one woman was concerned about the possibility of a baby having hypoglycemia after breastfeeding from a mother who was taking atenolol, but it seems that while atenolol might cause hypoglycemia in adults, he didn’t think it was present in breastmilk in suffiicient quantities to cause hypoglycemia in an infant:

I spoke with a Pediatric Cardiologist whom I greatly respect. He assured me that he’s used beta blockers and atenolol many times in pediatric patients and has yet to see hypoglycemia.It is true that in adult diabetics, it may induce hypoglycemia, but I’m reassured that his probably does not occur in infants, particularly from minor exposure via milk.He also told me that infants are apparently less sensitive to beta blockers and that even higher doses are sometimes required to be effective.So I’d look for something else causing hypoglycemia in your infants.

The thread on antihypertensives makes it very clear that beta blockers are fine during breastfeeding, so I think you would be okay taking atenolol and nursing at the same time. Medications in Mother’s Milk might be a really good resource for you.

Other treatment options for hyperthyroidism, if that is indeed what you have (as opposed to postpartum thyroiditis), include radioactive iodine treatment or surgery (partial thyroidectomy), but again, these are options best discussed with your endocriniologist.

I’m including a few resources here in case you want to look any of this stuff up yourself. These were some of the references from my presentation. Hope this helps!

Smeltzer, S., Bare, B. (2000) Metaboloic and Endocrine Function; Assessment and Management of Patient with Endocrine Disorders. Brunner and Suddarth’s Textbook of Medical-Surgical Nursing, Lippincott, Williams and Wilkins: New York.

Reid, J., & Wheeler, S. (2005) Hyperthyroidism: Diagnosis and Treatment. American Family Physician, 72(4): 623-630.

American Association of Clinical Endocrinologists. (2002). Medical Guidelines for Clinical Practice for the Evaluation and Treatment of Hyperthyroidism and Hypothyroidism. Endocrine Practice, 8(6):458-469.

During pregnancy, the corpus luteum, acting on instructions from the placenta, secretes the estrogen and progesterone necessary to maintain the pregnancy. These high levels of steroid hormones simultaneously supress Follicle Stimulating Hormone (FSH) and Leutenizing Hormone (LH), the two hormones most responsible for ripening an egg and then triggering ovulation—after all, if you’re already pregnant, there’s no need to ovulate. After delivery, once the placenta is removed, the high levels of estrogen and progesterone no longer exist, and the levels of FSH and LH gradually begin to rise again, preparing the body for ovulation. Eventually, as the levels creep up, the pituitary takes notice again, and begins to release more FSH and LH through a negative feedback loop, which eventually will trigger ovulation.

“Most nonlactating women resume menses within 4 to 6 weeks of delivery, but about one-third of the first cycles are anovulatory, and a high proportion of first ovulatory cycles have a deficient corpus luteum that secretes sub-normal amounts of steroids. In the second and third menstural cycles, 15% are anovulatory and 25% of ovulatory cycles have luteal-phase defects…Lactation, or breastfeeding, further extends the period of infertility and despresses ovarian function. Plasma levels of FSH return to normal follicular phase values by 4 to 8 weeks postpartum in breastfeeding women. In contrast, pulsatile LH stimulation is depressed…in the majority of lactating women throughout most of the period of lactational amenorrhea.” [1]

In other words, after not menstruating for so many months, it takes the body a few tries to get the delicate hormone balance back up to speed again. The first few cycles either don’t release an egg, or if an egg is released, the corpus luteum, which is responsible for secreting enough progesterone to maintain the pregnancy until the placenta can take over, isn’t quite up to the task. This is called a luteal phase defect, and it’s a very common cause of early miscarriages. In women who are breastfeeding, the process of returning to normal ovarian cycles takes even longer.

In breastfeeding women, FSH, the hormone responsible for ripening an egg, returns to normal pre-pregnancy values fairly early, but LH, the hormone responsible for triggering egg release, continues to be surpressed due to the breastfeeding. (However, contrary to popular belief, prolactin is not at all responsible for this supression. It’s the constant suckling and stimulation of the nipple itself which actually suppresses ovarian function, which is why on demand breastfeeding is so essential to maintaining lactational amenorrhea.)

So, there you have it. To answer the question: it will probably just take a few more cycles for your body to get back into full swing in terms of ovulating, but continued breastfeeding did not contribute or cause the miscarriage in any way, and will not prevent conception. Most likely, the miscarriage was caused by a short luteal phase or corpus luteum that just wasn’t quite ready to maintain a pregnancy, and this will no longer be a problem once your body goes through a few more cycles and gets used to ovulating again.

[1] Hatcher, R.A. et. al. (2004) Contraceptive Technology, 18th Revised Edition. Ardent Media, Inc.: New York.

2 plastic sheets or sheet covers to protect car seat from various juices (you probably only need one, but two is safer. Could also use a drop cloth or tablecloth.)
1-2 re-sealable sturdy gallon sized zip-lock bags for placenta.
3 plastic cord clamps (When the baby first comes out, put two clamps on the cord, about one inch apart, and cut in btw the clamps to seperate baby from placenta. Put the third clamp closer to the baby’s umbilicus, and then cut off the excess.)
1 pair of bandage scissors to cut cord.
1-2 warm baby hat(s)
1 16 oz. Alcohol bottle.
1 bottle of betadine.
1 Peri Bottle (a squirt bottle, basically, filled with water to clean off your vulva and labia after delivery.)
2 packs of 4×4 Gauze (usually 12 gauze squares per pack.)
6 Lube Packs.
1 2.5 Bulb Syringe (be sure bulb is compressed before inserting it into the baby’s nose, so that it only sucks fluid *out*, and doesn’t push any air *in*)
1 rectal thermometer to check baby’s temperature.
1 pack of sanitary napkins, Maternity Size.
1 pair of loose, comfortable panties that you don’t mind bleeding on.
4-5 large, absorbant towels.
2-3 warm baby blankets to wrap baby in (although the best thing to do would be to put the baby on your chest, and then wrap both of you.)
1 large blanket for yourself, in case you get the shakes on the way to the hospital.
4 pairs of latex gloves, in whatever size needed for whomever will be doing the delivering (her husband, most likely.)
4 single, sterile gloves (for checking position of baby as s/he descends the birth canal.)
1 large plastic trash bag for waste materials.
1-2 liters of water to re-hydrate yourself with, after you’ve delivered, and some snacks to eat.

It’s probably more than she’ll need, but I felt it was better to err on the side of too much rather than too little. I also included a few instructions on how to use the equiptment, how to massage the fundus after delivery of the placenta, how to check for a nuchal cord, and what to do in case she bleeds excessively, either from a tear or a soft fundus, but I really hope it doesn’t come to that.

For some reason, the idea of her having her baby in a car makes me a bit nervous. It’s not that I don’t think she’s capable of it—she’s young, fit and healthy, and takes very good care of herself—and it’s not that I really think anything will go wrong. After all, most births are blessedly uneventful, normal, healthy affairs, and women accidentally having their baby in the car on the way to the hospital is nothing new; you read about stories like that in the newspaper from time to time. Once, at work, we had an irate cabby storm up to our unit demanding payment from the patient we had just admitted, who had accidentally had her baby in the back of his cab on the way to the hospital and left the placenta on the floor of the taxi. I absolutely, unequivocably support homebirth, and Birth Centers, and having your baby in unconventional locations, and I have always believed that all the hysteria about birth—the emergency waiting to happen mindset—is unnecessary. Women’s bodies are designed for birth, and if left alone and supported and encouraged, most women are more than capable of delivering their own baby safely into this world. So why the nerves, kiddo?

I think it’s just the idea of her giving birth without a skilled birth attendant present that makes me nervous, just in case something unexpected happens. For what it’s worth, I really hope my friend makes it to the hospital in time. Given her history, they may have to drive pretty fast.