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Ovarian cysts (cysts on ovaries)
Ovarian cysts are sac-like structures, usually filled with fluid, localized in the ovary or on its surface. The ovaries are a paired organ, that is, one is located on each side of the uterus, below the fallopian tubes, and above one large blood vessel that supplies blood to all the organs of the small pelvis. Each of the ovaries is the size and shape of an almond and in it, in the structures we call follicles, egg cells mature and every month one of them is released from the ovary of a healthy and reproductively capable woman.
Ovarian cysts are common. In most cases, they do not cause problems, and mostly they are completely harmless. Most of them will disappear spontaneously, without treatment, within a few months.
We have already said that most cysts on the ovaries do not cause problems and that they mostly often pass by themselves. Large ovarian cysts can lead to:
- Pelvic pain that may stop and recur. You may feel discomfort, dull but sharp pain (like a stab) in the area below the belly button and higher towards one side of the body.
- A feeling of fullness, pressure or heaviness in your lower abdomen.
- Feeling bloated.
Simple ovarian cysts occur as a result of certain events during your menstrual cycle. These cysts are also called functional cysts. Other types of cystic changes on the ovaries are significantly rarer.
In certain situations, we can expect a higher frequency of ovarian cysts. One of them is taking drugs that stimulate the growth of follicles, which is sometimes used in the treatment of infertility. It primarily refers to clomiphene and letrozole. We also know that there are women who are prone to ovarian cysts. If you have already had an ovarian cyst, you are in the group of women with an increased risk for their recurrence.
Oral hormonal contraception can prevent functional ovarian cysts.
When should you see a doctor?
Go to an emergency examination if you feel sudden and severe pain in the abdomen or pelvis. The same applies to pain accompanied by high fever and vomiting, especially with signs such as cold, sweaty skin, fast breathing, general weakness, and a feeling of disorientation.
How does a functional ovarian cyst occur?
In each ovary, at each moment of time until menopause, we find the already mentioned structures called follicles in different stages of development. We have already said that egg cells mature in them. Follicles grow and fluid accumulates in them, and their wall actually produces estrogen and, at a certain moment, progesterone, which will define your menstrual cycle.
The entire machinery is organized so that in each monthly cycle, a certain number of follicles will start a rapid growth, of which one will most commonly stand out due to its size. This follicle becomes the dominant follicle and in the middle of the menstrual cycle, it will, through a strictly controlled process of ovulation, release an egg cell near the inner openings of the fallopian tubes. Before this moment, the main sex hormone in a woman's organism is estrogen, after this moment the concentration of progesterone increases. The dominant follicle, which releases increasing concentrations of estrogen, turns into a corpus luteum after ovulation, which begins to secrete progesterone.
If ovulation does not occur, that is, if the egg cell is not released from the follicle, it continues to grow, because fluid continues to accumulate in it. This is how an ovarian cyst, or a functional ovarian cyst, is formed.
Types of cysts
There are two types of these cysts.
Follicular cyst, the origin of which we have already explained. A follicular functional cyst is actually a follicle that has not released an egg cell, that is, it hasn’t ovulated.
Corpus luteum cyst is another, less common type of functional ovarian cysts. If we return to the physiological process of ovulation, it is already clear to us how this cyst is formed. Therefore, after fertilization of the egg cell, all the liquid from the follicle should be emptied, this leads to the collapse of the follicle, which in this way becomes the corpus luteum. Sometimes it happens that the opening through which the egg cell is released during ovulation closes (or blocks), causing fluid to accumulate in the corpus luteum and a cyst of the corpus luteum.
Functional cysts are almost always harmless. They will rarely cause pain and usually go away after 2 or 3 menstrual cycles.
Functional cysts are not the only cystic structures that can be seen on the ovaries. These other cysts are not related to the menstrual cycle and are formed through other mechanisms, but when we say ovarian cyst, and we do not define it further, we always mean a follicular functional ovarian cyst. Colloquially, they are also called simple ovarian cysts, and patients sometimes call them "water" ovarian cysts. Other ovarian cysts include:
Ovarian dermoid cyst. The other one is called ovarian teratoma. This cyst is formed from the reproductive cells. Because of this, they often contain tissues such as hair, skin, teeth, and fatty tissue. This cyst is usually not malignant.
Cystadenomas. These cysts are formed from cells located on the surface of the ovary and are filled with a somewhat thick liquid. They can increase significantly.
Endometriomas. When the tissue of the endometrium, the inner layer of the uterus, is outside the uterus, then we speak of endometriosis. Endometriosis it has several forms, one of them is endometrioma, a cyst whose content is old "menstrual" blood.
Dermoid cysts, cystadenomas, and other cysts can grow and move the ovary from its typical place. Under the influence of bowel movements, or as a result of exercise, or some other movement of the body, large cysts can " twist", turning the entire ovary around its own axis. This condition is called ovarian torsion and is by definition a very painful condition. The origin of the pain is actually a consequence of the reduction or complete interruption of circulation in the ovarian tissue, which can have serious consequences.
Complications
The two most dangerous include:
Ovarian torsion or twisting of the ovary. Cysts that are large displace the ovary from its seat. This further increases the chance of painful ovarian torsion. Ovarian torsion is almost always accompanied by sudden, severe pain in the pelvis, with nausea and sometimes vomiting, with eventual general weakness. This is a medical emergency.
Cyst bursting, or cyst rupture. When a cyst ruptures, it can cause severe pain in small pelvis and often bleeding in the abdomen (internal bleeding). The larger the cyst, the possibility of its bursting increases. Sexual intercourse also increases the risk of cyst rupture.
How are ovarian cysts diagnosed?
A cyst on the ovary that does not lead to symptoms is most often detected during a routine gynecological examination. They can be felt with the fingers through the vagina, and in this way we can determine additional properties, such as connection with the surrounding structure, consistency, and pain sensitivity. Depending on the size and ultrasound structure, it may be necessary to perform additional tests.
Additional tests and examinations
Cysts of the corpus luteum can occur in early pregnancy, when it is not yet visible by ultrasound examination.
In ovarian cancer (especially epithelial) certain proteins are found in increased concentrations in the blood. If there is a suspicion of malignancy, but also to rule it out, it is sometimes necessary to do CA 125 (cancer antigen 125, CA 125), or some other tests from a blood sample. CA 125 can be elevated, even in non-malignancies, such as endometriosis or an inflammatory process in the small pelvis, but also in situations that have nothing to do with diseases of the ovaries or internal genital organs of a woman (certain diseases of the intestines, liver).
A very narrow instrument that has a light source and a high- resolution camera is introduced into the abdomen through a small incision in the navel region. In most cases, surgery can be performed in the same action if it is determined that surgery is necessary.
Therapy, and/or treatment
The treatment depends on your age, type and size of the cyst. It also depends on the symptoms you have. Therefore, there are different approaches.
Expectant approach, “wait and see“. In many cases, the cyst will resolve on its own, and we will advise you to have a repeated examination after some time, in order to retroactively confirm that it was a functional cyst. This approach is reasonable in cases of smaller cysts, with a typical ultrasound appearance (thin and clear capsules, filled with clear liquid). It is often necessary to repeat the ultrasound examination of the small pelvis in order to monitor the dynamics of the appearance of the cyst (whether and how much it changes in size or appearance).
Hormonal contraception, anti-baby pills, achieve their contraceptive effect by preventing ovulation. This will prevent new cysts from forming, but will not reduce or eliminate the existing cysts.
Sometimes we will advise surgical treatment of the cyst, usually for very large cysts, cysts that do not appear to be functional cysts, if they grow extensively or cause pain. Some cysts can be removed while preserving the ovary, but sometimes it is necessary to remove the entire ovary together with the cyst.
Surgical treatment in most cases implies laparoscopy, which is actually a surgical procedure that uses a camera and several small incisions through which the instruments used in the operation are introduced. If the cyst is very large or complicated, as well as when we are unable to rule out potential malignancy, the official recommendation is classic surgery, with a larger incision on the abdomen. Ovarian cysts that appear after menopause are sometimes a sign of malignant ovarian disease, when the uterus, fallopian tubes, and, if necessary, other tissues are usually removed in addition to the ovaries, with further treatment according to the ME Report by Medical Advisory Board.
It is very important to choose the right surgical technique in order to damage the healthy tissue of the ovaries as little as possible, especially in women who plan to become pregnant. Ovarian cysts should be operated on in specialized centers with trained personnel and cutting-edge equipment. The tissue of the ovary is delicate and highly vascularized, and the number of egg cells (which should be understood as the possibility of pregnancy) is limited. During laparoscopy, electricity is used to stop the bleeding, because it is highly effective and comfortable. However, its use simultaneously leads to a decrease in the number of remaining egg cells, so it is important not to rush the operation and when it comes to it, to avoid bleeding, with a precise surgical technique, respecting the function of the ovaries.
Cysts in which there is no suspicion of malignant changes, but which give symptoms in the form of pain and discomfort in the stomach, can be punctured vaginally, that is, the contents can be aspirated with a special and thin needle, through the vagina, under ultrasound control.
Before coming to an examination
It would be good to make a list of:
Your symptoms. Even the ones you think are unrelated to the problem you're coming for. Note when the symptoms started and how they relate to your behavior and cycle.
- All medicines you take, including supplements and over-the- counter products.
- All medical procedures you have had.
- Questions you can expect in the Clinic, during the first consultation:
- How often do you feel discomforts?
- How severe are the symptoms? To what extent do they interfere with your daily functioning?
- Have you noticed that the discomforts are related to the cycle, and if so, to what phase of the cycle?
- Is there a drug or position or anything that relieves your discomfort?
- Is there anything that that worsens your discomforts?
- Have you ever had ovarian cysts?
Depending on the answer, the conversation will help in individualizing the strategy for your further treatment, so your willingness to discuss in detail your complaints and plans will help you to make the most of the limited time for the consultation.
What types of cysts can cause problems with fertility?
Some cysts may have something to do with your ability to get pregnant, these cysts are:
Endometriomas.
Ovarian cysts in PCO syndrome. Polycystic ovary syndrome is actually a metabolic disorder that, in certain cases, also includes a typical ultrasound appearance of the ovaries (very small circular/ cystic structures on the periphery of the ovary, no larger than 10 mm), along with irregular menstruations and altered concentrations of certain hormones. This condition implies irregularities or a complete absence of ovulation and thus can lead to infertility.
Do ovarian cysts affect my ability to get pregnant?
Cysts that do not change a woman's reproductive potential are:
Functional ovarian cysts. These are follicular cysts or corpus luteum cysts, i.e. the most common cystic changes on the ovaries. Functional cysts occur during a normal menstrual cycle and do not lead to infertility, on the contrary, they indicate healthy physiological events in the ovary that are necessary for pregnancy to occur.
Cystadenomas. Cystadenomas arise from cells located on the surface of the ovary, they do not affect pregnancy but require treatment.
Dermoid cyst. Such cysts also do not directly affect the possibility of getting pregnant.
Why is the CA125 level in the blood determined?
This analysis is often used in monitoring the effects of therapy for some malignant diseases. It can sometimes be used as a test for ovarian cancer in women who are at increased risk, with a routine examination.
Determining the concentration of this protein in the blood is not a suitable method for general "screening” of ovarian malignancy, because it is elevated in many situations, that is, it is very non- specific. Many benign conditions (such as uterine myomas, and even menstruation itself) can lead to an increase in the value of this protein in the blood.
Why do we determine the concentration of CA 125 in the blood?
As we have already said, it is for the purpose of monitoring the effects of therapy for malignant disease of the ovaries (but also of the endometrium, peritoneum or fallopian tubes). This, we have to say, is not the most ideal way to control these patients.
The "screening" for ovarian cancer is performed if you are in the group of women with a high risk for this disease, this includes a burdensome family history or proven mutations in genes that are associated with more frequent ovarian cancer. The test is done several times a year together with ultrasound examinations, and possibly magnetic resonance examinations.
However, there are ovarian cancers that do not lead to an increase in this marker.
Do elevated CA125 values always mean that it is cancer?
It is important not to interpret the findings by yourself. Consultation with the doctor who suggested this analysis is required. If CA125 is elevated, there is an objective chance that you have a non-malignant condition, and the finding should be interpreted along with other tests and examinations.
A number of conditions in which an elevated CA125 value can be found, which are not malignant in nature, include:
- Endometriosis;
- Liver diseases;
- Menstruation;
- Inflammatory process in the small pelvis;
- Pregnancy.
Are there any symptoms that accompany the rupture of an ovarian cyst?
Although we have already talked about this, we will repeat, because it is of an extreme importance that you consult a doctor in a timely manner. In certain situations, most often due to mechanical trauma during sexual intercourse or intense exercise, the cyst on the ovary can burst, and in doing so, one of the blood vessels in the ovary can be injured. The spilling of a large amount of liquid contained in the cyst will irritate the peritoneum (peritoneum) and the patient will experience this as a sudden and often very painful sensation. Typically, this pain decreases in intensity as time goes on. Furthermore, at the same time, in cases of ovarian blood vessel injury, together with the discharge of fluid from the cyst, there will be a gradual loss of blood into the abdomen (internal bleeding), which will lead to specific discomforts. In summary, if you experience:
- Severe sudden pain
- High fever
- Vomiting
- Cold and sweaty skin
- Rapid breathing
- General weakness
- Feeling disoriented
It is important to seek emergency medical help immediately.
How do you know if a cyst has burst?
In certain situations, fortunately or unfortunately, you will not be able to tell that the cyst has ruptured. The resolution of the cyst, i.e. its spontaneous disappearance, can happen without symptoms. If you know you have a cyst, your doctor will probably alert you to symptoms that indicate complications and the need for an urgent examination.
