Ovarian Cysts

>> Friday, December 20, 2013

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Nothing seems to scare women more than hearing that they have a cyst on their ovary.

It is rare for a cyst to be found at a regular, annual pelvic exam with Pap Smear because the ovaries and uterus can be difficult to feel on Bimanual exam, as the ovaries can be pushed and moved around. Most women do not even know they have a cyst unless it causes pain or abnormal bleeding. Most ovarian cysts are found on a routine ultrasound or CT scan ordered by the Emergency Room, Internal Medicine or Primary Care doctors to evaluate a medical condition. When the results show an ovarian cyst, most of these care providers do not have the expertise in women's care to counsel patients properly. So, women come to their OB/GYN feeling worried that any cyst is harmful or cancerous.

Most ovarian cysts start during the normal function of your menstrual cycle. These are known as functional cysts. The 2 types are Corpus Luteal and Follicular cysts. They are the most common type of benign cysts, they usually go away on their own, they are usually harmless, and they rarely cause pain. A positive pregnancy test usually indicates the presence of a Corpus Luteal cyst. They develop at the sight of ovulation on the ovary. They remain for the first 3 months of pregnancy and produce the hormone progesterone to keep the lining of the uterus from releasing. If not pregnant, they will stay for only 2 weeks and then dissolve, which then causes the period to start.

Your ovaries normally grow small, cyst-like structure called follicles each month. Follicles are about the size of a marble and produce the female hormones estrogen and progesterone. The follicles house the developing eggs which grow and mature until the egg is released at ovulation.

Once ovulation occurs all of the remaining follicles dissolve, leaving only the newly formed Corpus Luteum from the follicle where ovulation took place. But, sometimes one of the other follicles won't dissolve and instead keeps growing and filling with fluid. These can grow very large, even to the size of cantaloupe, with the largest know to be the size of a watermelon! Of course these must be drained or removed in surgery. Thankfully, most can be removed without damaging the ovary.

Sometimes the Corpus Luteal cyst bleeds into itself after ovulation and grows large - becoming painful. These can be watched, but if they become too painful, they will also usually be removed surgically.

Some cysts are not related to the normal function of your menstrual cycle. They are usually complex and not fluid-filled. For example:
  • Dermoid cysts are benign and the most common, yet unusual, of these complex cysts. These cysts may contain tissue such as hair, skin, muscle, fat or teeth. They form from out-of-control growth of ovarian tissue. They are rarely cancerous.
  • Cystadenomas are benign cysts that develop from ovarian tissue and may be filled with a watery liquid or a mucous material.
  • Endometriomas are benign cysts that develop from endometriosis, a condition where uterine endometrial cells grow outside your uterus. Some of that tissue may attach to your ovary, forming a growth.
  • Serous cystadenocarcinoma is a cancerous tumor. Other malignant tumors are named malignant teratomas, and metastatic from other organs.
Diagnosis can be obtained by ultrasound, blood work, and through surgical biopsy. Most of you have had an ultrasound at some point and know that it is a painless procedure where a small transducer is used to send and receive high-frequency sound waves to a screen which forms an image of what is being looked at. The transducer can be moved over your abdomen or a smaller one can be placed inside your vagina, to create an image of your uterus and ovaries in order see and measure ovarian cysts.

If a cyst looks suspicious the next step would be blood work and surgery. The type of surgery would depend on the size and location. A Laproscope is a slim camera with a light that can be inserted into your abdomen through a small incision below your belly button. This makes it very easy to see your uterus and ovaries, take pictures and remove the cyst if needed.

The radiologists will report cysts as fluid-filled, solid, complex or mixed. Those that are solid or mixed and filled with fluid, solid tissue or blood clots usually require further evaluation. Your age, size of the cyst and the possibility of pregnancy also have to be considered.

It is important to be alert to changes in your monthly cycle, including symptoms that may accompany menstruation that aren't typical for you (or that persist over more than a few cycles). If a cyst ruptures, it can cause severe pain and lead to internal bleeding.

In many cases you can wait and be re-examined to see if the cyst goes away on its own within a few months. This is typically an option, regardless of your age, but only if you have no symptoms and an ultrasound shows you have a small, fluid-filled, not a complex cyst.

Blood levels of tumor markers like Cancer Antigen-125 or CA -125, Alpha-feta protein, HCG (Human Chorionic Gonadatropin) can be elevated in women with ovarian cancer. Non-cancerous conditions like endometriosis, uterine fibroids and pelvic inflammatory disease can cause CA-125 to be elevated, so without an ultrasound, comparison is not complete or specific.

It is important that you get follow-up pelvic ultrasounds at periodic intervals to see if you have recurrent cysts, or if your cyst has changed in size.

Birth control pills can reduce the chance of new cysts developing in future menstrual cycles. Oral contraceptives offer the added benefit of significantly reducing your risk of ovarian cancer and the risk decreases the longer you take birth control pills. This is because it prevents ovulation and can reduce your risk by 80% if taken for one year.

So next time you have a cyst found on ultrasound, be sure you know the size and character of it and be sure the ultrasound wasn't done at time of ovulation.
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