Ovarian Cyst

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What is an Ovarian Cyst?

An Ovarian Cyst is a sac-like structure filled with fluid or viscous material and present within or on the surface of an ovary which is present on the side of the uterus. Ovarian Cysts are non-malignant growths that may range in size from small to large and can occur at any age in a woman.

Is Ovarian Cyst condition a Medical emergency?

An Ovarian Cyst is not a medical emergency, however, a large Ovarian Cyst that ruptures requires immediate medical attention.

Types

Ovarian Cysts may be classified as follows:

  • Functional Ovarian Cysts: They are seen to develop during the normal menstrual cycle and are further classified as follows:
    • Follicular cysts: Most common type and results when the follicular cyst containing the ovum does not rupture to release the ova during ovulation
    • Corpus luteum cysts: They appear after ovulation and are what remains of the follicular cyst after the ovum is in the fallopian tubes
    • Theca lutein cysts: They are usually seen in both the ovaries and develop from the thecal cells surrounding the developing oocytes
  • Non-Functional Ovarian Cysts: They are unrelated to the normal menstrual cycle and include:
    • Ovarian serous cystadenoma – can become very large
    • Ovarian mucinous cystadenoma - can become very large
    • Dermoid cysts - can become very large
    • Para ovarian cysts
    • Cystic adenofibroma
    • Hemorrhagic ovarian cysts
    • Endometrioma or Chocolate cysts which are caused by endometriosis
    • Borderline tumoral cysts
    • Luteoma of pregnancy
    • Teratomas

Causes

Ovarian Cysts which are functional and related to the menstrual cycle are caused due to an imbalance in the functioning of the hormones or an improper response of the ovaries to the hormones. The most common reasons for this include:

  • Excessive FSH stimulation
  • Absence of normal LH surge
  • Excessive progesterone
  • Excessive hCG stimulation

Other factors that can result in Ovarian Cysts include:

  • Replacement of ovarian parenchyma tissue with overgrowth of luteinized stromal cells

Risk factors

Factors that increase the risk of Ovarian Cyst formation include:

  • Infertility treatment
  • Pregnancy
  • Hypothyroidism
  • Smoking
  • Tubal ligation procedures
  • Medications such as tamoxifen
  • Endometriosis
  • History of Ovarian Cysts
  • Pelvic inflammatory disease
  • Maternal gonadotropins crossing the placental barrier can cause Neonatal or Fetal Ovarian Cysts

Symptoms & signs

Many Ovarian Cysts especially the small ones may not present with any symptoms and are mostly detected during routine tests or examinations. The signs and symptoms of Ovarian Cysts if present may include:

  • Lower abdominal and pelvic pain
  • Abdominal fullness and bloating
  • Indigestion, heartburn, and early satiety
  • Frequent urge to urinate
  • Difficulty with bowel movements or increased urge to defecate
  • Painful menstruation
  • Pain during sexual intercourse especially with deep penetration
  • Sharp, sudden, severe one-sided pain if there is a rupture or twisting of the cyst
  • Low blood pressure, a fast heartbeat may be present if there is a rupture of a cyst with severe bleeding
  • Fever may be present if there is torsion of the cyst

Investigations

Some investigations that are advised for the evaluation of an Ovarian Cyst include:

  • Laboratory tests:
    • CBP & ESR
    • Urine Pregnancy Test
    • Complete Urine Examination
    • Endocervical Swab – if the pelvic inflammatory disease is suspected
    • Cancer antigen 125 (CA125)
  • Imaging tests:
    • Ultrasound
      • Endovaginal Ultrasound
      • Transabdominal Ultrasound
      • Doppler Flow Studies
    • CT/MRI – only done if ultrasound is inconclusive
  • Procedures:
    • Diagnostic Laparoscopy

Diagnosis

A diagnosis of an Ovarian Cyst is established based on medical history, clinical evaluation, and investigations.

Treatment options

A majority of Ovarian Cysts especially those that are asymptomatic do not require any treatment while moderate-sized cysts are monitored. Symptomatic Ovarian Cysts are managed with pharmacological agents or surgical interventions when required.

Medical management

Medical management of Ovarian Cysts may include:

  • Analgesics: Such as opioid analgesics or NSAIDs for the management and relief of moderate to severe pain
  • Combined oral contraceptive pills: To prevent recurrence and not to reduce the size of existing cysts

Interventional including surgery and indications for surgery

Interventions for the management of Ovarian Cysts that are large, persistent, and causing symptoms may include:

  • Laparotomy and Laparoscopic Interventions for removal of the cysts
  • Bilateral Oophorectomy and Hysterectomy – for the removal of both ovaries and the uterus in postmenopausal women

Role of diet/ Exercise/ Lifestyle changes/ Preventive measures

Ovarian Cysts cannot be prevented but the use of combined oral contraceptive pills can reduce the risk of recurrence and development of cancer.

Complications

Some complications that are associated with Ovarian Cysts include:

  • Torsion: The Ovarian Cyst can twist around the cutting of the venous and arterial blood supply to the ovaries; usually seen in premenopausal women
  • Rupture: It is more common in corpus luteal cysts; can result in severe bleeding and shock
  • Collection of mucinous fluid in the abdomen
  • Ruptured cysts can cause – hemoperitoneum, peritonitis, and hypotension
  • Torsion of cysts can cause infertility, premature ovarian menopause, and preterm labor

Prognosis

The prognosis for Ovarian Cysts is generally very good, with a majority of functional cysts resolving spontaneously within 2-3 cycles. In complex cysts and cysts in pregnancy, there is an increased risk of malignancy.

When to contact the doctor or hospital? / How to identify the emergency or complications?

It is advisable to seek medical attention if the symptoms of an Ovarian Cyst are noticed, or there is a change in the pattern of the menstrual cycle.

Indications for hospitalization if required

Hospitalization is not required for the management of Ovarian Cysts unless surgical interventions are advised.

Screening methods

Women with a family history of ovarian carcinoma or who are at an increased risk of ovarian cancer are advised to get regular checkups and screening.

Suggested clinical specialist/ Departments to consult for this condition

  • Gynecology
  • Obstetrics
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