Thursday, April 13, 2006

What You Need To Know About Ovarian Cysts

More than any other organ in the body, the ovary has the capacity to form a large number and variety of cysts. In fact, the ovarian function of producing hormones and releasing eggs is directly linked to the formation of cysts. An ovarian cyst is a sac or pouch that develops in or on the ovary, often during ovulation. The contents of the cyst are usually liquid, but can also be solid or a mixture of liquid and solid materials. Although ovarian cysts are usually small (about the size of a pea or a kidney bean), they can become the size of a softball—or even larger. Large ovarian cysts are quite remarkable considering that the ovary itself is only about the size of a walnut.
Ovarian cysts are very common, and because most of them do result from changes in the normal function of the ovary, rather than from "new growths" or tumors, the vast majority are non-cancerous. Although they are most prevalent in women of childbearing age, ovarian cysts can occur in girls and women of all ages, from newborns to the elderly. You can develop a single cyst or multiple cysts.
Warning Signs of an Ovarian Cyst
Because there are many different kinds of ovarian cysts, and because their size and number may vary, they can cause a variety of symptoms. On the other hand, many cause no symptoms at all and may first be discovered during a routine gynecological exam, as your doctor examines the size and shape of your ovaries.
Pain
Abdominal pain is often the first indicator of an ovarian cyst. If the cyst is large, you may have pain, or a feeling of pressure or heaviness in the lower abdomen. Ovarian cysts can often bring on lower abdominal pain during intercourse. Another possible cause of pain is a process called "torsion," in which the stem that forms on some cysts becomes twisted, stopping the normal flow of blood and causing intense bursts of pain. If a cyst ruptures, this too can cause severe lower abdominal pain along with weakness, nausea and vomiting. Any of these pains may be severe enough to bring you to the emergency room or to your doctor, and may be the first time you learn you have a cyst.
Cysts can cause other, less daunting symptoms. For example, a cyst can press on the rectum, causing constipation, or on the bladder, creating an urge to urinate. Don't ignore these lesser symptoms. They could also be signs of a gastrointestinal disturbance or a bladder infection. Severe abdominal pain itself could also be due to appendicitis, an infection in the uterus or fallopian tubes, or an ectopic pregnancy.
Irregular Periods and Infertility
Occasionally ovarian cysts do cause irregular periods, particularly in a condition called polycystic ovaries in which the hormonal system that regulates the ovaries is disturbed, causing them to form a large number of cysts. More frequently, however, menstrual irregularities are due to other conditions, such as pregnancy, menopause, or thyroid problems.
Some women who have trouble becoming pregnant also have polycystic ovaries, but this problem is only one of many possible reasons for infertility. If you are having difficulty becoming pregnant, speak with your regular ob-gyn or with an infertility specialist. (For more information see "Overcoming Infertility: Tactics and Techniques.")
A Close Look at the Most Common Types
Once a month, your body produces what is, in effect, an ovarian cyst. It is part of ovulation, the process during which an egg ripens and is released from the ovary. The ovary contains follicles, sacs containing immature eggs and fluid. Each month during your childbearing years, the ovary produces hormones that cause a follicle to grow, and the egg within it to mature.
Once the egg is ready, the follicle ruptures and the egg is released. Thus the follicle is a fluid-filled cyst that ruptures when you ovulate. Many women experience pain or cramping when this occurs. This pain is known as mittleschmerz, the German word for "middle (mid-cycle) pain."
Once the egg is released, the follicle changes into a smaller sac called the corpus luteum, or "yellow body," named for the yellowish fatty material it contains. If the egg is not fertilized, the corpus luteum gradually disintegrates and a new follicle begins growing during the next menstrual cycle. If the egg is fertilized, the corpus luteum will remain for a few months, secreting estrogen and progesterone to support the developing embryo.
Functional Cysts
Cysts that develop as part of the natural function of the ovary are dubbed "functional cysts." There are two types, the follicle cyst and the corpus luteum cyst.
Follicle Cysts can develop in two ways: during ovulation when the follicle ruptures to release the egg, or when a developing follicle fails to rupture, leaving the follicle, or sometimes several follicles, to continue to enlarge. Follicle cysts rarely grow larger than three inches in diameter, and usually rupture or shrink after one or two menstrual cycles.
Because these cysts are usually painless, most women are unaware of them. However, when one ruptures, perhaps during sexual intercourse, you may experience intense abdominal pain that is often worsened by physical activity. The pain usually subsides after a day or two but quite often is severe enough to bring you to the emergency room. You may also experience abdominal discomfort if, in response to fertility drugs, several follicle cysts begin to grow.
Corpus Luteum Cyst. The corpus luteum that forms after ovulation is also a cyst-like structure, and it is very prone to the development of fluid or blood-filled cysts that can grow from the size of an egg to the size of a softball.
Unlike follicle cysts, corpus luteum cysts usually cause pain on only one side of the lower abdomen. If you have a corpus luteum cyst, you may be experiencing menstrual changes such as late periods or bleeding between periods. Because this set of symptoms is also associated with the dangerous condition known as tubal or ectopic pregnancy, you should be sure to go to a doctor.
Polycystic Ovaries
In some women, the ovaries tend to develop numerous follicle cysts. You may hear this condition referred to as polycystic ovarian syndrome or "disease" (PCO), Stein-Leventhal Syndrome, or sclerocystic ovarian disease.
Actually polycystic ovaries are not a "disease" at all, but the result of a hormone imbalance that causes the persistent growth of follicular cysts accompanied, usually, by failure of one follicle to mature and succeed in ovulating. The condition is fairly common, affecting between 3.5 and 7 women in 100. It generally develops during the 30s, but can begin in adolescence. Many women with polycystic ovaries have no symptoms, but the condition can cause fertility problems, due to infrequent ovulation, and can result in excess body hair and weight problems, due to hormone imbalances.
Because women with polycystic ovaries rarely or never ovulate, their menstrual periods are generally irregular, often with many months between periods. When they do have a period, it may be quite heavy, since the lining of the uterus has continued to grow during the months since their last period. While polycystic ovaries do not themselves become cancerous, excessive growth of the uterine lining, or endometrium, is thought to increase the risk of cancer of the uterus (endometrial cancer).
Endometrial Cysts
Endometrial cysts are also known as endometriomas or "chocolate cysts," because they are filled with dark blood that resembles chocolate syrup. These cysts form as the result of endometriosis, the disease in which patches of tissue from the uterine lining are found outside the uterus. In about half the cases of endometriosis, these patches appear in or on the ovaries.
With successive menstrual cycles, these misplaced pieces of endometrial tissue bleed, gradually forming endometrial cysts. Over time, the cysts grow, and some can eventually become as large as a grapefruit. Endometrial cysts can cover a large part of the ovary and prevent ovulation, resulting in infertility. Some women have no symptoms with an endometrial cyst; others have severe menstrual cramps, pain with intercourse, or pain during a bowel movement.
Although complications are infrequent, if a sizeable endometrial cyst ruptures, its contents can spill into the pelvic cavity, causing some internal bleeding. The material in the cyst may also spill onto the surface of other organs in the pelvis, such as the uterus, fallopian tubes, bladder, and intestines. This can cause the formation of scar tissue (adhesions), which in turn can cause pain and fertility problems. Other ovarian cysts, such as the follicle cyst, the simple serous cyst, and the corpus luteum cyst, may resemble a "chocolate cyst." An expert must examine the tissue under the microscope to make the diagnosis.
Cystadenomas
Unlike functional ovarian cysts, which develop from variations in the normal function of the ovaries, or endometrial cysts, which are a consequence of endometriosis, or even polycystic ovaries, which result from hormone imbalance, cystadenomas are known as neoplasms, meaning "new growths." Ovarian neoplasms are new and abnormal formations that develop from the ovarian tissue. Cystadenomas are the most common type.
Cystadenomas are classified according to the type of fluid they contain. A serous cystadenoma is filled with a thin watery fluid and is relatively large, between 2 and 6 inches in diameter. This type most frequently appears in women in their 30s and 40s, but may occur in women between the ages of 20 and 50.
A serous cystadenoma usually causes no specific symptoms, unless it grows to be so large that it results in weight gain and a large abdomen. Generally, these cysts are discovered during a routine gynecological exam. Although considered a benign growth, they do have the potential to become malignant.
A mucinous cystadenoma is filled with a sticky, thick gelatinous material and can become enormous. While most are between 6 and 12 inches in diameter, there have been rare cases of gigantic tumors measuring up to 40 inches and weighing over 100 pounds. Mucinous cystadenomas develop most often in women between the ages of 30 and 50.
Although cystadenomas are almost always benign, complications may develop. If they grow very large, they can interfere with other abdominal organs, disturbing the normal functioning of the stomach, intestines, and bowel. They may also twist, rupture, or bleed. Keep in mind, though, that if you have regular gynecological exams, your doctor would probably discover a cystadenoma long before it could grow to its potentially enormous size.
Dermoid Cysts
Dermoid cysts are also ovarian neoplasms. They are so named because they contain skin or related tissue such as hair, teeth, or bone. They are also known as benign cystic teratomas, teratoma meaning a tumor consisting of skin and hair tissue. Dermoid cysts contain this unusual type of tissue because they develop from the ovary's germ cells, the cells that normally produce the egg and contain the forerunner of all human tissues. Dermoid cysts may be present from birth, but rarely grow large enough to be noticed until adulthood.
Dermoid cysts are quite common, and although they can occur in women of any age, they most frequently affect women between the ages of 20 and 40. They generally measure between 2 and 4 inches in diameter, and usually cause no symptoms unless they become so large that they press on the intestines, bladder, or rectum. While these growths are almost always benign, there is about a 1 percent chance that a malignancy could develop. As is true of most types of cysts, the dermoid may be prone to bleeding, rupture, or twisting on its stem.
When to Seek Medical Attention
Because functional ovarian cysts usually remain quite small, often cause no symptoms, and may disappear on their own, treatment of them is not always necessary. However, since there are so many other types of ovarian cysts, you should see your doctor if you experience any of the following:
Abdominal pain or pressure that is severe or frequent
Pain with intercourse
Unusual vaginal bleeding or any vaginal bleeding after menopause
Unexplained weight gain or abdominal bloating
Irregular periods for several months or no period with a negative pregnancy test
Inability to become pregnant after 12 months of intercourse without using birth control
How Your Doctor Goes About a Diagnosis
The doctor will first ask about your symptoms, your medical history, and your family's medical history. If you are having irregular periods, it may be helpful to keep track of vaginal bleeding on a calendar and bring the information with you to your appointment.
Physical Exam and Lab Tests
Next, your doctor will give you a physical exam, including a pelvic examination. The pelvic exam involves inserting a speculum in the vagina to see the vaginal walls and cervix and to obtain a Pap smear or samples of vaginal discharge to check for possible infection. Once the speculum is removed, your doctor will do a "bimanual exam," (two fingers in the vagina, with the other hand pressing on your abdomen), during which he or she can feel the size and shape of the uterus and ovaries.
If you have an ovarian cyst, your doctor may find that your ovaries feel larger than normal, and you may have more discomfort during the bimanual exam than you normally do. In this case, the doctor may recommend additional laboratory tests to help make a diagnosis.
If you are of childbearing age, a pregnancy test is very important. If the doctor suspects you have polycystic ovaries, he or she may also want to check certain blood hormone levels that could be affected. The doctor may also draw blood for a "complete blood count" (CBC) to help identify a possible pelvic infection or to see if you have developed anemia due to excessive bleeding.
Ultrasound
Ultrasound, also called a sonogram or sonography, is one of the most frequently used methods of diagnosing ovarian cysts. This technology uses sound echoes to provide a picture of the tissues and organs inside the body. A sonogram can help determine the size of the ovaries; the number and size of any ovarian cysts; and whether a cyst is filled with solid or liquid material, or a combination of the two. Ultrasound may also show whether fluid has collected in the pelvis, which could be a sign of a recently ruptured cyst. If a pelvic ultrasound exam reveals that you have a functional ovarian cyst, there may be no need for further diagnostic procedures.
Ultrasound is a painless procedure performed in a radiology laboratory or doctor's office. For an abdominal ultrasound you will be asked to drink several glasses of water about an hour before the exam and to refrain from urinating until the exam is completed. It is important to have a full bladder because it enables the technician or radiologist to see all the pelvic organs. The technician will place the ultrasound transducer, a small hand-held device which receives and transmits the images, on your lower abdomen, move it around to get various views, and at certain points, capture these views on film for further review by a radiologist.
The most accurate pictures can be obtained by doing a transvaginal ultrasound, using a specifically designed transducer that is placed in the vagina. Because of the accuracy of the transvaginal ultrasound, some doctors skip the abdominal ultrasound and go directly to this method. The other advantage is that you do not have to have a full bladder.
If your ultrasound results show that your ovarian cyst could be composed of solid material or a combination of solid and liquid material, your doctor may recommend an x-ray (or occasionally a CAT scan or MRI). The x-ray is important because it can reveal the pieces of bone or teeth that are sometimes seen in dermoid cysts and because solid growths on the ovaries are more likely to be malignant.
Diagnostic Laparoscopy
Although the technologies of ultrasound and x-ray have helped to simplify the diagnosis of ovarian cysts, in certain cases more investigation is necessary. Sometimes your doctor will want to take a direct look at your pelvic organs in order to make a diagnosis. For example, if you have endometriosis, conventional tests and ultrasound are not very useful. Or, if your cyst is quite large, or not simply fluid-filled, or if you are over the age of 40 when the risk of cancer begins to increase, your gynecologist may wish to look directly at the cyst and the reproductive organs. This is done by performing a diagnostic laparoscopy. (See the nearby box, "What Happens during Laparoscopy.")
Treating Ovarian Cysts
Treatment depends on many factors, including the type of cyst, its size, its precise location, the type of material it contains, and your age.
Functional Ovarian Cysts: "Watch and Wait"
If you have a small functional ovarian cyst that is not causing any problems, your doctor may recommend a "watch and wait" approach. That is, you may need to return for a follow-up examination or ultrasound after one or two menstrual cycles, when there is a good chance that the cyst will have dissolved. Your doctor may suggest you avoid intercourse during this time, since it can cause a cyst to rupture. If the cyst grows, especially if it becomes larger than about 2 inches, it may need to be removed surgically.
While small functional ovarian cysts generally disappear over time, they also tend to recur with subsequent menstrual cycles. Many doctors believe that functional cysts can be controlled with the use of birth control pills, which reduce the hormones that promote growth of cysts and prevent formation of large, mature follicles that can turn into cysts. If you are already taking birth control pills for contraception, and think you may have an ovarian cyst, see your doctor because it is unlikely to be a functional cyst.
It may take a few months of using birth control pills before your cysts clear up. Your doctor can determine if the pills have been successful by repeating the pelvic exam, the ultrasound, or both. Your cysts may or may not return once you stop taking birth control pills. You can decide with your doctor how long you wish to stay on the pills.
Polycystic Ovaries: No More Surgery
Treatment for polycystic ovaries is more varied. If you have polycystic ovaries and are having problems conceiving, your doctor may recommend that you take clomiphene citrate (Clomid) to stimulate ovulation.
If you are not trying to get pregnant, and you have infrequent periods or no periods due to polycystic ovaries, the treatment is different. Your doctor may start you on the synthetic hormone called medroxyprogesterone acetate (Provera), which is similar to the natural progesterone your body would produce if you were ovulating. Provera fills in for the progesterone that would ordinarily appear after ovulation, allowing you to menstruate. This is important because even if you are not ovulating, your ovaries are still producing the estrogen that causes the uterine lining to grow. Without sufficient progesterone, the lining won't be shed during the menstrual period, and can grow too much. Although you probably feel fine and may not be eager for your periods to return, if your body is exposed only to estrogen without progesterone for long periods of time, the overgrowth of the uterine lining may increase the danger of cancer developing in the uterus.
There are several different schedules used for taking Provera tablets. Most experts agree that one good option is to take one 10-milligram tablet of Provera for 10 days each month. Taking the tablets on the first 10 days of the month makes it easy to remember. You should expect some menstrual bleeding approximately 3 to 5 days after you stop taking the tablets. Don't forget that even though you have polycystic ovaries, you may ovulate occasionally, and it is possible to become pregnant. Provera is not a contraceptive pill. In fact, it is not recommended for use during pregnancy. If you need contraception, you should continue to use your preferred method during your treatment with Provera.
Some doctors treat the symptoms of polycystic ovaries with low-dose birth control pills. When you take birth control pills your normal periods will resume, and you'll be protected against pregnancy if that is a concern. Another advantage of birth control pills over Provera is that they decrease the production of the male hormone androgen. Not only does this help control excess hair growth, sometimes a symptom of polycystic ovaries, but it also may reduce the risk of heart disease in women with polycystic ovaries. Danazol (Danocrine), a synthetic steroid that suppresses the ovaries' output of certain hormones, is another option employed by some doctors.
Because polycystic ovaries are frequently associated with high blood levels of insulin (the hormone that helps the body burn sugar), some doctors are now treating the problem with diabetes drugs that boost the body's response to insulin, thereby reducing the amount of insulin needed in the bloodstream. Drugs used for this purpose include metformin (Glucophage), pioglitazone (Actos), and rosiglitazone (Avandia). Doctors who advocate this type of drug therapy report that the hormonal imbalances associated with polycystic ovaries clear up after two or three months of treatment. After six months, they say, 90 percent of the women taking the drugs resume regular menstruation.
The original cure for polycystic ovaries was a surgical procedure called ovarian wedge resection. This involved removing at least one-third to one-half of each ovary in order to return it to normal size. In most women, this operation resulted in resumption of normal periods and normal fertility. The wedge resection is rarely done anymore thanks to the availability of drugs that induce ovulation and restore normal periods.
When Surgery Is Needed
Sometimes, however, surgical removal of a cyst is the only option. Doctors take several factors into account when deciding whether surgery is advisable. One of the most important considerations is the size of the cyst. Because there is a very slight risk of a large ovarian cyst becoming cancerous, the larger your cyst, the more likely the surgery. Although gynecologists differ on the precise "cut-off point," in most cases if a cyst is at least 2 to 2.5 inches in diameter (about the size of a tennis ball), it will be surgically removed. If your cyst is less than 2 inches, your doctor may want to track it with ultrasound examinations over a period of a few months to see whether it grows to a size that requires surgery.
Another factor doctors consider is your age. Because ovarian cysts are less likely to become cancerous in a woman in her 20s than one in her 40s, or in a woman who has passed menopause, your chance of needing surgical removal of an ovarian cyst increases with age.
The type of cyst is also an important consideration. A "simple cyst," containing only liquid material, is less likely to require surgery than a "complex cyst," containing a mixture of materials. However, if a "simple" functional cyst grows quite large or bleeds, surgery may be necessary. Once your doctor has determined the size and type of cyst you have, he or she will discuss with you the advisability of surgery. Women aged 50 years or older with complex or predominantly solid ovarian cysts should consider undergoing surgery even if the cyst is small. This is because, according to a recent study, there is a relatively high chance of these cysts becoming cancerous. The common types of cysts that almost routinely demand surgical removal are endometriomas, cystadenomas, and dermoid cysts. Surgery is also recommended occasionally for corpus luteum cysts, and for persistently enlarged follicle cysts.
Endometriomas. Because endometrial cysts are caused by endometriosis, you may wonder whether the drugs used to control endometriosis could also be effective in treating endometrial cysts. (See "Keeping Endometriosis at Bay" for more on these drugs.) And indeed, these medications may help control the growth of cysts. However, because endometrial cysts can grow quite large and are prone to rupture, perhaps causing internal bleeding, these cysts are often treated surgically.
Cystadenomas. Since cystadenomas are almost always benign, it would seem reasonable to leave them alone unless they are large or cause complications. The problem is that cystadenomas often do become enormous, causing complications simply due to their size. An additional concern is that cystadenomas are "neoplasms," or new growths of abnormal tissue, and evaluation of neoplasms can be tricky. It is difficult to determine whether a neoplasm is benign or malignant simply by looking at it. Instead, tissue from most types of neoplasms needs to be analyzed under a microscope, and the only way to get a tissue sample is through surgery.
Dermoid Cysts. Dermoid cysts are also neoplasms, and therefore candidates for surgical removal. You may know before surgery that your cyst is a dermoid because if it contains teeth as one-third to one-half of them do, your doctor may have seen them on an x-ray.
What to Expect When the Doctor Operates
Once surgery is decided upon, you'll have a meeting with your surgeon to discuss the operation and have a physical exam.
Before Surgery
Your surgeon will review the reason for your operation, the possible risks, no matter how small, and any possible aftereffects. You may find it helpful to bring a written list of questions to the meeting. Feel free to ask your surgeon to explain the operation by drawing a simple diagram of what will be removed.
Although at this point you will probably feel there are no lab tests you have not already undergone, a few basic studies may be ordered to establish that you are healthy enough for surgery:
A complete blood count (CBC), to make sure that you have no underlying infection and that your body can tolerate loss of a small amount of blood during surgery
A urinalysis to screen for infection and diseases such as diabetes or kidney problems
A blood sample to check your blood type, in the unlikely event that you need a transfusion
A recent chest x-ray or recent electrocardiogram (ECG) if you are over 40 years old
In Surgery
If you have a large cyst, your surgeon will probably remove it through an incision in your lower abdomen. The general term for any operation through the abdomen is laparotomy. If the cyst is small enough, your doctor may be able to remove it with a laparoscope, which requires only a small incision.
The type of operation you will have will depend on the size and nature of your cyst. The goal is to remove only the cyst, leaving the ovary intact. When the cyst alone is removed, the operation is called an ovarian cystectomy. The doctor may remove fluid from the cyst before taking out the cyst itself. The fluid is removed through a needle, in a process called aspiration. If a portion of the ovary is also removed, the operation is a partial oophorectomy. Occasionally, the large size of the cyst or complications such as bleeding, twisting, or rupture, may require removal of the fallopian tube with the ovary. This operation is called salpingo-oophorectomy. Surgeons make every attempt to preserve the reproductive organs, especially if you have not yet reached menopause since it's still possible to have children when only a small portion of one ovary remains. Removal of the uterus, fallopian tubes, and ovaries (total abdominal hysterectomy with bilateral salpingo-oophorectomy or TAHBSO) is very rarely used to treat the types of ovarian cysts described here, unless there is a reasonable chance that your cyst is cancerous.
After Surgery
If you have a laparotomy, you will probably be in the hospital for a few days after the surgery. During the early recovery and postoperative period, you will receive fluids and medication through your intravenous (IV) line, but you should be eating solid foods fairly quickly. You will receive medication for pain, and you can expect to be walking around the day after surgery. Your wound should heal quickly, and if your incision was closed with staples, the staples and bandage will probably be removed before you leave the hospital. If you have non-absorbable stitches, they will probably be removed 5 to 7 days after your operation.
Before you leave the hospital, you will receive a summary of the type of operation that was performed and the type of cyst that you had. You may wish to ask for a copy of the surgery report for your records. You should also receive complete instructions from your doctor or nurse regarding what to expect in the postoperative period.
You should expect to have some abdominal discomfort for a few days after you return home. You may be given a prescription for a mild pain reliever. You should call your doctor if the medication doesn't help, or if the pain does not improve after a week. You should also contact your doctor if you develop a fever of over 100 degrees, or if vaginal bleeding is heavier than a normal period.
You should expect your incision to look quite red and feel uncomfortable for a few weeks. It is normal to notice some dried blood around the incision, but call your doctor if you see pus oozing from the wound. It's fine to bathe and shower; don't worry about getting the incision wet as long as it's not oozing. The red color of the incision will gradually fade, and eventually the scar will barely be visible.
You may be able to start some non-strenuous physical activity after a week or two. Be sure not to resume intercourse or to use tampons or anything else in the vagina until you have had your postoperative checkup (usually about 2 weeks after surgery). You will probably be able to resume all your normal activities and return to work about 6 weeks after surgery.
Unless you have had both of your ovaries removed, your periods will return to normal, usually by about 4 to 8 weeks after surgery. Remember that if even a portion of one ovary remains, you can still become pregnant if you're of childbearing age. That's one of the many reasons it's important to discuss the specifics of your surgery with your doctor.
Chances are that once the ovarian cyst has been removed, it will not recur. However, the operation does not always guarantee that you'll be cyst-free in the future. As long as you have ovaries, you can have ovarian cysts. It's a good idea to continue any medical treatments your doctor has prescribed to control the cysts and, of course, to have regular gynecological exams.
Source: From the PDR® Family Guide to Women's Health and Prescription Drugs™
http://www.pdrhealth.com/content/women_health/chapters/fgwh09.shtml

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