Ovarian Cysts: An Overview

Introduction to Ovarian Cysts

• An ovarian cyst is a sac filled with liquid or semiliquid material within an ovary.
• Cysts are encapsulated and vary in size, resembling a cherry in most cases.
• Ovarian cysts usually result from hormonal shifts during puberty/menopause or may be congenital.
• Most ovarian cysts are non-cancerous and resolve without medical intervention.
• The adnexa, consisting of the ovaries and fallopian tubes, is important for reproductive health.
• Ovaries are connected to the uterus via the utero-ovarian ligament and produce follicles each month, where one follicle matures and ovulates.
• Fluid-filled sacs or ovarian cysts can then arise after ovulation.
• Ovarian cysts are common adnexal masses classified by characteristics and the patient's age and type.
• Most cysts are functional and benign.
• Complications with cysts like pelvic pain, blood loss, cyst rupture, and/or ovarian torsion require intervention.
• Medical imaging and routine physical exams have increased ovarian cyst diagnosis.
• Ovarian cysts are most common during active hormonal periods, such as infancy, adolescence and reproductive years.
• Ovarian cysts can indicate underlying malignancies or mimic ectopic pregnancy, ovarian torsion, or appendicitis.
• Large, painful, or persistent cysts or cysts with concerning imaging may require surgical removal of the ovary.
• The actual prevalence of ovarian cysts is hard to pin down, as many cases are asymptomatic and undiagnosed.
• Nearly 10% of women have ovarian cysts, but most are non-cancerous and need no treatment.
• Transvaginal sonograms detect ovarian cysts in nearly all premenopausal women, and up to 18% of postmenopausal women.
• Functional ovarian cysts, like Graafian follicles, frequently occur during menstrual cycles.
• Approximately 4% of women are hospitalized for ovarian cysts by the age of 65.
• Approximately 7.8% of 335 asymptomatic women aged 24-40 are shown to have adnexal lesions.
• The prevalence of simple unilocular adnexal cysts in postmenopausal women is 2.5%.
• Transvaginal ultrasounds have detected adnexal cysts in 46.7% of 33,739 premenopausal and postmenopausal women, with 63.2% resolving.
• Ovarian cysts are the most frequent fetal and infant tumor, with a prevalence rate over 30%.
• The incidence of ovarian carcinoma in the United States is approximately 15 cases per 100,000 women annually.
• Each year, over 21,000 US women are diagnosed with ovarian carcinoma, resulting in approximately 14,600 deaths.
• Epithelial ovarian cystadenocarcinomas are the most common malignant ovarian tumors.
• Tumors of low malignant potential comprise about 20% of malignant ovarian tumors, malignant germ cell tumors account for less than 5%, and granulosa cell tumors make up 2%.
• Most ovarian cysts are benign and do not pose significant health risks, despite how common they are.
• Follow-up and evaluation are important, particularly for postmenopausal women due to increased malignancy risk.

Pathophysiology

• Ovarian cyst formation arises from hormonal imbalances and disruptions in the ovulatory process.
• The normal menstrual cycle involves follicle-stimulating hormone (FSH) promoting follicular development, followed by a surge in luteinizing hormone (LH) that triggers ovulation.
• Increased LH levels can lead to hyperstimulation of the ovaries, causing hormonal imbalances, including elevated estrogen and human chorionic gonadotropin (HCG).
• Abnormal follicular proliferation occurs, follicles fail to ovulate and undergo atresia, leading to continued growth and cyst development.
• Hormonal fluctuations, ovulation disorders, endometriosis, and pregnancy can all contribute to cyst formation.
• Persistent cysts may cause symptoms like pelvic pain, bloating, irregular menstrual cycles, dyspareunia, and severe discomfort over time.

Classifications of Ovarian Cysts

• Ovarian cysts are sacs filled with fluid that form on or within the ovaries.
• Cysts are prevalent and mostly nonmalignant, from physiological mechanisms or clinical conditions.
• Classifications are essential for precise diagnosis and suitable management.
• Ovarian cysts include functional (physiological) cysts, pathological cysts, and Polycystic Ovaries.

Functional Cysts

• Common and not disease-related.
• Occur as a result of ovulation and a sign that ovaries are functioning.
• Functional cysts generally shrink within 60 days.
• Included are follicular cysts: occur when an ovarian follicle fails to rupture and release an egg during ovulation, leading to the follicle continuing to grow; usually benign and asymptomatic, often resolving spontaneously within a few menstrual cycles.
• Included are corpus luteum cysts: After the follicle releases an egg, it forms a hormone-producing structure called the corpus luteum; if conception doesn’t take place, the corpus luteum dissolves, but sometimes, instead of breaking down, it fills with fluid and forms a cyst.

Pathological Cysts

• Ovarian cysts develop due to abnormal cellular growth rather than being a result of the normal ovulatory process.
• Pathological cysts differ from functional cysts, which typically resolve on their own; pathological cysts may persist, grow larger, and sometimes require medical intervention.
• Not related to the normal ovulatory cycle.
• Dermoid Cysts (Mature Cystic Teratomas) can contain tissues such as hair, skin, or teeth; most common ovarian neoplasm in women under 30 and are usually asymptomatic but may cause ovarian torsion if large.
• Endometriomas (Chocolate Cysts) includes tissue that is similar to the lining of your uterus grows on other parts of your body; this tissue in the wrong places can cause painful symptoms that can impact not only your menstrual cycle but also your daily life; can cause issues getting pregnant.
• Endometriosis most commonly impacts females between the ages of 20 and 40.
• Cystadenomas are benign, epithelial tumors that can occur in various locations, including the ovaries, bile ducts, and pancreas, typically slow-growing and asymptomatic; they are often discovered incidentally during imaging and can be either unilocular or multilocular, with the two main types being serous and mucinous.
• Serous Cystadenomas are filled with clear, watery fluid, can be unilocular or multilocular.
• Mucinous Cystadenomas contain mucinous fluid, often becoming large and multilocular.
• Paraovarian (Paratubal) Cysts can becomes large and cause pelvic pain or torsion.

Polycystic Ovaries

• It is associated with polycystic ovary syndrome (PCOS).
• Complex hormonal disorder that affects ovaries and can disrupt reproductive, metabolic, and overall health.
• Ovaries produce higher-than-normal levels of androgens (male hormones), which interferes with egg development and release during ovulation.
• Small fluid-filled sacs (cysts) can form on the ovaries.
• Polycystic Ovaries is a leading cause of infertility and is also associated with irregular menstrual cycles, weight gain, excessive hair growth (hirsutism), acne, and scalp hair thinning.

Causes and Risk Factors

• Ovarian cysts form for various reasons, but ovulation is the most leading cause.
• It is a natural process during the menstrual cycle where an egg is released.
• Abnormal Cell Reproduction can lead to dermoid cysts (which contain hair, skin, or teeth) or cystadenomas (fluid-filled cysts on the ovary’s surface).
• Pelvic Inflammatory Disease (PID)Severe infections that spread to the ovaries can result in cyst formation.

Risk factors

• Hormonal drugs or imbalances
• Fertility drugs
• Polycystic ovary syndrome (PCOS)
• Age: Reproductive Years
• Pregnancy: Follicle may stay on ovary
• Medical Conditions: Endometriosis, PCOS
• Previous Ovarian Cysts
• The likelihood of recurring functional cysts can increase with persistent hormonal imbalance.

Clinical Manifestations and Symptoms

• Clinical manifestations vary depending on the size, type, and complications
• Many ovarian cysts do not present symptoms, particularly if they are small or benign
  • Pelvic pain or discomfort
    • Mild to moderate pain -Sharp or dull pain
  • Bloating or fullness
  • Pain during intercourse (dyspareunia)
  • Abnormal menstrual cycles - Irregular periods - Heavier or lighter-than-usual periods - Missed periods
  • Lower back or thigh pain
  • Nausea or vomiting
  • Increased frequency of urination or difficulty emptying the bladder
  • Sudden, severe pain (acute symptoms)
  • Signs of infection (rare)
  • Pelvic tenderness
  • Abdominal distension
  • Ovarian mass
  • Changes in ovary size or shape

When to seek medical attention

• Sudden, severe abdominal or pelvic pain
• Develops symptoms of infection
• Worsens or unrelieved pain

Diagnostic Procedures

• Ovarian cysts are fluid-filled sacs on or inside an ovary.
• They may require further evaluation for potential complications.
• Diagnostic process involves clinical examination, imaging studies, lab tests, and possible surgical evaluation.
• Clinical examination can detect tenderness, swelling, or masses in the pelvic region.
• Medical imaging can diagnose ovarian cysts.
• Transvaginal ultrasound: First-line tool that uses a probe inserted into the vagina providing high-resolution images of the ovaries.
• Abdominal
• CT Scan or MRI offers help for cysts that are complex
• Laboratory tests can assess malignancy.
• Pregnancy Tests can rule out pregnancy.
• CA-125 Blood tests can reveal cancer or any inflammation
• Hormonal testing
• Surgical Diagnosis (Laparoscopy) where imaging and labs tests are inconclusive, perform a laparoscopy for evaluation.

Complications

• Most cysts don't cause any serious complications.
• Cancer: Cysts after menopause have a higher risk of malignancy.
• Ruptured ovarian cyst: Ruptures can cause severe pain.
• Ovarian torsion: Twisting can prevent blood flow to the ovaries, and cause extreme pain, nausea/vomiting.

Treatment and Management

• Depends on symptoms, type, and cause of cyst.
• Options include monitoring, medication, or surgery.
• Watchful Waiting consists of waiting a short amount of time.
• Medicines often involve hormonal birth control pills.
• Surgery can be done depending on how big the cysts is; these can be a Laparoscopic or a Laparotomy type of surgery.

When to remove an ovarian cyst

• 10 cm and still growing
• Causing Pain
• Irregular periods; unable to get pregnant
• Cancer

Prognosis and Prevention

• Functional cysts usually resolve on their own.
• Benign Ovarian can be removed in surgery
• PCOS has no cure, but can be managed by weight, diet and birth control.
• Endometriomas can cause pain and fertility and can range from hormonal treatment, to surgery.
• Malignant depends on the diagnosis. Regular screening can increase success.

How to prevent cysts

• Regular checkups
• A healthy lifestyle and diet
• Birth control
• Manage existing condition
• Monitor menstrual cycles

Common Questions

• The length of time is unknown
• Weight lost is possible due to relieving the cysts
• Can be healed naturally if no other symptoms persist

Key points

• Cysts naturally occur
• Watch for irregular issues
• Test to ensure cancer is not present
• Regularly check to prevent any unwanted issues