#49 Ovarian Cysts

An ovarian cyst is a fluid sac that develops on the ovaries. There are four kinds of ovarian cysts. How much trouble they cause depends upon the kind of cyst you have.

In ovulating women, benign cysts are made and resolve (leave) every month. Menopausal women or women on hormone contraceptives don’t develop this kind of ovarian cyst. This type of cyst grows to slightly over 2 centimeters in its mature state before it ruptures (resolves) and sends the ovum (egg) out into the peritoneal cavity to find its way to the fallopian tube. This cyst resolves spontaneously when the egg is discharged.

Sometimes women who are undergoing fertility treatment with follicle stimulating hormone (FSH) will make several of these cysts, causing their ovaries to become quite large. These cysts can be six, seven, or even eight centimeters in diameter. Ovulating too many eggs can be problematic and can be associated with abdominal pain and mass. Medical care is needed.

Cysts also present in women who have polycystic ovarian syndrome (PCOS). Due to hormone irregularities, these cysts should potentially rupture each month but they do not rupture and release the enclosed egg in any predictable manner. They simply form every month without rupturing, accumulating multiple cysts. These cysts are associated with insulin resistance, adult onset diabetes, and infertility.  Women with PCOS tend to be overweight and sometimes have excessive hair growth. These symptoms respond to metformin treatment. Most importantly, women with PCOS tend to become pregnant at early age such as 18 and then remain infertile until they reach their forties. At that time, the increased FSH can cause ovulation and pregnancy.

Ovarian cysts can be benign cystic tumors. Benign ovarian tumors are usually one cyst, to be distinguished from malignant cystic tumors which have what we call septations (multiple walls within the ovarian cyst). We used to use the size 5.5 centimeters to determine whether the cyst can be watched or whether it needs to be surgically removed. With ultrasound, these tumors are easier to follow, and we now tolerate a larger tumor, especially if there is only one cyst and no septations.

Benign ovarian tumors can get to be very large, the size of a term pregnancy. Sometimes pregnant women present with these tumors. If the tumor is large, the best time to remove this type of tumor is during the second or middle trimester. I’ve removed these tumors surgically on several occasions without disturbance to the pregnancy.

Some ovarian cysts can be malignant. The most common are the serous cystadenocarcinoma and the mucinous cystadenocarcinoma. Unfortunately, the prognosis for these ovarian carcinoma’s has been and remains bleak because these cancers are found late in their development. Like all cancers, ovarian cancer is staged with Stage One being the best stage with the best prognosis and Stage Four being the highest stage with the worst prognosis. The stages are further subdivided into A & B stages. Most ovarian cancer is discovered in the Stage 3 A or B stage which offers a bleak outlook.

Discovery of malignant ovarian cysts is late as a rule because there are no early symptoms. The best and more common female cancer to have is endometrial (lining of the uterus) because the postmenopausal bleeding starts early in the cancer’s development. By the time most ovarian cancer becomes symptomatic, it is late and advanced. Symptoms will include abdominal pain and enlargement or mass formation. Treatment is surgery and chemotherapy. Radiation has not been very successful.

Fifty years ago, a gynecologist posited the theory that talc exposure caused ovarian cancer. At that time, this theory was not highly regarded. On the other hand, today it is a commonly accepted theory. Women should not be using any kind of powder that has to do with talc. If they feel that they must use something, they should consider using cornstarch or a powder without talc.

For decades we have observed that women whose ovaries have been hyperstimulated with follicle stimulating hormone to promote production of ova and women who are childless have a higher risk for developing ovarian cancer. In my experience, the most common patient to have ovarian cancer has two children. The idea is that pregnancy causes ovulation to stop at least during the pregnancy. Birth control pills also cause ovulation to stop and there has been an association with birth control pill use and less risk of ovarian cancer. The women who donate eggs, don’t use hormonal contraception, or don’t have several pregnancies are at greater risk for ovarian cancer.

How common ovarian cysts are depends on what kind cyst we are discussing. For example, a follicle cyst would be something that forms every month in a woman who is not pregnant, not on birth-control pills, and not menopausal or premenarchal. Polycystic ovaries can be managed with metformin, weight loss, management of diabetes, and pregnancy. Women who have benign ovarian cystic tumors are relatively uncommon. These would be probably one or two percent of adult females. Benign cystic ovarian tumors are also rare. Carcinoma of the ovary is rare.

Treatment of the benign cyst would be to remove it if it becomes large. Today we might be able to actually just drain the cyst laparoscopically and remove enough of it to get a biopsy to rule out cancer. This is a change in treatment from years ago when the entire cyst and sometimes the ovary were removed for benign tumors.

Today treatment of ovarian cancer has not changed much and still includes removal of the of both ovaries, both tubes, uterus, cervix and all of the little pieces of ovarian cancer growing in various places inside the abdomen. Most often treatment includes removal of the omentum, which is the fat pad insulation or bumper that we all have in our abdomens. Chemo treatment would most often follow.

Most ovarian cysts are benign and many don’t require treatment. The risk for ovarian cancer is very small, but it is nonetheless a very difficult cancer to treat because it has no early symptoms and is usually not discovered until late in the cancer’s development when treatment is less effective.