HEALTH TALK: Ovarian cysts

One on the most memorable persons in my medical career for whom I have had profound sympathy was a beautiful fifteen year old girl who lost both her ovaries to cysts.

I was a medical student and assisted a gynecologist in the operation.  It meant she could not have children and was thrown into artificial menopause.  (Recall my article on menopause).  I honestly had to fight the tears from showing in my eyes.

WHAT ARE OVARIAN CYSTS?

AN OVERVIEW

They are fluid-filled sacs in or on the surface of one or both ovaries.  Remember these are where the woman’s eggs are found and are released every month in the child bearing years.  Many women have ovarian cysts at some time of another, but they usually cause little of no discomfort and are harmless, and most disappear without treatment in a few months.  Some produce serious symptoms, however, especially those that have ruptured.  Rarely, they can be life- threatening.

SIGNS AND SYMPTOMS

Most women are likely to have no symptoms at all.  If they do, the symptoms may mimic other conditions such as pelvic inflammatory disease (PID), an infection affecting the reproductive organs, endometriosis, where tissue from the womb abnormally implants elsewhere in the system of even outside it, ectopic pregnancy, (pregnancy in the wrong place), or ovarian cancer.

Appendicitis or some large bowl disorders can appear as a ruptured cyst.  One should still be watchful for any suspicious change in the area of one’s reproductive system, because a cyst may cause some of the following signs and systems.

•    Menstrual irregularities
•    Fullness or heaviness of your abdomen
•    Pressure on your rectum or bladder – difficulty emptying your bladder completely
•    Pelvic (below the waist) pain – a constant or occasional dull ache that may be felt in the lower back and thighs.
•    Pelvic pain also: 1) just before your period begins of just before it ends.
2) during intercourse (dyspareunia).

An immediate visit to the doctor or Emergency Room is warranted if there is
a)    sudden, sever abdominal or pelvic pain
b)    pain accompanied by fever of vomiting.

WHAT CAUSES CYSTS?

Each month, the ovaries grow cyst-like structures called follicles.  These produce the female hormones, estrogen and progesterone, and release an egg (ovulation).

Occasionally, a normal follicle just keeps growing, becoming a functional cyst, meaning that it began during the normal function of the menstrual cycle.  There are two types of functional cysts.  Before I go into these, allow me to try to explain what really goes on with hormones, your brain and the ovaries.

During the first half of a menstrual cycle (the first 13 or so days in a normal 28-day cycle there is no estrogen circulating in the blood.  Then, at about mid cycle, there is a rise in estrogen and as a result, a message goes to a part of your brain, the hypothalamus, to produce a hormone, the FSHRH (Follicle stimulating hormone releasing hormone).  These hormones travel to another area of the brain, the front part of the pituitary gland to produce the Follicle Stimulating Hormone (FSH), to allow the follicle to grow, and the Leutenizing Hormone (LH), to cause the egg to be released from the ovary.  The final part, 14 days, of the cycle, is the luteal phase.

ONE TYPE OF CYST IS THE FOLLICULAR CYST.

When the LH surge does not occur, a follicular cyst begins because the follicle doesn’t rupture or release its egg; it grows and turns into a cyst.  These are usually harmless, seldom cause pain and often disappear on their own after two or three periods.

THE OTHER TYPE IS THE CORPUS LUTEUM CYST.

When the LH surge does occur and the egg is released, the ruptured follicle begins to produce large amounts of estrogen and progesterone in preparation for possible conception.  It is now called the corpus luteum.  Sometimes, however the egg’s escape opening seals off and fluid accumulates in the follicle, causing the corpus luteum to expand into a cyst.  It usually goes away on its own in a few weeks, but can grow to almost four inches in diameter.  It can bleed into itself or twist the ovary, producing pelvic or abdominal pain.  It may rupture if it fills with blood, causing internal bleeding and sudden, sharp pain.  By the way, the fertility drug clomiphene (clomid), used to induce ovulation, increases the risk of a corpus luteum cyst developing after ovulation.

If you’ve followed the reasoning so far, a follicular cyst precludes pregnancy – the egg is not released to be fertilized.  But a corpus luteum cyst doesn’t prevent or threaten a pregnancy – the egg is already released but the opening gets resealed.

SEEK MEDICAL ADVICE:

If you experience severe or colicky pain in your lower abdomen, with fever and vomiting.  There are symptoms of shock such as cold, clammy skin, rapid breathing, lightheadedness or weakness, indicating an emergency is on your hands.  Get to the doctor!!

SCREENING AND DIAGNOSIS

A cyst may be found during a pelvic exam.  If one is suspected, further testing may be advised to determine type or need for treatment.  We want to find out certain things to help diagnostic and management (how to handle) decisions.  For instance, what size is it? Is it fluid-filled, solid or mixed?  Fluid-filled cysts aren’t likely to be cancerous.  Solid, or a mixture of fluid filled and solid may require further evaluation to check for cancer.

To identify the type of cyst, we may want to do the following:
•    Pregnancy test.  Remember I said you will not get pregnant with a follicular cyst; a positive test means a corpus luteum cyst.
•    Pelvic Ultra Sound Scan.  I dare say that a good number of women reading this know this well.  This produce can identify a cyst, its size, location, and whether solid of fluid filled.
•    Laparoscopy.  This, too, is well known.  A slim lighted instrument inserted through a small cut below the navel can see the ovaries and remove a cyst.
•    CA125 blood test.  This is cancer antigen 125, which is increased in cases of ovarian cancer.  So if you are at risk of ovarian caner and you have a cyst that is partially solid, a high CA125 could be especially important.  However high CA125 levels can be found in non-cancerous conditions like fibroids, PID, and endometriosis.

ANY COMPLICATIONS?

Yes.  A large one can cause abdominal discomfort.  If it presses on your bladder, you urinate frequently because the bladder’s capacity is reduced.  This symptom is often due to bladder  infection, but bear a cyst in mind if there are reasons to be suspicious.  See the doctor.

There are other types of cysts which are much less common but which may be found on pelvic examinations.  Cysts or ovarian masses occurring after menopause may be cancerous.

The less common cysts are:
Dermoid cysts: These may contain tissue such as hair, skin or teeth because they are formed from cells that produce human eggs. Rarely cancerous, they may become large and cause painful twisting of the ovary.  You must be thinking ‘how gross!’
Endometriomas: These cysts develop from endometriosis, mentioned earlier.
Cystadenomas: These may be filled with a watery liquid or a mucous material.  They may grow as large as 12 inches (one foot) in diameter, and cause ovarian twisting.

HOW DO WE TREAT CYSTS?

This depends on your age, type and size of your cysts, and symptoms.  The options:
Watchful waiting: Regular examinations and monitoring for size by this method or ultra sound is all that’s needed a lot of times.
Birth control pills: These reduce the chance of new cysts developing in future menstrual cycles.  The added benefit of reducing your risk of ovarian cancer also make them useful.  The risk decreases the longer you take birth control pills.
Surgery: This is done if: a cyst is large and causes symptoms, does not look like a functional cyst, is growing, persists through more than a few cycles.  Either a cyst can be removed (cystectomy) or if necessary, one or both ovaries (oophorectomy).  Remember that a cyst after menopause suggests cancer, so surgery is almost always done in this case.

ANY WAY TO PREVENT?

None definite.  Just get regular examinations, so that any change in your ovaries can be diagnosed as early as possible.  Pay attention to changes in your cycle, and especially any changes or symptoms that persist for more than a few cycles.  Basically, talk to us about any concerns to do with your menses.

See you next week.

Dr. Victor Emanuel has been an educator of medical professionals in training, and the public, for over 20 years in Dominica. The contents of his articles are based on facts and research conducted, and not of his opinion.