Ovarian Cysts

What Are Ovarian Cysts?

Ovarian cysts are fluid-filled sacs or pockets that develop within or on the surface of an ovary. The ovaries are approximately 2–3 cm in size and are located on either side of the uterus, with one end connected to the uterus and the other to the lateral abdominal wall. The number of eggs, which is approximately seven million during foetal life, decreases to one to two million at birth and to 400,000 by puberty, when menstrual cycles begin. Eggs that develop and mature in the ovaries are released in monthly cycles throughout the reproductive years. If pregnancy does not occur, this cycle is repeated every month.

Many women develop ovarian cysts from time to time. Most ovarian cysts cause little or no discomfort and are harmless. The majority disappear spontaneously within a few months without treatment.

What Are the Symptoms of an Ovarian Cyst?

Most cysts do not cause any symptoms and resolve spontaneously. However, large ovarian cysts may cause:

• Dull or sharp pain in the lower abdomen or groin
• Bloating
• A sensation of fullness or heaviness in the abdomen

In Which Situations and When Should a Physician Be Consulted?

Immediate medical attention should be sought in the following situations:

• Sudden, severe abdominal or pelvic pain, which may indicate torsion—the interruption of blood flow to the ovary as a result of the ovary twisting around itself
• Pain accompanied by fever, discharge or vomiting

In Whom, When and Why Do Ovarian Cysts Occur? What Are Their Types?

Most ovarian cysts develop as a result of the menstrual cycle and are known as functional cysts. Other types of cysts are less common.

Functional Cysts

The ovaries normally develop cyst-like structures called follicles every month. These follicles produce the hormones oestrogen and progesterone, and when ovulation occurs, one or two eggs are released into the abdominal cavity.

If the follicle continues to grow during this cycle, it becomes what is known as a functional cyst. There are two types of functional cyst:

1. Follicular cyst: In the middle of the menstrual cycle, an egg is released from its follicle and moves towards the end of the fallopian tube. A follicular cyst begins to form when the follicle does not rupture or release its egg and instead continues to grow.
2. Corpus luteum cyst: Once a follicle releases its egg, it begins to produce oestrogen and progesterone to support conception. The follicle is then called the corpus luteum. Sometimes, fluid accumulates inside the follicle, causing the corpus luteum to develop into a cyst.

Functional cysts are usually harmless, rarely cause pain and generally disappear spontaneously within two or three menstrual cycles without requiring treatment.

Other Cysts

• Dermoid cysts: These cysts may contain tissues such as hair, skin or teeth. Although rare, they may be malignant.
• Endometriomas, or chocolate cysts: These develop when cells resembling the inner lining of the uterus implant and grow in tissues outside the uterus. When they occur in the ovary, they are called chocolate cysts; when they occur on the peritoneum, they are called peritoneal endometriosis; and when they affect deeper organs such as the bowel, bladder or nerves, they are called deep infiltrating endometriosis.
• Cystadenomas: These develop on the surface of the ovary and may be filled with watery, serous material or mucus-like, mucinous material.

In Whom and at What Ages Are Ovarian Cysts Seen?

Although ovarian cysts are more commonly seen in younger women of reproductive age, they may occur at any age.

Are Ovarian Cysts Harmful?

The potential harm caused by ovarian cysts varies according to the type of cyst. If a cyst twists around itself, blood flow to the ovary may decrease or stop, potentially resulting in the loss of the ovary.

In rapidly growing cysts and in cases where the ovarian wall becomes extremely thin, the amount of healthy ovarian tissue may decrease.

Which Cysts Are Dangerous?

1. Cysts that grow rapidly within a short period
2. Cysts detected after menopause
3. Cysts that cause ovarian torsion
4. Cysts that cause ovarian abscesses
5. Cysts that rupture and cause ongoing bleeding into the abdominal cavity

How Is an Ovarian Cyst Diagnosed?

Ovarian cysts are detected during a gynaecological examination and ultrasonography. Depending on their size, contents and characteristics, additional investigations such as magnetic resonance imaging may be requested.

Treatment of Ovarian Cysts

The treatment of ovarian cysts varies depending on the patient’s age, the type, size and characteristics of the cyst, and the patient’s symptoms. Different treatment alternatives may be considered:

• Observation and monitoring: In many cases, it is possible to wait and observe whether the cyst disappears within a few months. Regardless of age, if the patient has no symptoms and ultrasonography shows a simple, small, fluid-filled cyst, observation may be preferred, provided that appropriate follow-up and monitoring are carried out.
• Is medication available? Oral contraceptive pills or other hormonal contraceptives may be recommended to prevent ovarian cysts from recurring. However, it should be understood that oral contraceptive pills do not reduce the size of an existing cyst.

In Which Situations Is Surgery Required?

Cysts with the following characteristics should be surgically removed:

1. Cysts that are large in size
2. Cysts that do not resemble functional cysts
3. Cysts that increase in size during follow-up or persist despite monitoring
4. Cysts that persist despite monitoring or cause pain
5. Newly developed and/or growing cysts in postmenopausal women
6. Cysts with structurally suspicious features

Which Methods Are Used for Ovarian Cyst Surgery?

1. Laparoscopy: This is a minimally invasive surgical technique. Small tubes are inserted into the abdominal cavity through incisions measuring approximately 0.5–1 cm, and the operation is performed under visualisation with a camera system. Depending on the characteristics of the ovarian cyst, only the cyst may be removed, which is known as an ovarian cystectomy. In some cases, the ovary itself may also need to be removed, which is known as an oophorectomy. Laparoscopic surgery is a patient-friendly surgical method through which many operations can now be performed and is associated with less pain than open surgery.
2. Laparotomy: This is an open surgical technique. The operation is performed through an incision resembling a caesarean-section incision or through a vertical incision below the umbilicus. This type of surgery may be necessary for large ovarian cysts and masses or for masses that are suspicious for malignancy or cancer.

During all operations, the ovarian cysts and masses that are removed are sent for pathological examination while the patient is still under anaesthesia. They are evaluated to determine whether the ovarian cyst or mass contains cancerous tissue. If the tissue contains cancer or precancerous cells, the scope of the operation may be extended to include the removal of the other ovary, the uterus and other tissues.

Can an Ovarian Cyst Rupture?

Ovarian cysts may rupture and release their contents into the abdominal cavity. Depending on the structure and contents of the cyst, the patient’s symptoms and her overall condition, either monitoring or surgery may be planned. Many ovarian cysts do not rupture. The likelihood of a cyst rupturing into the abdominal cavity is higher during strenuous exercise or sexual activity. Functional cysts are the most common type of cyst to rupture.

How Can a Ruptured Ovarian Cyst Be Recognised?

When ovarian cysts rupture and release their contents into the abdominal cavity, they may not cause any symptoms. In some cases, however, they may cause lower abdominal or lower back pain, abdominal bloating, pain radiating to the vagina or rectum, and bleeding.

Examination and ultrasonography may show that the cyst has ruptured and that fluid is present in the abdominal cavity. Because conditions such as ectopic pregnancy, appendicitis or kidney stones may cause similar symptoms, your physician may request additional tests to exclude these possibilities. These tests include:

1. Pregnancy test
2. Blood tests
3. Urinalysis
4. Ultrasonography and, rarely, magnetic resonance imaging

What Happens If an Ovarian Cyst Ruptures?

In cases of haemorrhagic ovarian cysts, the patient is usually evaluated and monitored through observation alone, provided that there is no decrease in blood values.

If a ruptured ovarian or tubal abscess is present, or if an ovarian cyst causes internal bleeding severe enough to reduce the patient’s blood values, emergency surgery is required.

Frequently Asked Questions

1. Is Sexual Intercourse Possible in the Presence of an Ovarian Cyst?

Many women develop ovarian cysts. Most of these are not complicated cysts, do not cause any symptoms and disappear spontaneously from the ovary. Therefore, it is not possible to state that sexual intercourse is necessarily harmful.

However, if an ovarian cyst has been diagnosed and is being monitored, the patient is informed in detail that sexual activity may cause the cyst to rupture into the abdominal cavity, that this may result in an emergency and what such an emergency may involve.

2. When Is an Ovarian Cyst Dangerous?

Some ovarian cysts may be dangerous or cancerous. Your physician will provide detailed information about the condition, particularly with advancing age, during the postmenopausal years and in the presence of complicated ovarian cysts.

3. Can a Woman with an Ovarian Cyst Become Pregnant?

Many ovarian cysts do not affect the ability to become pregnant. However, there are three different ovarian conditions that may affect fertility:

1. Endometriosis:This is a condition in which tissue resembling the inner lining of the uterus is located outside the uterus. It may impair the structure and function of the ovaries, fallopian tubes, uterine lining and intra-abdominal environment, thereby preventing pregnancy.
2. Polycystic ovary syndrome:This is one of the leading conditions that may make conception difficult. It is characterised by the presence of numerous small cysts in the ovaries. The egg does not mature, ovulation does not occur, menstrual periods occur at long intervals, and the condition affects not only the ovaries but the entire body.
3. Tubo-ovarian abscesses:These are serious infections involving the ovaries and fallopian tubes. In addition to antibiotic treatment, the infection must be drained.

4. Can a Benign Ovarian Cyst Become Malignant?

This may occur very rarely; however, most ovarian cysts are benign. Ovarian cysts may carry a higher risk of ovarian cancer, particularly during the postmenopausal period.

5. Can a Cyst Disappear with Menstruation?

Functional ovarian cysts may disappear spontaneously from the ovary within two or three menstrual cycles. Although oral contraceptive pills do not reduce the size of existing ovarian cysts, they suppress ovulation and may therefore reduce the development of new ovarian cysts.