Dr Suman Bijlani, Gynaecologist, Sonologist, Infertility Specialist, Obstetrician and Laparoscopic Surgeon, Mumbai.

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Ovarian Cysts

Ovarian cysts are one of the most common gynaecological problems that can be a cause for worry. If you have an ovarian cyst, you should have a basic understanding of this condition.

Q. What is an ovarian cyst?

An ovarian cyst is a fluid filled sac inside the ovary. It may be a follicle (egg) which has overgrown ovarian-cyst(hormonal or physiological cyst) or bled inside (haemorrhagic cyst) or it may be a benign or cancerous tumor.

Q. My doctor has told me that I have a physiological cyst? And that I should do nothing about it? What does it mean?

Every month, many eggs (follicles) grow in the ovary. The normal follicle is thus a fluid filled sac which also contains a premature egg. Out of many growing follicles, one becomes the largest (between 18-15 mm) and is known as the ‘dominant follicle’. This dominant follicle ruptures to release the egg. After rupture, the dominant follicle forms a structure known as the ‘corpus luteum’ which contains fluid which contains hormones for implantation. This corpus luteum disintegrates 2 days before expected menses.

Ovarian physiological cysts

 

If the follicle, instead of rupturing, grows further and persists, it is known as a ‘follicular cyst’.

If the corpus luteum persists or grows, it is known as a ‘luteal cyst’.

At any point of time, if there is bleeding in the follicle, the follicle enlarges and gets filled with blood, known as a ‘hemorrhagic cyst’.

The above three types of cysts are hormonal and not tumors. These are therefore known as ‘physiological cysts’. This type of cysts are usually not more than 3-4 cm in size, filled with clear fluid (simple cysts), painless, are accidentally found on a routine sonography and most often require no treatment. They shrink and dissolve on their own in the coming months, or may require some minor hormonal treatment.

PCOS (polycystic ovaries) is a special condition wherein the ovary is filled Polycystic ovaries

with multiple small immature follicles and thus the ovary appears cystic.

Please refer to article on PCOS for more details.  

 

 

 

 

Q. How do I know that I have an ovarian cyst?

Ultrasound is the best way to diagnose an ovarian cyst. It can also tell us whether the cyst is filled with clear fluid (simple cyst), blood (hemorrhagic cyst) or has solid material or septations (tumor).

 

USG simple cyst                hemorrhagic cyst USG

 

Ultrasound can also give some indications about whether the tumor is likely to be benign or cancerous.

Q. Do all ovarian cysts require surgery?

Not all ovarian cysts require surgery. Whether surgery is needed or not depends on the size and type of the cyst. Simple and hemorrhagic cysts may dissolve with time whereas a tumor needs to be removed surgically. Occasionally a very large simple cyst which does not resolve naturally over time, may have to be operated upon.

 A ‘chocolate cyst’ is a special type of hemorrhagic cyst which is found in a condition called ‘endometriosis’ (its management is discussed in the section on Endometriosis).Chocolate cyst

Q. What complications can happen with an ovarian cyst?

An ovarian cyst can cause the following complications:

  1. The cyst can get twisted (torsion) which can cause severe pain and inflammation and may damage the ovary.
  2. The cyst may rupture causing severe pain and internal bleeding.
  3. Hemorrhage in the cyst (bleeding into the cyst) causing severe pain.

Q. How do I know that my ovarian cyst is not cancerous?

Ultrasound (sonography) features can tell us a lot about the cyst. If the cyst is filled with clear fluid (simple cyst), it is almost certainly benign. A vast majority of the hemorrhagic cysts (blood filled cysts) are also benign.

Features suggestive of cancerous cyst are:

  • Solid areas/nodule or papillary(finger like) growths in a cyst
  • Thick septations in a cyst
  • Thick walls
  • Increased blood flow on doppler
  • Free fluid in the pelvis
  • Raised tumor markers in blood (e.g. CA-125. AFP, HCG, LDH)

Please note that these features are only suggestive of cancer. All tumors with one or more of these tumors are NOT cancer. In fact, only a small proportion of them are cancer, but all of them need to be operated upon to remove them and confirm the same.

Q. How do I confirm that the cyst is cancer or not?

MRI or CT Scan can give us a better understanding of the tumor features. If the tumor shows one or more of the above features, CT/MRI will tell us also tell us whether the tumor is infiltrating into the surrounding organs (uterus, pelvic wall, blood vessels, ureters or opposite ovary) and whether lymph nodes, liver, kidneys or spleen are involved, which may mean cancer.

If there is free fluid in the abdomen, your doctor may test the fluid which would confirm cancer.

Q. My CA-125 is 92, which is high. Does that mean I have cancer? Please help.

CA-125 is one of the tumor markers for a certain type of ovarian cancer (epithelial tumors). It is only indicative of cancer if very high. CA-125 may also be raised in pelvic infections, endometriosis, tuberculosis and peritonitis (inflammation of the peritoneum). Conversely, CA-125 may be quite normal in ovarian cancer too.

Q. Which surgery is best for ovarian cyst?

There are certain rules of thumb in the treatment of ovarian cysts.

  1. Simple cysts – Observation. Should disappear in three months. If does not shrink or disappear, or it grows, consider further evaluation (CT/MRI) or hormonal treatment. If the cyst is very large (more than 6 cm) or undergoes torsion (twisting), it may have to be operated upon.
  2. Hemorrhagic cysts – Observation. Should disappear in three months. If it does not shrink or disappear or it grows or is associated with painful periods, painful sex or pelvic pain, it may be a ‘chocolate cyst’. Please refer to the section on Endometriosis for management of chocolate cysts.
  3. Suspicious ovarian cysts – Cysts with features suggestive of malignancy should be removed at laparoscopy or open surgery.

If you are young (less than 40) and premenopausal, your gynaecologist may prefer to remove only the cyst and not the ovary. He/she would do a ‘frozen section’ (testing of the tumor in the operation theatre). If the tumor is benign, your ovary need not be removed. Some ovarian tumors have a tendency to recur and the gynaecologist may decide to remove the ovary also, after discussion with you.

On the other hand, if the verdict is cancer, it is better to remove your uterus and opposite ovary too along with sampling of lymph nodes and peritoneal fluid.

For all postmenopausal women with ovarian tumors, it is best to remove the uterus and opposite ovary at the same sitting.

Most gynaecologists today prefer the laparoscopic route of surgery due to its various advantages. But in cases strongly suspicious of cancer or confirmed cancer, open surgery may be preferable as it allows for better lymph node sampling and testing of the internal organs. However, today, there are a few experienced oncosurgeons who perform laparoscopic cancer surgery. But these are relatively few experts in the field.

 

 

 

 

 

 

 

 

 

 

 

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