Ovarian cysts are found in nearly all pre-menopausal women, and up to 15 percent of those who are postmenopausal. What makes them occur, what is the chance that a cyst is or will become cancerous and how aggressively should it be treated? "Today" health contributor and gynecologist Dr. Judith Reichman was invited to appear on "Today" to share some insight on understanding the cystic nature of a woman’s pelvic area. She shares more on the subject here.
First, what is the difference between a cyst and a fibroid?
A cyst is a fluid-filled sac. Cysts found in the pelvis usually originate in the ovary, but may also develop within the fallopian tube. A fibroid is a solid smooth muscle growth that develops in the walls of the uterus.
Fibroids tend to grow in the later reproductive years and indeed are found in at least one-third of women over the age of 35. They are more common in women whose mothers or sisters have a history of fibroids, and in African American women. They can either grow into the wall of the uterus (intramural), project from the outer surface of the uterus (subserosal), or grow into the endometrial cavity (submusosal). Most women with fibroids have no symptoms. These benign tumors are often found during routine pelvic exam or ultrasound. They constitute a problem only if they become large (causing pressure on the bladder and rectum, and-or protruding abdominally) or cause excessive bleeding or pelvic pain. It may be difficult to differentiate a fibroid from an ovarian cyst or mass by pelvic exam alone, but pelvic ultrasound will definitively differentiate between the two.
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Although we are dealing chiefly with ovarian cysts, I want to address a common misconception. Non-symptom causing fibroids do not become cancerous and do not have to be removed “just in case.” Procedures for treatment of fibroids should only be contemplated if these benign uterine tumors cause significant problems.
Now, let’s consider ovarian cysts.
Most cysts that develop in women in the reproductive age are a function of their “working” ovaries. We start puberty with about 400,000 egg-producing follicles in our ovaries. Each month hundreds of these follicles attempt to develop, fail to do so and (sadly) die. Only one (rarely several) succeeds in it’s developmental effort and continues the process that allows it to produce a mature egg. It enlarges, produces estrogen and secretes fluid that surrounds the egg, then breaks open and releases the egg into the fallopian tube during ovulation. Once its egg is extruded, the follicle continues to function for the next two weeks as a corpus luteum secreting both estrogen and progesterone; hormones that prepare the uterine lining to receive and nourish a possible pregnancy. In the absence of a pregnancy, the corpus luteum collapses and disappears. Hence, each month that a woman ovulates, a small ovarian cyst is formed; this usually measures 1.5 to 2 centimeters. Subsequent to the release of the egg, this cyst or corpus luteum may collect a small amount of blood prior to its degeneration.
Now on to larger functional cysts… Prior to ovulation, the follicle may accumulate too much fluid and form a cyst that is greater than three centimeters. This can cause mid-cycle pain. After ovulation, a corpus luteum can bleed into itself and also enlarge, forming a hemorrhagic cyst. A woman may present to her physician with pain, or she may go in for a routine exam at which time an enlarged ovary or mass in the pelvis is detected. At this point, an ultrasound is usually done. Then comes the announcement: “you have an ovarian cyst.” And that’s where the concern (and unfortunately for many women, the panic) begins. (By the way, women who smoke have a two-fold increased risk of developing functional ovarian cysts compared to non-smoking women.)
So here is my reassuring gynecologic statement: Functional cysts rarely become larger than six centimeters and should resolve and dissolve after two to three cycles.
There are, of course, cysts that are not functional. They remain and continue to grow. Age is a factor for both symptoms and diagnosis. Blood-filled cysts in women of reproductive age may be due to endometriosis. This disease affects at least 10 percent of women. Endometrial-like cells that are normally part of the lining of the uterus attach themselves or develop on the wrong surfaces in the pelvis (the ovaries, pelvic wall, bladder, or intestines) and respond to hormonal cycling by expanding, bleeding, causing irritation and the formation of scar tissue. They can also collect to form a blood-filled cyst on the ovary (an endometrioma). Although this type of cyst can become quite large, the pain caused by endometriosis is not directly related to size of the lesions. Small implants of endometrial cells scattered in the pelvis (and not felt during exam or seen on ultrasound) may actually cause the worst pain.
Aren’t some ovarian cysts tumors?
Yes. But not all ovarian tumors are cancer. A tumor means a growth. There are several types of benign growths that can develop on the ovaries. Once more, the age at which the tumor occurs usually impacts the type of tumor or cyst that is most commonly found. Dermoid cysts (also called benign cystic teratoma) are the most common form of benign ovarian tumors in young women. These develop from germ cells which are primitive cells that are capable of producing eggs and all human tissues. A dermoid cyst is formed if the germ cells multiply bizarrely without fertilization, forming an encapsulated tumor that contains hair, sebaceous or oil materials, cartilage, bone, neural tissue and teeth. Dermoid cysts are most commonly diagnosed in women between the ages of 20 and 40. They range in size from one to 45 centimeters. Up to 15 percent of dermoid cysts occur on both ovaries. The good news is that 98 percent of these tumors are benign. Only on rare occasions do the overactive germ cells form malignant tumors ( malignant teratomas).
There are other types of cysts that arise from benign tumors and are more likely to occur in older women. They’re called cystadenomas. These arise from cells on the outer surface of the ovary that secrete a watery or jelly-like fluid. Cystadenomas can become quite large and cause pain. The most worrisome (and largest) are mucinous cystadenomas. They are filled with a sticky, thick, gelatinous material which can seed onto other pelvic and abdominal surfaces causing multiple growths and collections of mucinous fluid. These tend to recur and may ultimately be fatal.
What about the condition called polycystic ovarian syndrome (PCOS)? Doesn’t this cause the formation of many cysts?
PCOS is a complicated endocrine condition in which the follicles develop, but don’t normally erupt and extrude an egg. As a result, multiple small cysts remain under the ovary’s surface causing the ovary to become mildly enlarged. These polycystic ovaries appear “hole-ridden” on ultrasound. But contrary to the name, multiple large cysts, measuring more than two and a half centimeters rarely occur. The small cysts of PCOS do not cause pain.
Can other pelvic organs form cysts?
Fluid can accumulate in the fallopian tubes if they become blocked by infection. This condition is termed hyrdosalpinx. Blood collections and swelling of the tube can occur as a result of an ectopic pregnancy. Occasionally growths from the surface of the tube can fill with fluid and cause small cysts (paratubal cysts). All of these diagnoses have to be considered when pain occurs and a cyst is found.
What sort of symptoms are associated with cysts?
Most cysts don’t cause symptoms and are discovered on routine pelvic exam. However, cysts can cause intense pelvic pain if they rupture, twist, bleed, are pushed around (during intercourse or pelvic exam) or become large enough to press on adjacent structures. If the cyst undergoes torsion and twists or causes the ovary to twist, it can cause spasms of pain. Sudden or sharp pain may indicate that the cyst has ruptured. Either torsion or rupture of the cyst can also cause fever, vomiting, and even symptoms of shock.
How is a diagnosis made?
First, on pelvic exam, one or both of the ovaries will feel larger than normal and the exam may illicit unusual discomfort. Sometimes the doctor will feel that a mass fills the pelvis and she or he cannot tell whether it comes from the uterus, tubes or ovaries. Laboratory tests should follow, including a complete blood count (CBC) to check for infection or internal bleeding, a pregnancy test to detect a uterine or ectopic pregnancy. (An early, perfectly normal pregnancy can be associated with a functional ovarian cyst during the first trimester). And ultrasound should be done to “picture” the cyst. The echo pattern allows for assessment of the size of the cyst, whether it is filled with clear fluid or blood and will also detect the presence of internal solid elements. A special ultrasound measuring the flow of blood to and from the ovary and cyst (a Doppler study) may help in deciding if the cyst is actively growing and being fed by the vascular system. If the cyst is found to have solid elements, it’s also helpful to get an x-ray which can detect characteristic teeth, bone and/or cartilage in dermoid cysts. Finally, a CT scan or MRI can help determine whether the cyst is suspicious for malignancy or whether it’s pressing on or invading adjacent organs, lymph glands or blood vessels.
The words ovarian cyst inevitably cause fear of ovarian cancer. What tests can reassure the patient?
First, I have to emphasize: Most cysts are benign, especially those that occur during the reproductive years. The incidence of ovarian cancer begins to increase after menopause. If there is no significant family history of ovarian cancer or combinations of certain cancers, such as breast, colon, and prostate cancer, you don’t have a known genetic risk, and if you are younger than 50, you should be reassured. If the cyst appears on ultrasound to be filled with clear fluid ( a simple cyst), it’s less than six centimeters in diameter and you’re not in pain, a wait-and-see approach over the next three months is appropriate. Know that 90 percent of simple cysts are functional and will disappear after five weeks. Your doctor may repeat the ultrasound to make sure the cyst is gone. If, however, you are over the age of 50 and/or the cyst has solid elements and appears complex (with internal walls), further workup is usually done. This includes a blood test for the protein CA125, which may be produced by an ovarian cancer. However, this test is not foolproof. About 50 percent of early ovarian cancers don’t produce detectable amounts of CA125. And non-cancerous diseases such as uterine fibroids and endometriosis can cause mild elevations in the level of the CA125 protein.
The final diagnosis, especially if the cyst looks suspicious, may have to be surgical via a laparoscopic procedure. The cyst (and sometimes the ovary) will be removed and examined. In women who are menopausal, both ovaries are usually excised in order to prevent recurrences and/or reduce the future risk of ovarian cancer. If the doctor has a very high suspicion of cancer, a laparotomy (an abdominal incision) may be indicated. And if ovarian cancer is found, the surgery usually includes hysterectomy, removal of both ovaries, tubes, adjacent lymph glands and an excision of all visible cancer. This should be scheduled at surgical centers where a specialist in gynecologic cancer surgeries (a gynecologic oncologist) can be present.
Can ovarian cysts be prevented?
Birth control pills can decrease development of functional cysts and may also help issues related to endometriosis. Since ovarian cancer seems, to some extent, to be correlated with “incessant ovulation”, birth control pills (which stop ovulation) have been shown to decrease the risk of ovarian cancer by 40 percent if used for over two years and 80 percent if used for more than 10 years.
Dr. Reichman's bottom line: Don’t panic if your doctor tells you that you have an ovarian cyst. Chances are it is benign. The proper workup is essential and will often allow you to safely wait, followup and avoid unnecessary surgical intervention.
Dr. Judith Reichman, the “Today” show's medical contributor on women's health, has practiced obstetrics and gynecology for more than 20 years. You will find many answers to your questions in her latest book, "Slow Your Clock Down: The Complete Guide to a Healthy, Younger You," which is now available in paperback. It is published by William Morrow, a division of HarperCollins.
PLEASE NOTE: The information in this column should not be construed as providing specific medical advice, but rather to offer readers information to better understand their lives and health. It is not intended to provide an alternative to professional treatment or to replace the services of a physician.