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Ovarian Cysts

Ovarian cysts are common, frequently asymptomatic and often resolve spontaneously. Ovarian cysts are found either during the course of investigation of abdominal pain or as a result of performing scans for other reasons.

As pelvic ultrasound, and particularly transvaginal scanning, is now used more frequently, physiological cysts are detected more often. The normal egg produced in teh first half of the menstrual cycle is called a follicle and is about 18mm 20mm in size. The corpus luteumis the natural cyst that develops post –ovulation andmay persist and continue to secrete progesterone beyond its natural lifespan and thus cause some menstrual irregularity, or haemorrhage may occur in to the cyst at or just after ovulation.

Most good radiologists will recognise the features of a follicle, corpus luteum or haemorrhagic cyst and will report these as such. Most simple cysts will resolve spontaneously over a period of 6 months. Occasionally they can persist for longer or grow in size to become a clinical problem. Physiological cysts should simply be regarded as large versions of the cysts which form in the ovary during the normal ovarian cycle.

Failure of development of the lead follicle results in lack of ovulation and is a classical finding in polycystic ovaries (PCO). The latter is predominantly an endocrine abnormality and will be dealt with elsewhere suffice to say that PCOs do not cause abdominal pain.

Clinical presentation of symptomatic ovarian cysts

Presentation of ovarian cysts is as follows:
  • Pain - acute and chronic
  • Abdominal swelling, bloating and pressure effects
  • Menstrual disturbances and hormonal effects

Pain

Acute Onset Pain: For a woman to present with acute onset abdominal pain in the presence of an ovarian cyst suggests a cyst accident such as torsion, rupture or haemorrhage. Torsion usually gives rise to an acute onset sharp, constant pain. Haemorrhage may occur into the cyst and cause pain as the capsule is stretched. Rupture of the cyst causes severe pain and may result in collapse as bleeding occur in to the peritoneal cavity (tummy).

If it is possible to obtain emergency ultrasound imaging then this would be beneficial but surgery should not be delayed whilst waiting for tests which would not necessarily affect the management.

Acute on chronic pain: Pelvic inflammatory disease may give rise to a mass of adherent bowel. In such circumstances the pain will be gradual in onset rather than acute. If there is a diagnostic dilemma, a laparoscopy normally resolves the problem.

Abdominal Swelling, bloating and pressure effects

Patients seldom note abdominal swelling until the cyst is very large whilst bloating of which women complain so often is rarely due to an ovarian cyst. Sometimes, uterine prolapse is the presenting complaint in a woman with an ovarian cyst.

Hormonal effects

Occasionally the patient will complain of menstrual disturbances but this may be coincidence rather than due to the cyst.

Investigation and management

Apart from a full history and clinical examination your doctor may order some extra tests. As a minimum an ultrasound scan is usually undertaken as this gives the doctor important information regarding the nature of your cyst. In addition, a blood test called a tumour marker will be measured. This is called a Ca 125. Benign conditions that cause an elevation are endometriosis and infection. Ca 125 is raised in 80% of ovarian cancers.  Other tumour markers may be useful in certain circumstances. The management will depend upon the severity of the symptoms; the size and ultrasound characteristics of the cyst; the CA125 results; the age of the patient and therefore the risk of malignancy; and her desire for further children.

Ultrasound-guided diagnostic ovarian cyst aspiration

This investigation has been introduced gradually into gynaecological without the benefit of its use. Currently, cyst aspiration is not recommended in ovarian cyst assessment or management.

Types of cysts

A normal follicular cyst up to 3 cm in diameter requires no further investigation. A simple cyst < 8cm with a normal CA 125 should have a repeat ultrasound in 3 – 6 months. If the cysts persist or grows then laparoscopic removal is advised.

If the cyst is thought to be an endometrioma (a cyst filled with old blood often called a “chocolate cyst”) should be removed either through the telescope or as a cur in the tummy. Your surgeon should discuss with you what they advise and why.

Another common cyst is called a teratoma or “Dermoid” cyst. These are unusual as they may contain teeth and hair. They are found on both ovaries around 10% of the time and can recur. These have to be removed as they do not resolve. There is a small chance that they might be cancer and thus tumour markers called AFP and HCG will be taken. The surgeon will discuss the results with you.

Ovarian Cancer

Luckily this is rare. Clues that your cyst may be cancer are:
  • What is looks like on ultrasound scan
  • The tumour marker level
  • Your personal and family history
  • What the doctor finds on clinical examination

The tests can predict the presence of cancer 75 – 80 % of the time. If cancer is suspected you may be advised to have your womb, tubes, ovaries and a bit of fat around the gut called omentum. Only certain doctors are allowed to operate on suspected ovarian cancer as they get the best results in term of survival from cancer and therefore you may be referred to an expert in cancer surgery called a Gynaecological Oncologist. If you have any questions your doctor will happily answer them for you

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