Ovarian Cysts

Usually ovarian cysts are nonneoplastic sacs on an ovary that contain fluid or semisolid material. Although these cysts are usually small and produce no symptoms, they require thorough investigation as possible sites of malignant change.

Common ovarian cysts include follicular cysts, lutein cysts (granulosalutein [corpus luteum] and theca-lutein cysts), and polycystic (or sclerocystic) ovarian disease. Ovarian cysts can develop anytime between puberty and menopause, including during pregnancy. Granulosa-lutein cysts occur infrequently, usually during early pregnancy. The prognosis for nonneoplastic ovarian cysts is excellent.

There are also other types of cysts:

• Endometriomas. These cysts develop in women who have endometriosis, when tissue from the lining of the uterus grows outside of the uterus. The tissue may attach to the ovary and form a growth. These cysts can be painful during sexual intercourse and during menstruation.
• Cystadenomas. These cysts develop from cells on the outer surface of the ovary. They are often filled with a watery fluid or thick, sticky gel. They can become large and cause pain.
• Dermoid cysts. The cells in the ovary are able to make hair, teeth, and other growing tissues that become part of a forming ovarian cyst. These cysts can become large and cause pain.
• Polycystic ovaries. The eggs mature within the follicles, or sacs, but the sac doesn't break open to release the egg. The cycle repeats, follicles continue to grow inside the ovary, and cysts form.

Causes

Follicular cysts are generally very small and arise from follicles that overdistend instead of going through the atretic stage of the menstrual cycle. When such cystspersist into menopause, they secrete excessive amounts of estrogen in response to the hypersecretion of follicle-stimulating hormone and luteinizing hormone that normally occurs during menopause.

Granulosa-lutein cysts, which occur within the corpus luteum, are functional, nonneoplastic enlargements of the ovaries caused by excessive accumulation of blood during the hemorrhagic phase of the menstrual cycle.

Theca-lutein cysts are commonly bilateral and filled with clear, strawcolored fluid; they are often associated with hydatidiform mole, choriocarcinoma, or hormone therapy (with human chorionic gonadotropin [HCG] or clomiphene citrate).

Polycystic ovarian disease is part of the Stein-Leventhal syndrome and stems from endocrine abnormalities.

Signs and symptoms

Many women have ovarian cysts without having any symptoms. Sometimes, though, a cyst will cause these problems:

• pressure, fullness, or pain in the abdomen
• dull ache in the lower back and thighs
• problems passing urine completely
• pain during sexual intercourse
• weight gain
• painful menstrual periods and abnormal bleeding
• nausea or vomiting
• breast tenderness

The signs and symptoms that signal the need for immediate medical attention include:

• Sudden, severe abdominal or pelvic pain
• Pain accompanied by fever or vomiting

Diagnosis

Generally, characteristic clinical features suggest ovarian cysts. Visualization of the ovaries through ultrasound, laparoscopy, or surgery (often for another condition) confirms ovarian cysts.

Extremely elevated HCG titers strongly suggest thecalutein cysts.

In polycystic ovarian disease, physical examination demonstrates bilaterally enlarged polycystic ovaries. Tests reveal slightly elevated urinary 17 -ketosteroid levels and anovulation (shown by basal body temperature graphs and endometrial biopsy). Direct visualization must rule out paraovarian cysts of the broad ligament, salpingitis,
endometriosis, and neoplastic cysts.

Treatment

The type of cyst dictates the treatment method.

Follicular cysts

This type of cyst generally doesn't require treatment because it tends to disappear spontaneously within 60 days. However, if it interferes with daily activities, administration of oral clomiphene citrate for 5 days or I.M. progesterone (also for 5 days) reestablishes the ovarian hormonal cycle and induces ovulation. Oral contraceptives may also accelerate involution of functional cysts (including both types of lutein cysts and follicular cysts).

Granulosa-lutein and theca-lutein cysts

If granulosa-lutein cysts occur during pregnancy, treatment is symptomatic because they diminish during the third trimester and rarely require surgery. Theca-lutein cysts disappear spontaneously after elimination of the hydatidiform mole, destruction of chorio carcinoma, or discontinuation of HCG or clomiphene citrate therapy.

Polycystic ovarian disease

Treatment of polycystic ovarian disease may include the administration of such drugs as clomiphene citrate to induce ovulation, medroxyprogesterone acetate for 10 days of every month for the patient who doesn't want to become pregnant, or low-dose oral contraceptives for the patient who needs reliable contraception.

Surgery, in the form of laparoscopy or exploratory laparotomy with possible ovarian cystectomy or oophorectomy, may become necessary if an ovarian cyst is found to be persistent or suspicious.

Prevention

Although there's no definite way to prevent the growth of ovarian cysts, regular pelvic examinations are a way to help ensure that changes in your ovaries are diagnosed as early as possible. In addition, be alert to changes in your monthly cycle, including symptoms that may accompany menstruation that aren't typical for you or that persist over more than a few cycles. Be sure to talk with your doctor about any concerns relating to menstruation.