What is an Ovarian Cyst?

An ovarian cyst is an enlarged sac on the surface or within the ovary, which can contain fluid, blood products, endometriosis, or other contents.  Ovarian cysts are common, especially in pre-menopausal women.  Generally, they do not hurt or cause problems. Many people get them monthly as part of their menstrual cycle without ever realizing it.  Anyone with ovaries is susceptible to get an ovarian cyst and they usually go away on their own without treatment.  However, an ovarian cyst can be a problem when it does not go away, gets bigger, causes bleeding, or starts to hurt. There is also a slim (less than 1%) chance that an ovarian cyst is cancerous.

Symptoms of Ovarian Cysts

Many ovarian cysts don’t cause any noticeable symptoms. However, if a cyst gets large, infected, ruptures, or otherwise disrupts ovarian function, the result may cause lower abdominal or pelvic pain. The pain might be intermittent or constant and produce a feeling of fullness, pressure, swelling or discomfort, particularly during a menstrual cycle or sex.  Also common is feeling an increased need to urinate, even when the bladder isn’t full or sensing the inability to have a complete bowel movement.    In summary ovarian cysts symptoms include:

• pelvic pain 
• pain during sex
• difficulty emptying your bowels
• a frequent need to urinate
• heavy, irregular or lighter periods than normal
• bloating and a swollen stomach
• feeling full despite eating a little
• pain in the lower back or thighs
• weight gain or breasts tenderness

When does an Ovarian Cyst become a problem?

Ovarian cysts themselves aren’t inherently problematic and most are harmless going unnoticed. Occasionally, ovarian cysts can compromise health and necessitate treatment when the following situations occur:

Large Size: A tennis ball is about 6.5 cm in diameter and cysts usually exceeding 5-10 cm can lead to pelvic pressure and pain.  The weight and mass of the cyst can press on surrounding organs causing discomfort or pain in the lower abdomen. Large cysts might press on the bladder, causing frequent urination or difficulty emptying the bladder completely. Similarly, large cysts can press on the bowels, leading to constipation and a myriad of ‘bowel’ centered problems.

Cyst Rupture: Be it due to vigorous exercise, sexual intercourse, trauma, hormonal influences, blood thinners, or any of dozens of possible causes, a ruptured cyst can cause sudden and sharp pelvic pain, along with bleeding. In rare cases, this can lead to severe internal bleeding.   

Ovarian Torsion: An ovarian cyst can cause the ovary to twist on its supporting ligament, cutting off blood flow. This can cause severe pain, nausea, and vomiting and is a medical emergency requiring surgery to preserve the health of the ovary.   

Concerning Characteristics: While ovarian cysts typically disappear on their own within a few menstrual cycles, a cyst persisting for several cycles without going away might warrant further evaluation.  Regular ultrasound monitoring can be an effective way to track ovarian cysts and concerning characteristics like:

• Solid in appearances areas within the cyst raise concern for potential malignancy
• Thick or numerous divisions (septations) within the cyst may indicate a more complex growth.
• Irregular size, shape, or growths on the inside of the cyst or on its surface are worrisome.

While these features raise suspicion, they don’t automatically mean an ovarian cyst is cancerous.  If an ultrasound is concerning, additional imaging (MRI, CT) is often recommended.

What is the connection between Ovarian Cysts and Endometriosis?

Ovarian cysts and endometriosis can be related conditions but are not the same thing.  Ovarian cysts are solid or fluid-filled sacs that have developed on or inside the ovaries.  The most common types are classified as functional cysts which form during ovulation and usually disappear on their own. Other types of cyst are classified as non-functional and include endometrial cysts. 

Endometriosis is a disorder where tissue similar to the lining of the uterus (endometrium) grows in places where it doesn’t belong outside of the uterus.  Common locations include the ovaries and pelvic lining.  This misplaced tissue may respond to hormonal changes just like the uterine lining, causing inflammation, pain, and scar tissue formation.When this abnormal tissue implants itself on or inside an ovary, it can form a specific type of cyst called an endometrioma. Over time, this endometrioma bleeds and accumulates old blood, giving it a brown appearance, hence endometrioma have been given the nickname “chocolate cyst.”  Endometriomas are a threat to the health of the reproductive tract, can destroy healthy ovarian tissue and can burrow deep into the ovary. Large endometriomas can affect ovarian function and can contribute to infertility.  Endometriomas don’t respond well to medications and so while birth control pills, progestin-only options, or GnRH agonists can help manage the pain and prevent the formation of new endometrioma cysts, they won’t shrink or eliminate existing endometriomas.  While not all ovarian cysts are related to endometriosis the presence of an endometrioma indicates the presence of severe endometriosis.

Diagnosing of Ovarian Cysts

Ultrasound is the most common initial imaging for ovarian cysts and uses sound waves to create a detailed image of the pelvic organs, including the ovaries. Transvaginal or transabdominal ultrasound can reveal the size, location, and the internal structure or contents of an ovarian cyst.   

Next steps are determined based on the evaluation, imaging results, and specific situation. In some cases, further imaging might be used for a more detailed view of the cyst, especially if an ultrasound is inconclusive or when there is concern about potential malignancy. MRI has superior ability to differentiate between different types of cyst tissue and excels at identifying complex features, irregular growths, and plays a significant role should surgical pre-planning be required.

Oftentimes, small or otherwise uncomplicated cysts require no treatment and are simply monitored with follow-up ultrasounds to see if they resolve on their own.  For larger or persistent cysts with concerning features, treatment strategies are determined that may involve medication and/or surgery.  Early detection and monitoring can be important for mitigating the risk of ovarian cysts from affecting your health and wellness. 

Ovarian Cysts Treatment

Ovarian cyst treatment depends on the type, size, and symptoms of the cyst.  The most basic level of treatment for small, uncomplicated cysts is simple observation (regular monitoring) with ultrasound.  These cysts often disappear on their own within a few menstrual cycles and resolution can be confirmed with follow-up ultrasounds.

Hormonal medication, such as birth control pills, can be an effective strategy for those who do not desire immediate pregnancy and would like a non-invasive way of preventing future ovarian cysts. Birth control pills won’t shrink or eliminate existing cysts but they do suppress ovulation, which can help in preventing new cysts from forming and minimizing the risk of recurrence.  Birth control can also regulate menstrual cycles, potentially reducing hormonal imbalances that contribute to cyst development.  However, even with birth control, some women may still develop cysts.  

Surgery is often considered to treat an ovarian cyst if: 

• It is large or persistent (not going away on its own after several menstrual cycles), which can increase the risk of ovarian torsion
• It causes significant pain, pressure, bleeding, or bothersome symptoms 
• It is an endometrioma and the patient is facing fertility challenges
• It appears to be a mature teratoma (dermoid ovarian cyst), which has the risk of malignant transformation (or becoming cancerous later on)
• There is a concern about malignancy (cancer), particularly in postmenopausal women 

Laparoscopy is generally the preferred option for treating most ovarian cysts due to several advantages over traditional open surgery (laparotomy).  Laparoscopy is minimally invasive needing only a few small incisions in the abdomen instead of a large abdominal cut.  It all translates to the patient experiencing less postoperative pain and discomfort, shorter hospital and faster recovery, and smaller, less noticeable scars.  

A laparoscope, a thin lighted instrument, is inserted through a small incision in the abdomen. The surgeon views the ovaries on a screen and can remove the cyst with tiny instruments inserted through other small incisions.  When treating ovarian cysts in women desiring future pregnancy, minimally invasive approaches like laparoscopy are preferred to preserve ovarian tissue.

Ovarian Cysts & Fertility 

The impact of ovarian cysts on fertility depends on the type and size of the cyst.  Most cysts are temporary, don’t affect fertility and usually disappear on their own within a few menstrual cycles. Ovulation can still occur normally, and they don’t block the fallopian tubes or interfere with egg release or fertilization.

However large cysts can take up space in the pelvis, potentially hindering the movement of the egg or sperm. The sheer mass of the cyst might distort the pelvic anatomy, affecting the position of the ovary or fallopian tube.  When endometrial tissue implants itself on an ovary, it can form a specific type of cyst called an endometrioma which can lead to inflammation, pelvic anatomy distortion, scar tissue formation around the ovaries and fallopian tubes, which can disrupt fertilization. 

Polycystic Ovary Syndrome (PCOS)  is a hormonal disorder characterized by multiple small ovarian cysts, irregular periods, and sometimes excess male hormones. It can limit healthy ovulation leading to fertility difficulties.

Ruptured cyst or ovarian torsion (twisting that can cut off the blood supply) can damage ovarian tissue and potentially affect fertility, although the extent of the damage varies.  When treating ovarian cysts women desiring future pregnancy, minimally invasive approaches like laparoscopy is preferred to maximize ovarian tissue preservation.

Ovarian Cysts after Hysterectomy

It is possible for a person who has had a hysterectomy to develop ovarian cysts, if one or both ovaries have been left in place.  Hormonal fluctuations can still occur, which can lead to development of ovarian cysts.  Women who’ve had a hysterectomy prior to menopause along with women coping with endometriosis are more prone to experience ovarian cysts, even post-hysterectomy.  Many of these cysts are asymptomatic and discovered during regular pelvic exams or imaging.  However larger cysts might cause pelvic pain, pressure, bloating, or urinary changes.  

Also taking hormonal suppressants, such as birth control pills, prior to a hysterectomy may stop ovulation and decrease formation of cysts, but after a hysterectomy, cysts could recur if hormonal treatment is not resumed.  Lastly it’s worth noting there are rare disorders like:

Residual ovarian syndrome (ROS) which can occur after a hysterectomy in which one or both ovaries have been preserved and cause chronic pelvic pain and thus cyst development.  Ovarian Remnant Syndrome (ORS) where during surgical removal of one or both ovaries (oophorectomy) is incomplete and tiny fragments of ovarian tissue are left behind unintentionally. The tiny remnant tissue can grow, develop cysts, and continue producing hormones like estrogen.

Ovarian Cyst Rupture

Ovarian cysts may not always rupture, yet if they do, it can induce abrupt and intense pain. The increased size of larger cysts places more mass and stress on the cyst wall, making larger cyst more prone to tear. Moreover, complex cysts possess delicate walls, rendering them susceptible to rupture due to their multiple chambers, stress points, internal bleeding, solid components, and overall complexity.

Sudden pressure changes and activities with forceful twisting or jarring motions can stress the abdomen and potentially rupture a cyst.  Physical trauma such as a direct blow to the abdomen from an accident or fall or deep sexual penetration can sometimes lead to cyst rupture. Also, hormonal changes during the menstrual cycle and other medication changes (such as anticoagulant medications or blood thinners) may increase the risk of cyst rupture.

Signs and Symptoms of Cyst Rupture include:

• Sudden, Severe Pelvic Pain: This is the most common symptom and can be sharp, stabbing, or cramping.  
• Nausea and Vomiting: Often accompanying the severe pain.
• Vaginal Bleeding: May occur, but not always.
• Bloating: Feeling full or swollen in the abdomen.
• Dizziness or Lightheadedness: Can happen due to internal bleeding.