Ovarian Cysts and Ovarian Cancer

It is a natural function of the ovaries to produce ovarian cysts. Benign cysts are routinely produced by the ovaries during the menstrual cycle in women who are premenopausal and frequently by women who are menopausal.

The ovaries are the female gonads, and the testes are the male gonads. They regulate certain functions in every cell of your body and are vital to your health and wellbeing all of your life. There is no age or time in a woman’s life when the uterus and ovaries are no longer needed.

Like a person’s height or the size of their hands and feet, the size of the ovaries varies and is usually familial, a family trait. The ovaries are largest in girls in their teens, and they begin to decrease in size a few years before menopause. In menstruating women they vary in size from about 1 cm to 6 cm.

Knowing the features that are typical of ovarian cysts will enable you to distinguish between common and uncommon cysts. It will also help you determine the diagnostic tests needed to obtain a probable diagnosis. When you have the information you need, you can choose the most conservative treatment option for the type of cyst you have, which may be no treatment at all.

An ovarian cyst is a closed sac that can encapsulate the ovary (the ovary is inside the cyst) or, more commonly, it can be encapsulated within it (the cyst is inside of the ovary). There are many different types of benign ovarian cysts that may develop around or within an ovary. They may contain fluid, an ovum (egg), or other material, depending on what type of cyst it is.

A majority of ovarian cysts are benign. Ovarian cancer is rare, listed as a “rare disease” by the Office of Rare Diseases at the National Institutes of Health. Approximately 1.3 out of every 10,000 women is diagnosed with ovarian cancer each year.

Physiologic cysts, also called follicular cysts, are benign functional cysts that contain follicles. They develop naturally during the menstrual cycle. Post-menopausal ovarian cysts are also usually benign functional cysts, but they do not contain follicles.

Girls are born with over a million ovarian follicles. Each follicle contains an ovum. At ovulation one of the ovaries develops a mature ovum within its follicle and releases it. From puberty to menopause, the ovaries take turns developing a mature ovum each month, one month in the right ovary, the next month in the left ovary.

As the ovum matures, the ovarian wall thins in the area of the follicle containing the mature ovum. This is the stigma, which ruptures and creates a tiny opening in the ovarian wall, allowing the ovum to pass through and enter the fallopian tube where fertilization may take place.

Sometimes the ovum is not released or the rupture does not disappear right away. When this happens it is common for a cyst to develop around the ovum or at the point of the rupture. These functional, follicular cysts, also called physiologic cysts, Graafian follicle cysts, or corpus luteum cysts, usually disappear within the next few menstrual cycles.

Most ovarian cysts are asymptomatic (they do not cause symptoms), although some large cysts may cause pelvic pressure. Ovarian cysts are most often found incidentally during a routine pelvic exam.

Some gynecologists seem concerned when an ovarian cyst grows even slightly. This should not be a cause for alarm. Ovarian cysts tend to wax and wane, becoming larger before menstruation and smaller after menstruation.

Certain benign ovarian cysts appear to have one or more of the characteristics associated with possible cancer. Such cysts are referred to as borderline. Borderline ovarian cysts have a low malignant potential. The prognosis—the projected outcome—is generally good.

If you are concerned about whether a borderline ovarian cyst remains benign or has become malignant, a cystectomy can be performed. In a cystectomy only the cyst is removed, without removing the ovary. It is preferable to find a surgeon who has performed many cystectomies with consistently good outcomes. Not every surgeon has the skill to perform cystectomies with consistently good outcomes. The following questions and the answers you should expect from a gynecologist will help you evaluate the doctor’s skill:

Q. Are you board certified in gynecology?
A. If the answer is no, ask them if they ever took their OB/GYN boards. If they have practiced for more than three or four years and have not taken their boards, you might want to find another doctor.

Q. How many cystectomies have you performed?
A. A minimum of 30 should give you some idea of their competence performing this surgery.

Q. How many procedures that started out as a cystectomy turned into removal of one or both ovaries?
A. If it is more than two or three out of 30 that is too many.

Q. How often did a cystectomy turn into a hysterectomy and removal of the ovaries?
A. One is too many.

Ovaries are very resilient. They can be cut into pieces, a cyst removed, and the pieces of the ovary sutured back together. Afterwards, the ovary usually continues to function normally.

The features of a benign or malignant ovarian cyst can often be seen with an ultrasound. Ovarian cysts with all of the features of ovarian cancer warrant the recommendation of removal of the cyst to definitively determine if it is benign or malignant. A solid ovarian cyst with papillary projections and a significant amount of free fluid in the pelvis (called ascites, pronounced uh-sight-ez) has a higher probability of being malignant. Ovarian cysts that do not have two of the three features of malignant cysts (solid, papillary projections, and ascites) have a probability of being benign. If an ovarian cyst has all of the features of a malignant growth, you know there is a greater probability that it is cancer.

Another test to determine if a cyst is benign is a color-flow Doppler of the blood supply to both ovaries. A color-flow Doppler is a test similar to an ultrasound in the way that it is performed and in the way you experience it. It measures the resistive index. When the resistive index is normal in both ovaries, you know that there is a high probability that the cyst is benign. It is important that the blood flow to both ovaries is measured, not only the ovary with the cyst. There is no IV or contrast material needed when a color flow Doppler is performed.

Other common benign ovarian cysts include hemorrhagic, endometrioma, and dermoid cysts.

Hemorrhagic cysts are benign ovarian cysts that contain blood.

Endometriomas are chocolate cysts that are benign. They are called chocolate cysts because they contain blood and endometrial tissue that looks like dark chocolate. These cysts often occur without the presence of endometriosis elsewhere in the pelvis. Endometriomas tend to grow bilaterally, on both ovaries, but they can also develop unilaterally, on one ovary.

Endometriomas may develop around the ovary and encapsulate it, or they may occur inside the ovary, with the ovary encapsulating the endometrioma. Unlike functional cysts, endometriomas do not wax and wane—they do not get larger and smaller with the menstrual cycle. Over a period of months or years, endometriomas may stay the same size, or they may grow. It is not unusual for endometriomas to grow to 18cm-20cm (7-8 inches).

Because they do not often cause symptoms, endometriomas are usually discovered incidentally during a routine pelvic exam. If they become large and cause an annoying symptom like pelvic pressure, endometriomas can be removed with a cystectomy. If a gynecologist says it cannot be done because the cyst is too large, you may want to look for a doctor who has the skill to perform a cystectomy and has consistently good outcomes. See the Q&A above to help you evaluate a doctor’s skill at performing cystectomy

Dermoid cysts, also called cystic teratomas, are benign primordial cysts that contain hair, teeth, or fat, but they are not a cause for concern. Like endometriomas, dermoids tend to grow bilaterally, on both ovaries, but they can also develop unilaterally, on one ovary.

Similar to endometriomas in the way they grow, dermoid cysts may develop around the ovary and encapsulate it, or they may occur inside the ovary. They may stay the same size for months or yours, or they may grow. Like endometriomas, some dermoids grow to 18cm-20 cm.

Dermoid cysts generally do not cause symptoms and are usually an incidental finding during a routine pelvic exam.

Gynecologists often tell women that dermoid cysts cannot be removed without removing the ovary. This recommendation begins with the presumption that the development of cysts requires action. Although they can become quite large, dermoid cysts are benign and may never cause symptoms. If they do not bother you, there is no reason to bother them.

Endometriomas and dermoid cysts will usually only rupture if there is a severe blow to the pelvis. It is unlikely that they will rupture spontaneously. If they do rupture, surgery is performed to flush the pelvis with a saline solution (distilled water containing salt), to irrigate and wash away the contents of the cyst.

Functional cysts generally occur during ovulation and resolve after menstruation. Occasionally these cysts do not resolve after menstruation and may grow to be fairly large. Because they are fluid-filled and do not contain blood or solid matter, the fluid can be removed with a thin needle aspiration. After application of a local numbing agent, a long, thin needle is inserted into the pelvis and then into the cyst, allowing the fluid to be drawn out of the cyst and into the syringe. The syringe is then removed from the pelvis and the fluid is sent to a cytology laboratory to determine exactly what type of fluid was found. You can obtain the Cytology Report from the doctor who performed the aspiration.

There are some dietary factors that may cause cysts to grow. A diet high in soy, for example, can stimulate the production of excess estrogens, which may cause cysts to grow. Environmental factors may also cause the development and growth of some types of cysts. The consumption of endocrine disruptors like bisphenol-A (BPA is found in many plastics) may stimulate abnormally high estrogen levels and cause cysts other than typical functional cysts to develop.

Some women are prone to developing dermoid or endometrioma cysts and may never know they have them. They may experience no symptoms at all, while others may feel pelvic pressure that is more of an annoyance than a problem. If the cyst is removed, new cysts may form in several months or years. If this occurs doctors often recommend removal of the ovaries and hysterectomy, because “you can’t just keep having surgeries.” In the event of significant symptoms, a cystectomy, which preserves the important functions of the ovaries, can be performed.

Multiple cystectomies may be preferable to the lifelong problems women experience after hysterectomy and oophorectomy.

Occasionally there is torsion (twisting) of the blood supply to an ovary, with or without the presence of an ovarian cyst. It is quite painful, and often results in a visit to a hospital emergency room for acute pain. A diagnostic laparoscopy is usually suggested to evaluate the cause of the pain. If treated early enough, the surgeon can untwist the blood supply to the ovary. The pain will go away and the ovary will function normally. If a significant amount of time passes before treatment, the ovary may become necrotic (the tissue will die) from being deprived of blood flow, and the ovary will not be able to be saved.

When women sign a surgical consent form for a diagnostic surgery such as a laparoscopy or laparotomy, if the form says “exploratory laparoscopy and possible total abdominal hysterectomy and bilateral salpingo oophorectomy, TAH/BSO” or “laparoscopic assisted vaginal hysterectomy and bilateral salpingo oophorectomy, LAVH/BSO,” the caveat “possible” on the consent form gives the surgeon permission to perform a hysterectomy and oophorectomy. When women question why “possible TAH/BSO” is on the consent form, they are usually reassured that the doctor will only remove their uterus or ovaries if cancer is found. Sometimes they are told “the hospital requires the consent form to say possible, but it means nothing—no organs will be removed.” Regardless of what you are told, you do not need to sign the consent form until you have modified it to reflect your understanding of what will, and will not, be removed from your body.

An alarming number of women who go into an operating room for exploratory surgery come out without their uterus and/or ovaries. When they seek legal remedy with a medical malpractice lawyer, they are shocked to discover that the word “possible” on the consent form gave the gynecologist carte blanche (permission) to remove their female organs. It is construed in the law as consent, regardless of what you were told by a doctor or nurse, or what you believed to be true when you signed it. The written consent will prevail, not what you say you were told.

You can modify a consent form by crossing out anything that is not true, and anything you do not agree with. You can cross out “possible TAH/BSO” or “LAVH/BSO” and write in, “I consent to diagnostic laparoscopy, possible untwisting of the ovarian blood supply, and possible cystectomy only. I do not consent to removal of any tissue other than ovarian cysts from my body.” Both you and the gynecologist should initial and date any changes you make to the consent form. If a doctor refuses to go ahead with the surgery because you modified the consent form to make it accurate, it is time to find another doctor.

Polycystic Ovarian Syndrome (PCOS), also called Stein-Leventhal Syndrome, is usually diagnosed when there are about 15 or more cysts on or in an ovary. Although PCOS is benign and the cysts are functional, they do not completely resolve after menstrual cycles.

Because these fluid-filled cysts contain a high level of hormones, particularly androgens, PCOS causes excess facial hair, heavy growth of body hair, and thinning scalp hair in a male pattern at the top front and the crown. A hallmark symptom of PCOS is a heavy vertical line of hair from the navel to the pubic bone.

The elevated levels of hormones associated with PCOS can play havoc with menstruation and mood. Diabetes, and the more difficult to control insulin-resistant diabetes, is more common among women who have PCOS. Many women find weight management and excessive facial and body hair among the biggest challenges of coping with PCOS.

PCOS can be evaluated with a pelvic and transvaginal ultrasound. It is diagnosed in about 5-10% of women of childbearing age. PCOS may be familial.

Acupuncture is often helpful when there is an endocrine imbalance, especially if it is hormonal. Although it will not cure PCOS, it may help mediate some of the symptoms. Hormone agonists, drugs such as Lupron that block the production of hormones, are the most common treatment, but they may cause endocrine problems and other serious health issues, such as brittle bones.

The ovaries are important glands that have critical functions in the endocrine system. The endocrine system works in harmony to release hormones and other substsances into the bloodstream in the quantity that is needed, at the time it is needed, to regulate important functions throughout your body. The harmonious balance achieved by the endocrine system cannot be replicated or replaced by drugs.

The principal source of hormones is the ovaries. The uterus is hormone responsive, and it produces substances that are also vital to health and wellbeing. The many hormones and other substances produced by the uterus and ovaries are self-regulated in a way that hormone creams, pills, patches, and injections cannot duplicate.

Different types and quantites of estrogens, progestins, and other hormones are constantly in flux and secreted by the endocrine glands as needed. Hormones are released directly into the bloodstream to regulate various functions such as metabolism, stamina, energy, reproduction, the ability to build and maintain muscle, and the growth and maintenance of hair, nails, skin, and other tissue. They help to maintain weight, strong bones and teeth, and they provide protection against heart disease, osteoporosis, dementia, dry skin, dry eyes, and joint and muscle pain.

The loss of the functions of the female gonads, the ovaries, is castration. When the ovaries are removed it is surgical castration. When it is drug induced or the ovaries are damaged during surgery it is de facto castration. Regardless of how or why ovarian function is lost, the consequences are far-reaching and life-altering.

Although doctors often appear alarmed by the presence of ovarian cysts, there is no reason to remove them unless they cause significant symptoms. If an ultrasound shows that an ovary or cyst is solid rather than fluid-filled, with nodules or papillary projections and/or a significant amount of free fluid in the pelvis, further diagnostic testing is warranted. A cystectomy or biopsy of the cyst or ovary will help determine the type of cyst it is.

The female organs have many important lifelong functions. The most consistent problems women experience after hysterectomy, with or without oophorectomy, include a 25-pound average weight gain in the first year following the surgery, a loss of sexual feeling, a loss of vitality, joint pain, back pain, profound fatigue, and personality change.

For more information, watch the short video “Female Anatomy: the Functions of the Female Organs.”