Ovary Cysts: Frequently Asked Questions

• Small cyst causing a lot of pain
• Are complex ovarian cysts the same as polycystic ovarian disease?
• What alternatives to fertility drugs and OCPs to treat polycystic ovaries?
• Complex cyst on ultrasound
• How to prevent recurrent ovarian cysts
• Possibly cancerous mass after ruptured appendix
• Will dermoid removal affect getting pregnant?
• Following a postmenopausal ovarian cyst with ultrasound
• What is a Ca-125 test?
  

Small cyst causing a lot of pain

I had a CT scan showing a ovarian cyst. The size of the cyst is 1.7 mm (about the size of a penny). The pain began 6 months ago, as a sharp pain that literally doubled me over. My period began the next day, and the pain continued so I went to the Dr. and he treated me for kidney stones (There was a trace amount of blood in my urine). An ultrasound was done in 5 months ago, and nothing showed on it. On a pelvic exam, he said he could feel "something", but he didn't know or say what,other than a "tender spot".

Two months ago I changed Drs. Her initial course of treatment was the same (kidney stones). The CT scan was done 2 months ago and a pelvic ultrasound done again last month, after my period. The cyst was still there, but the pelvic mass had disappeared. I was given a pregnancy test, which was negative. I had a tubal ligation 9 years ago, so that was good news to me! What I am wondering is could the cyst have been there from the beginning, only too small to show on ultrasound? I've had a feeling that endometriosis could be a possible cause for all this, and from what I understand, the only way to verify it is through surgery (it doesn't show on any other types of tests). Something I am also curious about...why do some women get grapefruit size cysts with no problems, and I'm experiencing a lot of pain with mine? The Xanax is working, sort of. I can't take it during the day, because it affects my driving. At least I'm getting some sleep now. The Dr. also started me on BC pills.

There are several possibilities here. Usually a 1.7 cm cystic area in the ovary is NOT an ovarian cyst. It is a follicle of the ovary (egg to be ovulated) or a corpus luteum cyst (gland formed after the egg was ovulated). Both of these are physiologic changes that should be watched because they almost always change, go away, and return in later ovulatory cycles. Almost any reproductive age woman will have findings like that (1.7 cm cystic area) but they do not generally have pain.

We are then left with a couple of choices. The cystic area can just be coincidental and not the cause of the pain or it may still be causing the pain. Endometriosis is still a possibility and an endometrioma of the ovary would give pain even though small because the bleeding in it causes irritation. Having had a tubal ligation 9 years ago is somewhat against endometriosis because most endometriosis is due to retrograde menstrual flow (not all cases) in which endometrium goes out the tubes instead of out the vagina. The tubal prevents that.

Another possibility is that the cystic area is not really in the ovary but actually closely adjacent to it in the tube or next to the tube (paratubal cyst). These can sometimes give pain if they twist or swell.

A this point, it sounds as if your doctor is trying to suppress ovulation and follicle cyst formation in the ovary using the birth control pills. If that cystic area goes away or gets smaller at the next ultrasound but you are still having pain, that would indicate that the ovary is not the problem. In any case, if the pain keeps up, you may need a laparoscopic evaluation, assuming this is not a kidney problem which it sounds as though they don't think it is any more. Why some women have little pain with large cysts and some have a lot of pain with little cysts is a mystery. Sometimes it has to do with the rate of distension of the peritoneal (skin) lining around the ovary. If it is enlarged rather quickly, there is more pain than if it is slowly enlarged. Many large cysts get that way over months and don't hurt as much. A small cyst that twists and swells acutely may have severe pain just like a kidney stone.

Are complex ovarian cysts the same as polycystic ovarian disease?

Are complex ovarian cysts the same as polycystic ovarian disease?

Complex ovarian cysts are not the same as polycystic ovarian disease (PCOD). The ultrasonic appearance of PCOD is multiple follicle (clear,simple) cysts usually arranged at the periphery of the ovary. Characteristically there will be more than 4-6 small cystic areas. Complex cysts are more poorly defined. On ultrasound reports it usually refers to areas seen that contain cysts but they are not clear and often they are not distinct. They are different from mixed cystic and solid cysts however in which the anatomy is clearer but of mixed consistency. Complex cysts are often hemorrhagic corpus luteum cysts or follicle cysts with bleeding in them, inflammatory processes such as pelvic infection, endometriosis of ovary and occasionally dermoid cysts or other benign tumors of the ovary. As a result they are often associated with pain and abnormal menses if the former and are asymptomatic if they are benign tumors of the ovary.

This is to be distinguished from mixed cystic and solid tumors which are more worrisome and may represent malignancy. Usually they are not as symptomatic and don't affect menses unless they are fairly large.

What alternatives to fertility drugs and OCPs to treat polycystic ovaries?

I am 24 yrs old and have just been diagnosed with polycystic ovaries (PCOD). I want to treat my PCOD and do not want to take fertility drugs or birth control pills. I know that reducing my weight will help, but what other treatments are available?

Weight reduction is the single best way to improve ovulation with polycystic ovaries. Progestins alone (eg., Provera®) for the last part of the cycle also sometimes helps ovulation. It seems to decrease some of the high LH values.

Complex cyst on ultrasound

I wrote recently about prolapse and pregnancy. I went to my obgyn yesterday just for a consultation about surgery to repair the prolapse. We talked briefly and then he examined me. During this he felt a mass. He immediately did an ultrasound. He found a cyst on my left ovary. He said he wasn't sure what type it was. It had separate pockets within it and he told me he did know that it was a complex cyst, not a functional cyst. Then he ordered blood work, and told me to come back in one week he would know more. Dumpy me being so shocked at the time that I had my first cyst, I never asked him if the blood work will show what type it is so we can treat it. I do not want to play the waiting game. I want it out. So first of all will the blood work show us more about the type of cyst it is?

He probably obtained what are collectively known as tumor (cancer) markers. These blood tests are abnormal in certain types of cancer. The most common ovarian marker used is a CA-125. A complex cyst does not necessarily mean cancer as it could just as easily represent bleeding into a corpus luteum cyst or an endometrioma. In fact, under age 40 these complex cysts are usually benign.

And second knowing it will not go away on its own will he do something soon?

Here is a list from Clinical Gynecologic Oncology by DiSaia (a leader in his field) on adnexal masses: indications for surgery.

1. Ovarian cystic structure >5 cm that has been followed 6-8 weeks without regression
2. Any solid ovarian lesion
3. Any ovarian lesion with papillary vegetation on the cyst wall
4. Any adnexal mass greater than 10 cm in diameter
5. Ascites (fluid in the abdominal/pelvic cavity)
6. Palpable adnexal mass in a premenarchal or postmenopausal patient
7. Torsion or rupture suspected

Since you are going to have surgery anyway, the cyst can be evaluated at the time. If because of your age the ovaries are going to be left in, then the doctor may just do a cystectomy. If the ovaries are going to be removed anyway (age over 40-45) then knowing and being prepared for a small chance of malignancy is better.

How to prevent recurrent ovarian cysts

I just had a laparoscopy for an ovarian cystectomy three days ago. My cysts were monitored over 6 weeks and were enlarging and were approximately 7x6cm combined the day of surgery. This was my second laparoscopy; I had my first one two years ago for the exact same reason. The cysts caused minimal pain and I am recovering quickly from the surgery. If anyone wants to know about laparoscopy from a patient's perspective, let me know... Here is my question.. Can I avoid all this trouble by going on the pill? And how long would I need to be on it? Forever? I am twenty-two years old.

Recurrent ovarian cysts are thought to be due to abnormal follicle development which is part of the process that results in ovulation each month. Birth control pills may block ovulation but be sure you are prescribed ones that are strong enough to block ovulation. Some of the low dose ones and some of the triphasic pills tend not to block ovulation.

There is no answer that I know of as to how long to stay on pills. It may be that you can take them for a couple of years and then stop and the problem doesn't recur. On the other hand sometimes women have a cyst forming tendency for many years.

My doctor said my cysts were mucosa cysts and she isn't sure if the pill would help. Do you know why she might think that?

I'm not familiar with the term, mucosa cysts. If by that she means mucinous cysts (pseudomucinous cystadenoma) or epithelial cysts (serous cystadenoma) then birth control pills will not stop those from forming. They only work on ovulatory or follicular cysts.

Possibly cancerous mass after ruptured appendix

I'll try to give you a brief history to bring you up to date. Seven years ago, I had laparoscopic surgery for endometriosis. Very little was found but I had massive adhesions. The endometriosis and adhesions were removed. Two weeks later I had surgery again because adhesions had quickly grown back and were attaching to my bowel and causing great pain.

Six years ago, I had a ruptured abdominal ectopic pregnancy on the right side with no actual damage found. No endometriosis or adhesions were found.

Four years ago, I had a full term pregnancy and live birth. Last year, I had a second ectopic pregnancy. This time it was at the tip of my right fallopian tube. The doctor removed a small portion of the tube and massive endometriosis. I was later told at that stage of a pregnancy it isn't abnormal to find a lot of endometriosis if you have been known to have it. Because of the two ectopics I am now seeing a fertility specialist.

Six months ago, I woke with a pain in my abdomen that got progressively worse. I went to the ER and they misdiagnosed it as a ruptured ovarian cyst and sent me home. It was actually my appendix and it ruptured while I was at the ER. I was very sick over the next day but the actual pain from peritonitis didn't set in until the following night. The ER properly diagnosed it this time and I had surgery for it. During the surgery a cyst on each ovary was seen but neither had ruptured. The peritonitis was severe and I was in the hospital on two IV antibiotics for 8 days and had to continue on antibiotics for 3 weeks following to clear up the infection.

Over the next 8 weeks of packing the open incision and seeing the nurse practioner to check it, I complained that my abdomen was still quite sore, distended and I was having pain with stomach and bowel function. I was told it was normal.

Three months ago, the fertility specialist wanted to do a sonogram to check for the cysts that the surgeon had found during the surgery. He said he could see curtains of scar tissue with fluids trapped in it above my uterus ~ inflammatory cysts. He located my right ovary and said he also thought he could see my left ovary and tube suspended above my uterus in the scar tissue. He wasn't able to identify any ovarian cysts at the time. He recommended I see a gastroenterologist. Thinking the scar tissue may be causing my abdominal pain. The gastroenterologist requested I have a CT scan done and it was on 4/28. The upper abdominal came back fine but they found a mass in the pelvic exam. This was the finding:

This is where I get confused. The gastroenterologist met with the head of radiology, reviewed the films and they thought it was my ovary and could be cancer. The gastroenterologist sent me back to my fertility specialist for surgery. The fertility specialist read the report and said he didn't think it was my ovary . . . even though he had just told me he thought he saw it there. He did say "if" it was my ovary that it could be endometriosis that has caused the condition. He sent me back to the surgeon that did my appendectomy. The surgeon felt positive it's a cystic mass from the peritonitis and not my ovary. He wanted to do a CT guided aspiration of it. The surgeon met with a group of radiologists at the hospital to review my films and discuss the procedure. They refused to do it stating they thought it was my ovary and could be cancer. They decided to do another sonogram to see if they could better decide what the mass was. They weren't able to identify it any better and recommended surgery to remove it intact.

At that point the surgeon decided it would be best if I saw a gynecological oncologist. I saw him last month and he said he wasn't able to palpate anything so he was sure it wasn't my ovary. He also added that he wouldn't do surgery even though I've had substantial pain. BUT he wants to assist my surgeon anyway. Also, concern has been expressed regarding surgery because of the scar tissue and the high possibility of rupturing my intestines and getting peritonitis again. For the last two weeks they've been trying to schedule the two doctors and the OR . . . I'm still waiting.

Can you explain to me exactly what the CT results mean? My actual questions are:

1. I have researched ovarian cancer and have all the symptoms but understand that a cyst could cause them too. Seeing how I just had surgery in October and February and cancer was not found then, how could they think it could be there, at this stage, now?

It is not likely to be cancer for the reasons you said. You have a lot of adhesions and when that is present, no one can really say until they look at the time of surgery. The fact the oncologist can't feel a mass on pelvic exam would be consistent with bowel adhesions (a lot of them) causing this ultrasound and CAT scan picture. The reason the non-surgeons think there may be cancer is because the x rays show a very complex mass which many malignancies will also show. Those doctors are ignoring your other surgical and medical history and not including it in their assessment of the probability of cancer.

2. If the cyst cannot be felt, why is it causing problems like ovarian cancer? Could that be the scar tissue and inflammation instead?

Yes it can. There's no way to differentiate on the basis of symptoms except cancer usually produces much less pain if any.

3. Here's a really silly question . . . could the inflammation in my abdomen be causing inflammation in my joints also?

Some abdominal infections can give joint pain if you are septic (bacteria from infection in blood stream) but I don't think you are at this point. Anything is possible but the connection is uncertain.

4. What questions should I be asking prior to surgery. Any other comments you have I would find extremely helpful. Sorry this was so long :)

I would guess you have severe adhesive disease involving the bowel and pelvic organs. You may need to be prepared for possible bowel injury (with colostomy) or need to remove some or all of the pelvic reproductive organs. I think its a good idea to have both the oncologist and the reproductive specialist involved in the surgery. You will have to make a tough decision as to whether the primary goal of the surgery is to reduce/cure the pain or to preserve fertility function.