Polycystic Ovarian Syndrome and Pelvic Pain
Frederick R. Jelovsek, MD
"Last month I had a vaginal hysterectomy due to PCOS (polycystic ovarian syndrome), but the Dr. refused to take out the cysts in my ovaries and didn't take out the ovaries either. The pain is still present and feels like someone is squeezing the ovary really hard. I can't stand it and it affects both ovaries. Birth control pills didn't work. Any suggestions as to what I can do? The Dr. is no help. I'm 36 years old and in pretty good health." KE
Actually you may be quite surprised to hear that polycystic ovarian syndrome (PCOS) is not thought by most physicians to cause any pain at all. In fact insurance companies will not authorize payment for hysterectomy for PCOS. They will authorize it for pelvic pain and I suspect that is what your physician put down on the forms as a diagnosis. This does not mean that women with PCOS do not have pelvic pain, but it questions whether the cause of the pelvic pain is something other than the ovaries.
PCOS affects about 4-7% of women (1) although the incidence can vary by the definition used. Be sure to see our disease profile about polycystic ovarian syndrome and what is usually considered to be part of the syndrome. Pain is not included as part of the definition.
I thought that any type of ovarian cysts cause pain.
There is a difference between periodic or chronically recurring ovarian cysts that cause pelvic pain and PCOS that is an endocrine syndrome which happens to have small immature follicle cysts in the ovary. All functional ovarian cysts that are the result of arrested development of an egg are a result of anovulation. These cysts accumulate and persist in the ovary and will show up on ultrasound as multiple cystic areas in the ovary. One proposed classification divides this follicular ovarian disease into two groups (2):
- polycystic ovarian syndrome (small follicles usually less than 2.0 cm)
- multi follicle ovaries (larger follicles)
- macro polycystic ovaries (multiple cysts larger than the usual polycystic ovarian cysts)
- functional cysts (one to several larger, simple cysts)
- luteinized unruptured follicle syndrome (i.e., and egg that did not ovulate but the cystic area went on to form a corpus luteum gland for support of possible pregnancy as if an egg did ovulate)
Thus if a diagnosis of polycystic ovarian syndrome was made on the basis of an ultrasound rather than an endocrinological basis, you may have one of the other conditions of multicystic ovaries which are associated with pain.
What is pelvic pain like when it is due to ovarian cysts?
Many episodes of ovarian cyst formation not due to PCOS occur on one side or the other but usually not on both ovaries simultaneously. The pain is most often either in the right lower abdominal or left lower abdominal area. If the pain presents on both sides of the abdomen at once in the "ovary" area, there is the possibility of cysts on both ovaries, but it is more likely that the pain is due to vascular congestion, endometriosis or large bowel problems such as irritable bowel, lactose intolerance etc. Pelvic congestion is often associated with a polycystic appearance of the ovaries on ultrasound (3).
Most non-PCOS ovarian cyst formation comes and goes. The natural history of follicular cysts is that about 50-70% regress in 2 months and about another 5% in 3 months (4). On infrequent occasions, ovarian cysts can rupture, causing internal bleeding. This is somewhat more frequent in women over 30 years of age and involves a follicular cyst less often than a corpus luteum cyst (5).
Do birth control pills or DepoProvera® make cysts go away?
No. they don't seem to have any effect once the cyst is formed.
Do oral contraceptives or injectable progestins (DepoProvera®) prevent the formation of ovarian cysts?
Oral contraceptives are known to block ovulation in women with polycystic ovarian syndrome as well as lower the circulating androgens which can cause excessive hair growth (6). They are also used as pretreatment to decrease cyst formation when giving LHRF for in vitro fertilization (7). Thus they can be used to lessen the risk of new ovarian cyst formation even though they will not suppress any currently existing cysts.
Neither oral contraceptives nor injectable progestins totally suppress all follicle development but they do suppress large follicles in the range of 3.0 cm (8).
Should ovarian cysts be aspirated or removed or is it best to just wait and see if they regress?
There seems to be little difference as to whether the cysts are aspirated under ultrasound guidance or followed (9). About half of the cysts regress by themselves. The rest may need to be explored surgically and cystectomies performed.
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