Written by Dr Ryan Lee, Consultant obstetrician and Gynaecologist Specialist

‘ I thought  I was gaining weight’ . Women often fail to realise that they have an ovarian cyst, mistaking any symptoms for menstrual or weight problems.

‘I thought my bulge was due to weight gain until I discovered I had a large ovarian cyst the size of a grapefruit’  were the remarks made by a patient of mine during a consultation.  She thought she merely put on weight with a bulge made more obvious on lying down which she dismissed and went to see me for consult. I enquired about her symptoms which she mentioned she had mild abdominal cramps over several months which she thought was indigestion.

Abdominal examination revealed a firm pelvic mass about the size of a 16 week pregnant uterus. Ultrasound scan  performed large right 15 cm ovarian cyst . She subsequently underwent  appropriate early surgery and recovered well  postoperatively. Histology showed a benign dermoid cyst.

This is a commonly encountered scenario where patients present with a bulge or vague non- specific abdominal symptoms .

Ovarian cysts

The ovaries are responsible for producing the hormones that regulate your reproductive system. Ovarian cysts are fluid-filled growths on an ovary.  The most common causes of ovarian cysts include:

●Ovulation – “Functional” ovarian cysts develop when a follicle (sac) grows, but does not rupture to release the egg. These cysts usually resolve without treatment.

●Dermoid cysts – Dermoid cysts (teratomas) are one of the most common types of cysts found in females between age 20 and 40 years. A dermoid cyst is made up ovarian “germ cells” and can contain teeth, hair, or fat. Most dermoid cysts are benign, but rarely, they can be cancerous.

●Endometriosis – People with endometriosis can develop a type of ovarian cyst called an endometrioma, or “chocolate cyst.”

●Ovarian cancer is more likely in people who have

-family history of ovarian or related cancers)

-a previous history of breast or gastrointestinal cancer

-a complex cyst with  solid areas, nodule or multiple fluid-filled areas

-a fluid collection (called ascites) found in the pelvis or abdomen during the imaging test However, it’s important to know that people without cancer may also have these characteristics.

Symptoms

Most ovarian cyst do not have any symptoms. However,  they can cause pain or pressure in the lower abdomen on the side of the cyst.

If you have an ovarian cyst that ruptures, you may experience a sudden sharp pain, which can be severe. Torsion (twisting) of an ovary can also cause sudden pain along with nausea and vomiting.

Certain cysts like endometriotic cysts ( chocolate cysts) can leak and become infected causing fever and abdominal pain.Ovarian cancer may also present with symptoms like early fullness, bloated, abdomen getting bigger.

Diagnosis

Diagnosis of an ovarian cyst is done by a pelvic or “transvaginal” ultrasound which provides information about the cyst’s size, location, and other important characteristics.

A computed tomography (CT) scan or magnetic resonance imaging (MRI) scan may be performed to look for evidence of  cancer spread.

Cancer antigen 125 (CA 125) . CA 125 is a protein in the blood that can go up when a person has ovarian cancer. Note that noncancerous conditions can also cause CA 125 to be high including endometriosis, uterine fibroids, pelvic infections and liver and kidney disease. As a result, measurement of the CA 125 is not recommended in every case.

• CA 125 is recommended if you are postmenopausal and have an ovarian cyst.

CA 125 may be recommended if you are premenopausal and have an ovarian cyst that appears very large or suspicious for cancer on ultrasound.

Treatment

Ovarian cysts do not always require treatment. In people who still have monthly periods, ovarian cysts often resolve on their own within two months without treatment. In people who have been through menopause, ovarian cysts are less likely to resolve.

If a cyst is large, causing pain, or appears suspicious for cancer, treatment usually involves surgery to remove the cyst or the entire ovary.

 Surgery may be recommended in the following situations:

●A cyst is causing persistent pain or pressure, or may rupture or twist.

●A cyst appears on ultrasound to be caused by endometriosis and removed for fertility reasons or causing persistent pain.

●Large cysts (>5 to 10 cm) are more likely to require surgical removal compared with smaller cysts. However, a large size does not predict whether a cyst is cancerous.

●If the cyst appears suspicious for cancer (based on tests) or if you have risk factors for ovarian cancer.

Types of surgery

Cystectomy

During laparoscopic surgery, your gynaecologist may also remove the cyst. This is known as a cystectomy, which removes the cyst while leaving the ovary intact.

Oophorectomy

For some women, an oophorectomy (removal of one or both ovaries) may be necessary if the ovary or ovaries cannot be saved.

There are several variations of the procedure that may be performed:

• Salpingo-oophorectomy removes ovary and the fallopian tube
• Hysterectomy with salpingo-oophorectomy removes the uterus (hysterectomy), and one or both tubes/ovaries.

If both ovaries are removed, you will no longer be able to produce eggs and surgical menopause will begin immediately.

Monitoring

Some types of ovarian cysts are more likely to recur than others. These include endometriomas and functional ovarian cysts. If you still have monthly periods and are concerned about recurrent cysts, taking birth control pills ( COCP) or another hormonal form of birth control may help to prevent ovarian cysts from developing.

Summary

Early diagnosis and treatment are key to successful treatment of ovarian cysts. Ovarian cysts may initially develop without symptoms. However, when they increase in size or number, symptoms like pain, vomiting, bloated, are more likely to appear and  medical attention sought early as earlier diagnosis often improves treatment outcomes.