by Robert B. Albee, Jr MD FACOG ACGE FOUNDER
Women are often told, "Don’t worry about it, it’s just a cyst," but they are also told, "I’m concerned, you’ve got a cyst." How do you know what’s what? Dr. Albee provides an encyclopedia of information about many types of cysts.
A cyst is a spherical area in any organ in which an outer wall encloses a type of tissue of a different consistency than the normal tissue. In most cases, the cyst wall encloses a softer or more liquid tissue. If the growth is solid it is called a tumor or neoplasm.
Within the ovary itself there are well over a dozen different types of cysts. There are many descriptive terms used to categorize these cysts. Some of these include:
Functional cysts are the result of normal processes within the ovary and are self-limiting. Each ovulation a woman has is accompanied by a follicle cyst and then a corpus luteum cyst. At the end of each cycle they are expected to completely resolve.
These cysts may be functional or not. When seen on ultrasound, they have a single cavity without the echoes that indicate compartments within the cyst.
These cysts have more than one compartment within them and are less likely to be functional.
This term refers to any cyst felt to have blood or clots within it. This term can be linked with another, such as when some bleeding occurs within a corpus luteum cyst, and the result is called a hemorrhagic corpus luteum.
These cysts are not freely moveable. This immobility suggests that they are involved with adhesions or have attached themselves to adjacent structures.
These cysts are a type of nonfunctional, benign cyst. Their actual name is "benign cystic teratoma." These cysts may have hair, teeth, and fat in them. They are formed in embryo and should be removed but are rarely harmful. They can almost always be removed while preserving some portion of healthy ovary.
These cysts are caused by endometriosis in the ovary or other tissues. The cyst wall has endometrial glands in it. As these cysts progress they frequently produce a thick dark material the consistency of fudge syrup trapped inside. Thus they have been given the name "chocolate cyst."
Treating Functional Cysts
If a functional cyst is found but isn’t causing symptoms, it is usually just observed. Sometimes pain or long duration forces us to try to hasten its resolution. Anything that prevents ovulation or turns off estrogen and progesterone production should help. Oral contraceptives are the most common treatment.
What if it Ruptures?
Ruptures may result in various experiences. They may go unnoticed or they may be associated with sudden, often intense, pain. Because the cyst contents are normal body fluids (like follicle fluid), this spillage is not harmful. The body naturally absorbs and removes these fluids. Even blood is generally removed without a problem, although usually more slowly than other fluids.
When Should I Worry?
Any cyst that does not behave like a functional cyst should be evaluated further so that serious problems like cancer can be ruled out. Criteria possibly indicating the need for further evaluation include family history, symptomatology, size, duration, complexity, and mobility.
These criteria are evaluated in the following ways:
- Patient-physician communication provides important history regarding the family and the patient's symptoms.
- Pelvic examination provides the initial estimates of size, tenderness, and mobility.
- Ultrasound and/or CT scans (occasionally MRI) provide some details regarding size, complexity, and mobility.
- Repeat exam after intervals of time provide information regarding duration.
Once the physician determines that a cyst is probably not functional, exact information must be obtained. Although sometimes a needle guided aspiration will provide the needed information, it does not allow for treatment at the same time. In most cases diagnostic laparoscopy is recommended. This allows for visual inspection, tissue biopsy (frozen section) if needed and, in most cases, definitive treatment all at the same time.
How Are Ovarian Cysts Treated?
There are several approaches to treating an ovarian cyst:
Aspiration - A cyst may be treated by simply draining the fluid out. This technique does not remove the cyst wall and frequently allows the cyst to reform over a period of time.
Aspiration plus cyst wall ablation - This form of treatment adds the use of some form of energy such as electrical current (cauterization, fulguration), or laser to destroy the cyst wall after the aspiration is done. Its limitation is the inability to determine when the entire wall has been completely destroyed. In my opinion, when a vigorous attempt is made to destroy the wall of a cyst using this technique, it tends to cause additional tissue destruction to the normal areas of ovary surrounding the cyst.
Excision - This form of treatment involves totally removing the entire cyst wall by cutting it out of the ovary. This can be accomplished by using cautery, sharp scissors dissection, or laser cutting (not to be confused with laser ablation). In rare cases after excision, suturing of the ovary is required to restore its normal shape, but this is not common. Excision is my preference for treating endometriosis of the ovary. It has by far the lowest risk of recurrence.
- Removal of the ovary is rarely required to remove a benign cyst. It is still the recommended form of treatment for all malignant cysts.
Is Biopsy a Treatment?
Ovaries and Adhesions
Adhesions are the method the body uses to isolate injury, infection, and certain types of irritants to the peritoneal surfaces, such as blood or cancer cells.
The ovary may be the source of the problem, or it may be an innocent bystander. Pelvic infection may come from the tubes and involve the ovaries, or be secondary to a different type of pelvic surgery, such as for atubal pregnancy. The ovary itself can spill contents that create adhesions, such as blood, fat (from a dermoid), or chocolate from an endometrioma.
If an ovary is stuck to another organ, we can often tell the source of the problem, especially with active endometriosis. Certain patterns and types of adhesions also suggest certain causes. Pelvic Inflammatory Disease (PID) is almost always bilateral and generalized, as opposed to unilateral and focal. Sometimes we can match a patient's known history of infection or previous surgeries with her adhesions. This can help eliminate some possible causes for the scarring.
For more information about scarring, please see the CEC newsletter about Adhesions.
Cancers are almost always immediately visible and obvious.
Although this article has only touched on some aspects of cysts, I hope we've helped you sort through some of the possibilities you may face.