Ovarian Cysts

Usually nonneoplastic, ovarian cysts are sacs on an ovary. These cysts contain fluid or semisolid material. They are usually small and produce no symptoms, but they require thorough investigation as possible sites of malignant change. Common ovarian cysts include follicular cysts. lutein cysts (granulosa-lutein, corpus luteum, and theca-lutein cysts), and polycystic (or sclerocystic) ovarian disease. Ovarian cysts can develop anytime between puberty and menopause, including during pregnancy. Granulosa-lutein cysts occur infrequently, usually during early pregnancy. The prognosis for nonneoplastic cysts is excellent.

Causes

The normal function of the ovaries is to produce an egg each month. During the process of ovulation, a cyst-like structure called a follicle is formed inside the ovary. The mature follicle ruptures when an egg is released during ovulation. The corpus leteum forms from the empty follicle and if pregnancy does not occur, the corpus leteum dissolves. Sometimes this process does not conclude appropriately causing the most common type of ovarian cyst -- functional ovarian cysts.

Signs and Symptoms

Small ovarian cysts (such as follicular cysts) usually don't produce symptoms unless torsion or rupture occurs. The patient may report mild pelvic discomfort, low back pain, dyspareunia, or abnormal uterine bleeding secondary to a disturbed ovulatory pattern. Inspection may reveal signs of an acute abdomen similar to signs of appendicitis (abdominal tenderness. distention. and rigidity).

Granulosa-lutein cysts that appear early in pregnancy may grow as large as 2" to 2 ½ (5.1 to 6.4 cm) in diameter and produce unilateral pelvic discomfort. If rupture occurs, massive intraperitoneal hemorrhage may result. A nonpregnant patient may report delayed menses, followed by prolonged or irregular bleeding.

Palpation may disclose enlarged ovaries caused by lack of ovulation. It may also reveal large follicular cysts. Theca-lutein cysts usually aren't palpable.

Diagnostic tests

Visualization of the ovary through ultrasonography, laparoscopy, or surgery (often for another condition) confirms ovarian cysts. The following tests provide additional diagnostic information:

• HCG titers that are extremely elevated strongly suggest theca-lutein cysts.
• Urine 17-ketosteroid concentrations that are slightly elevated accompany polycystic ovarian disease.
• Basal body temperature graphs and endometrial biopsy results indicate anovulation.
• Direct visualization is used to rule out paraovarian cysts of the broad ligament, salpingitis. endometriosis, and neoplastic cysts.

Treatment

Follicular cysts generally don't require treatment because they tend to disappear spontaneously by reabsorption or silent rupture within 60 days. If follicular cysts interfere with daily activities, administration of oral clomiphene citrate or I.M. progesterone for 5 days reestablishes the ovarian hormonal cycle. Oral contraceptives are used to accelerate involution of functional cysts (including both types of lutein cysts and follicular cysts).

Treatment for patients with granulosa-lutein cysts that occur during pregnancy is based on the patient's symptoms because these cysts diminish during the third trimester and rarely require surgery. Theca-lutein cysts disappear spontaneously after elimination of the hydatidiform mole, destruction of choriocarcinoma, or discontinuation of HCG or clomiphene citrate therapy.

Treatment for patients with polycystic ovarian disease may include clomiphene citrate to induce ovulation, medroxyprogesterone acetate for 10 days of every month for the patient who doesn't want to become pregnant, or low-dose oral contraceptives for the patient who needs reliable contraception.

If an ovarian cyst is persistent or suspicious, surgery in the form of laparoscopy or exploratory laparoscopy with possible ovarian cystectomy or oophorectomy may be needed.

Prevention

Although there's no definite way to prevent the growth of ovarian cysts, regular pelvic examinations are a way to help ensure that changes in your ovaries are diagnosed as early as possible. In addition, be alert to changes in your monthly cycle, including symptoms that may accompany menstruation that aren't typical for you or that persist over more than a few cycles. Be sure to talk with your doctor about any concerns relating to menstruation.