Ovarian Cysts Overview

Ovarian cysts are small fluid-filled sacs that develop in a woman's ovaries. Most cysts are harmless, but some may cause
problems such as rupturing, bleeding, or pain; and surgery may be required to remove the cyst(s). It is important to
understand the function of the ovaries and how these cysts may form.

Women normally have two ovaries that store and release eggs. Each ovary is about the size of a walnut, and one ovary is
located on each side of the uterus. One ovary produces one egg each month, and this process starts a woman's monthly
menstrual cycle. The egg is enclosed in a sac called a follicle. An egg grows inside the ovary until estrogen (a hormone),
signals the uterus to prepare itself for the egg. In turn, the lining of the uterus begins to thicken and prepare for implantation
of a fertilized egg resulting in pregnancy. This cycle occurs each month and usually ends when the egg is not fertilized. All
contents of the uterus are then expelled if the egg is not fertilized. This is called a menstrual period.
In an ultrasound image, ovarian cysts resemble bubbles. The cyst contains only fluid and is surrounded by a very thin wall.
This kind of cyst is also called a functional cyst, or simple cyst. If a follicle fails to rupture and release the egg, the fluid
remains and can form a cyst in the ovary. This usually affects one of the ovaries. Small cysts (smaller than one-half inch)
may be present in a normal ovary while follicles are being formed.
Ovarian cysts affect women of all ages. The vast majority of ovarian cysts are considered functional (or physiologic). This
means they occur normally and are not part of a disease process. Most ovarian cysts are benign, meaning they are not
cancerous, and many disappear on their own in a matter of weeks without treatment. While cysts may be found in ovarian
cancer, ovarian cysts typically represent a harmless (benign) condition or a normal process. Ovarian cysts occur most
often during a woman's childbearing years.
The most common types of ovarian cysts are the following:

 Follicular cyst: This type of simple cyst can form when ovulation does not occur or when a mature follicle
involutes (collapses on itself). A follicular cyst  usually forms at the time of ovulation and can grow to about 2.3 inches in
diameter. The rupture of this type of cyst can create sharp severe pain on the side of the ovary on which the cyst
appears. This sharp pain (sometimes called mittelschmerz) occurs in the middle of the menstrual cycle, during
ovulation. About one-fourth of women with this type of cyst experience pain. Usually, these cysts produce no symptoms
and disappear by themselves within a few months.

 Corpus luteum cyst: This type of functional ovarian cyst occurs after an egg has been released from a follicle.
After this happens, the follicle becomes what is known as a corpus luteum. If a pregnancy doesn't occur, the corpus
luteum usually breaks down and disappears. It may, however, fill with fluid or blood and persist on the ovary. Usually,
this cyst is found on only one side and produces no symptoms. 

 Hemorrhagic cyst: This type of functional cyst occurs when bleeding occurs within a cyst. Symptoms such
as abdominal pain on one side of the body may be present with this type of cyst. 

 Dermoid cyst: This is a type of benign tumor sometimes referred to as mature cystic teratoma. It is an abnormal
cyst that usually affects younger women and may grow to 6 inches in diameter. A dermoid cyst can contain other types
of growths of body tissues such as fat and occasionally bone, hair, and cartilage. 

o The ultrasound image of this cyst type can vary because of the spectrum of contents, but a CT
scan and magnetic resonance imaging (MRI) can show the presence of fat and dense calcifications. 

o These cysts can become inflamed. They can also twist around (a condition known as ovarian torsion),
compromising their blood supply and causing severe abdominal pain.

 Endometriomas or endometrioid cysts: Part of the condition known asendometriosis, this type of cyst is
formed when endometrial tissue (the lining tissue of the uterus) is present on the ovaries. It affects women during the
reproductive years and may cause chronic pelvic pain associated with menstruation. 

o Endometriosis is the presence of endometrial glands and tissue outside the uterus. 
 o Women with endometriosis may have problems with fertility.

o Endometrioid cysts, often filled with dark, reddish-brown blood, may range in size from 0.75-8 inches.

 Polycystic-appearing ovary: Polycystic-appearing ovary is diagnosed based on its enlarged size - usually twice
that of normal - with small cysts present around the outside of the ovary. This condition can be found in healthy women
and in women with hormonal (endocrine) disorders. An ultrasound is used to view the ovary in diagnosing this
condition. 

o Polycystic-appearing ovary is different from the polycystic ovarian syndrome (PCOS), which includes

other symptoms and physiological abnormalities in addition to the presence of ovarian cysts. Polycystic ovarian
syndrome involves metabolic and cardiovascular risks linked toinsulin resistance. These risks include increased
glucose tolerance, type 2 diabetes, and high blood pressure. 

 Polycystic ovarian syndrome is associated with infertility, abnormal bleeding, increased

incidences of miscarriage, and pregnancy-related complications. 

 Polycystic ovarian syndrome is extremely common and is thought to occur in 4%-7% of

women of reproductive age and is associated with an increased risk for endometrial cancer. 

 The tests other than an ultrasound alone are required to diagnose polycystic ovarian
syndrome.

 Cystadenoma: A cystadenoma is a type of benign tumor that develops from ovarian tissue. They may be filled
with a mucous-type fluid material. Cystadenomas can become very large and may measure 12 inches or more in
diameter.

Ovarian Cysts Causes

The following are possible risk factors for developing ovarian cysts:

 History of previous ovarian cysts 

 Irregular menstrual cycles 

 Increased upper body fat distribution 

 Early menstruation (11 years or younger)

 Infertility 

 Hypothyroidism or hormonal imbalance 

 Tamoxifen (Soltamox) therapy for breast cancer

Oral contraceptive/birth control pill use decreases the risk of developing ovarian cysts because they prevent the ovaries
from producing eggs during ovulation.

Ovarian Cysts Symptoms

 Usually ovarian cysts do not produce symptoms and are found during a routine physical exam or are seen by chance on an
ultrasound performed for other reasons. However, the following symptoms may be present:

 Lower abdominal or pelvic pain, which may start and stop and may be severe, sudden, and sharp

 Irregular menstrual periods

 Feeling of lower abdominal or pelvic pressure or fullness

 Long-term pelvic pain during menstrual period that may also be felt in the lower back

 Pelvic pain after strenuous exercise or sexual intercourse 

 Pain or pressure with urination or bowel movements

 Nausea and vomiting

 Vaginal pain or spotty bleeding from the vagina 

 Infertility

When to Seek Medical Care

A health care practitioner should be contacted if the following symptoms occur:

 Fever 

 Abnormal pain or tenderness in the abdominal or pelvic area 

 Nausea or vomiting 

 Weakness, dizziness, or fainting 

 Pallor or anemia (possibly from loss of blood) 

 Abnormally heavy or irregular menstruation 

 Abdominal swelling or unusual increased abdominal girth 

 Abdominal pain if blood thinners such aswarfarin (Coumadin) are taken 

 Increased facial hair similar to a male pattern 

 High or low blood pressure unrelated to medications 

 Excessive thirst or urination 

 Unexplained weight loss 

 A noticeable abdominal or pelvic mass

 A woman with the following symptoms should go immediately to a hospital'semergency department:

 Weakness, dizziness, or feeling faint, especially from standing 

 Fainting 

 Persistent fever 

 Severe lower abdominal or pelvic pain

 High or low blood pressure unrelated to medications 

 Excessive thirst or urination 

 Unexplained shoulder pain combined with abdominal pain 

 Persistent nausea and vomiting

Ovarian Cysts Diagnosis

A health care practitioner may perform the following tests to determine if a woman has an ovarian cyst or to help
characterize the type of cyst that is present:

 Endovaginal ultrasound: This type of imaging test is a special form of ultrasound developed to examine the
pelvic organs and is the best test for diagnosing an ovarian cyst. A cyst can be diagnosed based on its appearance on
the ultrasound. 

o An endovaginal ultrasound is a painless procedure that resembles a pelvic exam. A thin, covered wand
or probe is placed into the vagina, and the examiner directs the probe toward the uterus and ovaries. 

o This type of ultrasound produces a better image than a scan through the abdominal wall can because
the probe can be positioned closer to the ovaries.

o Using an endovaginal ultrasound, the internal cystic structure may be categorized as simple (just fluid
filled), complex (with areas of fluid mixed with solid material), or completely solid (with no obvious fluid).

 Other imaging: CT scanning aids in assessing the extent of the condition. MRI scanning may also be used to
clarify results of an ultrasound. 

 Laparoscopic surgery: In this procedure the surgeon makes small incisions through which a thin scope
(laparoscope) can pass into the abdomen. The surgeon identifies the cyst through the scope and may remove the cyst
or take a biopsy from it. 

 Serum CA-125 assay: This blood test checks for a substance called CA-125, which is associated with ovarian
cancer (the CA stands for cancer antigen). This test is used in the assessment of epithelial ovarian cancer and may help
determine if an ovarian mass is harmless or cancerous. However, sometimes benign conditions such as endometriosis
or uterine fibroids may result in the elevated levels of CA-125 in the blood, so the test does not positively establish the
diagnosis of ovarian cancer.
 Hormone levels: A blood test to check LH, FSH, estradiol, and testosterone levels may indicate potential
problems concerning these hormone levels. 

 Pregnancy testing: The treatment of ovarian cysts is different for a pregnant woman than it is for a nonpregnant
woman. An ectopic pregnancy (pregnancy outside the uterus) must be ruled out because some of the symptoms of
ectopic pregnancy may be similar to those of ovarian cysts. 

 Culdocentesis: This test involves taking a fluid sample from the pelvis with a needle inserted through the vaginal
wall behind the uterine cervix.

Ovarian Cysts Treatment

Functional ovarian cysts are the most common type of ovarian cyst. They usually disappear by themselves and seldom
require treatment. Growths that become abnormally large or last longer than a few months should be removed or examined
to determine if they are a sign of a more serious condition.

Self-Care at Home

Pain caused by ovarian cysts may be treated at home with pain relievers, includingnonsteroidal anti-inflammatory
drugs such asibuprofen (Motrin), acetaminophen (Tylenol), or narcotic pain medicine (by prescription). Limiting strenuous
activity may reduce the risk of cyst rupture or torsion.

Ovarian Cysts Medical Treatment

Ultrasonic observation or endovaginal ultrasound are used repeatedly and frequently to monitor the growth of the cyst.

Ovarian Cyst Medications

Oral contraceptives: Birth control pills may be helpful to regulate the menstrual cycle, prevent the formation of follicles
that can turn into cysts, and possibly reduce the size of an existing cyst.

Pain relievers: Anti-inflammatory medication such as ibuprofen (for example, Advil) may help reduce pelvic pain.
Narcotic pain medicationsby prescription may relieve severe pain caused by ovarian cysts.

Ovarian Cysts Surgery

 Laparoscopic surgery: The surgeon makes small incisions through which a thin scope (laparoscope) can pass
into the abdomen. The surgeon identifies the cyst through the scope and may remove the cyst or take a sample from it. 

 Laparotomy: This is a more invasive surgery in which an incision is made through the abdominal wall in order to
remove a cyst. 

 Surgery for ovarian torsion: An ovarian cyst may twist and cause severe abdominal pain as well as nausea
and vomiting. This is an emergency, surgery is necessary to correct it.

Follow-up

Follow-up depends largely on the type of cyst that is present. Cysts in premenopausal women that show no evidence of
cancer and are fewer than 4 inches in diameter may be observed for a period of time, while suspicious-appearing cysts
may warrant immediate evaluation.
 Prevention

Little medical information is available on the prevention of ovarian cysts. Smoking was not found to be a risk factor for their
development.

Outlook

The outlook for a woman with an ovarian cyst depends on the type and size of cyst as well as her age. Benign
(noncancerous) masses or cysts greatly outnumber malignant (cancerous) ones.

 Age: The development of a functional ovarian cyst depends on hormonal stimulation of the ovary. A woman is
more likely to develop a cyst if she is still menstruating and her body is producing the hormone estrogen.
Postmenopausal women have a lower risk for developing ovarian cysts since they are no longer having menstrual
periods. For this reason, many doctors recommend removal or biopsy of ovarian cysts in postmenopausal women,
particularly if the cysts are larger than 1-2 inches in diameter.

 Cyst size: The size of the ovarian cyst relates directly to the rate at which they shrink. As a rule, functional cysts
are 2 inches in diameter or smaller and usually have one fluid-filled area or bubble. The cyst wall is usually thin, and the
inner side of the wall is smooth. An endovaginal ultrasound can reveal these features. Most cysts smaller than 2 inches
in diameter are functional cysts. Surgery is recommended to remove any cyst larger than 4 inches in diameter.

 Pictures
 Media file 1: An ovary containing small cysts on endovaginal ultrasound (looks similar to a chocolate chip cookie).

Media type: Ultrasound

Media file 2: An ultrasound image of a functional ovarian cyst. The round, dark, bubblelike structure is a cyst
present on the ovary.

Media type: Ultrasound

Synonyms and Keywords

cyst on the ovary, simple cyst, functional cyst, functional ovarian cysts, physiologic ovarian cysts, corpus luteum cyst,
follicular cyst, hemorrhagic cyst, dermoid cyst, mature cystic teratomas, endometrioma, endometrioid cyst, polycystic-
appearing ovaries, polycystic luteal cysts, torsion of the ovary, paraovarian cyst, ovarian cancer, polycystic ovary
syndrome, ovarian cyst, laparotomy, laparoscopy, ovarian torsion, endometriosis, tubal pregnancy, ectopic pregnancy

Pathophysiology
Each month, normally functioning ovaries develop small cysts called Graafian follicles.1 At mid cycle, a single dominant
follicle up to about 2.8 cm in diameter releases a mature oocyte.

The ruptured follicle becomes the corpus luteum, which, at maturity, is a 1.5- to 2-cm structure with a cystic center. In the
absence of fertilization of the oocyte, it undergoes progressive fibrosis and shrinkage. If fertilization occurs, the corpus
luteum initially enlarges and then gradually decreases in size during pregnancy.

Ovarian cysts arising in the normal process of ovulation are called functional cysts and are always benign. They may be
follicular and luteal, sometimes called theca-lutein cysts. These cysts can be stimulated by gonadotropins, including follicle-
stimulating hormone (FSH) and human chorionic gonadotropin (hCG). A theca-lutein cyst is shown in the sonogram below.

Theca-lutein cysts replacing an ovary in a patient with a molar pregnancy. Despite their size these cysts are
benign and usually resolve after treatment of the underlying disease.

Multiple functional cysts can occur as a result of excessive gonadotropin stimulation or sensitivity. In gestational
trophoblastic neoplasia (hydatidiform mole and choriocarcinoma) and rarely in multiple and diabetic pregnancy, hCG
causes a condition called hyperreactio luteinalis. In patients being treated for infertility, ovulation induction with
gonadotropins (FSH and luteinizing hormone [LH]), and rarely clomiphene citrate, may lead to ovarian hyperstimulation
syndrome, especially if accompanied by hCG administration.

Neoplastic cysts arise by inappropriate overgrowth of cells within the ovary and may be malignant or benign. Malignant
neoplasms may arise from all ovarian cell types and tissues. By far, the most frequent are those arising from the surface
epithelium (mesothelium), and most of these are partially cystic lesions. The benign counterparts of these cancers are
serous and mucinous cystadenomas. Other malignant ovarian tumors may contain cystic areas, and these include
granulosa cell tumors from sex cord stromal cells and germ cell tumors from primordial germ cells. A clear cell carcinoma is
shown in the image below.
Cross-section of a clear cell carcinoma of the ovary. Note the cystic spaces intermingled with solid areas.

Teratomas are a form of germ cell tumor2 containing elements from all 3 embryonic germ layers, ie, ectoderm, endoderm,
and mesoderm. A mature cystic teratoma is shown in the image below.

A dermoid cyst (mature cystic teratoma) after opening the abdomen. Note the yellowish color of the
contents seen through the wall.

Endometriomas are cysts filled with blood arising from the ectopic endometrium. In polycystic ovary syndrome, the ovary
often contains multiple cystic follicles 2-5 mm in diameter as viewed on sonograms. The cysts themselves are never the
main problem, and discussion of this disease is beyond the scope of this article.

Race
Malignant epithelial ovarian cystadenocarcinomas are the only ovarian cysts associated with racial differences.

 Women from northern and western Europe and North America are affected most frequently, whereas women from
Asia, Africa, and Latin America are affected least frequently.
 Within the United States, age-adjusted incidence rates in surveillance areas are highest among American Indian
women, followed by white, Vietnamese, Hispanic, and Hawaiian women. Incidence is lowest among Korean and
Chinese women.7
 Among women for whom sufficient numbers of cases are available to calculate rates based on age, incidence in
those aged 30-54 years is highest in white women, followed by Japanese, Hispanic, and Filipino women. For
those aged 55-69 years, the highest rates occur in white women, followed by Hispanic and Japanese women.
Among women aged 70 years or older, the highest rate occurs among white women, followed by those of African
descent and Hispanic women.
Age

 Functional ovarian cysts occur at any age (including in utero), but are much more common in reproductive-aged
women. They are rare after menopause. Luteal cysts occur after ovulation in reproductive-aged women. Most
benign neoplastic cysts occur during the reproductive years, but the age range is wide and they may occur in
persons of any age.
 The incidence of epithelial ovarian cystadenocarcinomas, sex cord stromal tumors, and mesenchymal tumors
rises exponentially with age until the sixth decade of life, at which point the incidence plateaus. Tumors of low
malignant potential occur at a mean age of 44 years, with a span from adolescence to senescence. The average
age is more than a decade less than that for invasive cystadenocarcinoma. Germ cell tumors are most common in
adolescence and rarely occur in those older than 30 years.

Clinical

History

 Most patients with ovarian cysts are asymptomatic but some cysts may be associated with a range of symptoms,
sometimes severe.8 Even malignant ovarian cysts commonly do not cause symptoms until they reach an
advanced stage.
 Pain or discomfort may occur in the lower abdomen. Torsion (twisting) or rupture may lead to more severe pain.
An ovarian cyst that has undergone torsion is shown in the image below.
o

An ovarian cyst that has undergone torsion (twisting of the vascular pedicle). The patient
presented with a short history of severe lower abdominal pain. The twisted pedicle can be
seen attached to the cyst, which has turned dusky due to ischemia. No viable epithelial
lining was available for histologic diagnosis.

 Patients may experience discomfort with intercourse, particularly deep penetration.

 Having bowel movements may be difficult, or pressure may develop, leading to a desire to defecate.
 Micturition may occur frequently and is due to pressure on the bladder.
 Irregularity of the menstrual cycle and abnormal vaginal bleeding may occur. Young children may present with
precocious puberty and early onset of menarche.
 Patients may experience abdominal fullness and bloating.
 Patients may experience indigestion, heartburn, or early satiety.
 Endometriomas are associated with endometriosis, which causes a classic triad of painful and heavy periods and
dyspareunia.
 Polycystic ovaries may be part of the polycystic ovary syndrome, which includes hirsutism, infertility,
oligomenorrhea, obesity, and acne.

Physical
  Advanced malignant disease may be associated with cachexia and weight loss, lymphadenopathy in the neck,
shortness of breath, and signs of pleural effusion.
 A large cyst may be palpable on abdominal examination. Gross ascites may interfere with palpation of an intra-
abdominal mass.
 Although normal ovaries may be palpable during the pelvic examination in thin premenopausal patients, a
palpable ovary should be considered abnormal in a postmenopausal woman. If a patient is obese, palpating cysts
of any size may prove difficult.
 Sometimes, discerning the cystic nature of an ovarian cyst may be possible, and it may be tender to palpation.
The cervix and uterus may be pushed to one side.
 Other masses may be palpable, including fibroids and nodules in the uterosacral ligament consistent with
malignancy or endometriosis.

Causes

 Multiple functional cysts can occur as a result of excessive gonadotropin stimulation or sensitivity.
o In gestational trophoblastic neoplasia (hydatidiform mole and choriocarcinoma) and rarely in multiple or
diabetic pregnancy, hCG is the stimulating gonadotropin. The condition is called hyperreactio luteinalis.
o Patients being treated for infertility by ovulation induction with gonadotropins or other agents, such as
clomiphene citrate or letrozole, may develop cysts as part of ovarian hyperstimulation syndrome.
 Tamoxifen can cause benign functional ovarian cysts that usually resolve following discontinuation of treatment.
 Risk factors for ovarian cystadenocarcinoma include strong family history, advancing age, white race, infertility,
nulliparity, a history of breast cancer, and BRCA gene mutations.
PATHOPHYSIOLOGY

Increased Lutenizing Hormone

Hyperstimulation of ovaries

Increase estrogen Hormonal imbalances Increase HCG

Abnormal proliferation of follicle

Menstrual Irregularities Follicles fail to ovulate and fail to undergo

atresia and continue to grow

Dull, unilateral lower Cyst grow in size up to Increase abdominal girth

quadrant pain 15 cm in diameter
Increase pelvic pressure

Hemorrhage & acute pain Rupture of the cyst Fatigue & sense of Urinary frequency,
heaviness in the pelvis constipation &
painful defecation
Infection

Sepsis

Death
Top leading causes of morbidity according to the DOH:

1. Pneumonia
2. Diarrhea
3. Bronchitis/bronchiolitis
4. Influenza
5. Hypertension
6. TB respiratory
7. Diseases of the heart
8. Malaria
9. Chicken Pox
10. Measles

Top 10 leading causes of mortality:

1. Heart diseases
2. Vascular System disease
3. Cancer
4. Accidents
5. Pneumonia
6. Tuberculosis
7. Hypertension
8. Chronic Lower Respiratory diseases
9. Diabetes
10. Perinatal conditions

Top 10 leading causes of infant maternal mortality and morbidity:

1. sleeping in a crib with the stuffed animals, they can suffocate

2. sleeping on back instead of side, they vomit its got no where to go but the lungs
3. sleeping in bed with parent, the parent can roll on the baby and suffocate or squish it.
4. simply sids, hereditary
5. u could overheat the baby
6. preterm babies
7. smoking around the baby, to much smoke inhalation
8. loose bedding can cause strangulation
9. soft sleeping surfaces like water bed can also cause suffocation
10. babies with low birth weight