What are Ovarian Cysts and What Should be Done with Them?

Most women have experienced pelvic pain at one time or another during their reproductive years. Quite often the cause of pelvic pain can be due to ovarian cysts which have ruptured. There are certain features of ovarian cysts to be aware of and it is important to know which ones to follow and which ones to investigate.

What is an ovarian cyst?
A simple ovarian cyst is defined as a thin walled fluid filled sac which arises in the ovary. Symptoms of an ovarian cyst can includes lower abdominal discomfort, bloating, distention, fullness, indigestion, heartburn, painful intercourse, irregular menses or abnormal vaginal bleeding. Bladder pressure, urinary frequency and difficulty with having bowel movements can also be signs of an ovarian cyst.

What are the risk factors for ovarian cysts?
The following are some of the more commmon ones; infertility treatment, tamoxifen use, hypothyroidism, cigarette smoking, pregnancy, maternal gonadotrophins and tubal ligation. There are other disorders which can mimic an ovarian cyst which include paraovarian cyst, hydrosalpinx (obstructed fluid filled fallopian tubes), pyosalpinx (fallopian tubes which are infected and filled with pus), tubo ovarian abscess, ectopic pregnancy, uterine fibroids, pelvic lymphocele or pelvic kidney.

How do we find ovarian cysts?
The first line of investigation is a pelvic and transvaginal ultrasound. It is important to determine whether an ovarian cyst is simple or complex. Complex cysts can contain blood, debris, septations or nodules. There is a higher risk of cancer if the cyst is complex, contains nodules and there is increased blood flow, particularly in older and postmenopausal women.

Not all cysts are simple:
Cysts which contain blood can be secondary to endometriosis and are referred to as endometriomas. They have a typical appearance on ultrasound. Dermoid cysts or teratomas have fat and other cellular components. They can be painful because of torsion or twisting which requires surgical intervention.

How are ovarian cysts managed?
Cysts can be followed if they are less than 7 cm in size and there is no history of ovarian cancer and a blood test known as CA 125 is normal. Note that CA 125 can be elevated in many benign conditions and is not specific for ovarian cancer. Other tests may be required such as a CT scan, MRI, beta hCG (choriocarcinoma), alpha fetoprotein (endosinus tumour), LDH (dysgerminoma) and human epididymis protein 4 (ovarian cancer).

Which tests should be done?
No test is 100% accurate for predicting whether an ovarian cyst is cancer. The Risk of Malignancy Index is a score based on ultrasound findings, menopausal status and serum CA 125 level.
The Multivariate Index Assay is another method which can improve the ability to determine ovarian cancer in women with pelvic masses. It is composed of five biomarkers: transthyretin, apolipoprotein, β2 microglobulin, transferrin, and CA125 II.
Testing for serum human epididymis protein 4 and CA 125 has been reported to increase the accuracy of prediction of cancer in an ovarian mass or cyst.
If you have an ovarian cyst, see your doctor and find out whether you need to have a pelvic and transvaginal ultrasound, see a specialist and have follow up or additional tests done.

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