Earlier this year in January, famous actress Kate Beckinsale was hospitalised for a ruptured ovarian cyst. Ovarian cysts are fluid filled sacs which grow on one or both ovaries. They are very common and can be diagnosed during an incidental pelvic ultrasound scan. It is estimated that one in ten women will have surgery during her life to remove an ovarian mass. So what symptoms these cysts can cause and do all ovarian cysts need to be removed when diagnosed? In this blog I will summarise the reasons to suggest the surgical intervention with ovarian cysts.
What does it feel like to have an ovarian cyst?
Ovarian cysts often don’t cause any symptoms and can be diagnosed incidentally by medical imaging. Frequently, they can cause symptoms such as pelvic pain, pelvic discomfort, bloating, abdominal distention or indigestion. If causing pain, this may build up slowly over weeks or months or can start suddenly. The pain can be mild or severe and in many times spreads to the inner thigh.
What is the best way to find out if I have an ovarian cyst?
The best test to look for and assess an ovarian is the pelvic ultrasound scan, preferably transvaginal if possible. The transvaginal, or “internal” ultrasound scan, can closely visualise the ovaries and provide a better image of the cyst. An expert examiner will be able to diagnose the nature of the ovarian cyst in the majority of the cases. In very few cases, another imaging may be required such as MRI.
How are ovarian cysts treated?
Most of ovarian cysts are benign cysts and have no risk of progressing into cancer. In these cases taking the cyst out surgically can be justified only if causing symptoms such as pain, pressure, or discomfort and if medical treatment is not helpful. This can be done by keyhole surgery in almost all the cases, even if the cyst is very large (more than 15 cm).
Can ovarian cysts be treated with medicine?
Yes, in many times simple pain killers can control the symptoms caused by the cyst until it resolves on it’s own. Combined oral contraceptive pills can be used to prevent certain cysts, such as functional cysts which are related to the ovarian ovulation, from coming back.
Can I leave ovarian cysts alone if they are not causing a problem?
If the ovarian cyst is diagnosed as benign and causing no symptoms, then careful assessment and counselling is required to decide whether to leave the cyst alone or to remove it surgically.
In general, most asymptomatic benign ovarian cysts can be left alone. Follow-up ultrasound scans may be required especially if the cyst happen after menopause. The follow-up scan frequency and intervals can vary slightly in practice and three follow-ups within one year is most acceptable by clinicians.
However, asymptotic benign ovarian cysts can cause complications occasionally. For example ovarian torsion can happen especially in younger women during childbearing years. This can happen when the cyst is moderate in size (5 cm diameter) and when the ovary, with the cyst, moves freely in the pelvis. Ovarian torsion is an acute episode normally and it happens as the ovarian cyst changes the balance axis of the ovary which can cause the ovary to twist around the blood supply pedicle. Based on the severity of the torsion and how many times the ovary with the cyst twists around its blood supply, the ovary can get swollen and if the torsion is not corrected the ovary will eventually lose its blood supply and die. The surgical correction of the torsion is an emergency operation and needs to be done immediately to save the ovary. With enough counselling and assessment, surgical vs. conservative management can be decided with the patient with an ovarian cyst. For example, an ovarian cyst which has reduced mobility or which looks as part of endometriosis is unlikely to twist.
How will I know that the ovarian cyst is not cancerous?
With ultrasound scan, an experienced examiner can suspect malignant cysts with high accuracy. Moreover, using an ultrasound can differentiate between ovarian cancer and another group of ovarian cysts called “borderline” ovarian tumours. A borderline ovarian cyst or tumour is not cancerous. It is a special type of cyst that rarely has the potential to become cancer over many years if left untreated. Borderline ovarian cysts are usually diagnosed early and treated successfully with complete recovery. In the majority of the cases the fertility can be preserved as well. The experienced examiner can as well decide the type of malignant ovarian cyst to rule out if it’s cancerous. This step is crucial to decide further management of these cysts especially that in many cases fertility preservation is possible in some cases of ovarian cancers.
Other modality of imaging such as MRI and some blood tests such as tumour markers can help as well in characterising ovarian masses.
Conclusion
Most ovarian cysts are benign and many of them can be managed conservatively. The first and main step to diagnose an ovarian cyst the ultrasound scan when performed by an experienced examiner. This ultrasound is a dynamic test which can tell the type of the cyst, its relation to nearby organs and eventually allows to decide the correct management.
