Ovarian Cysts and Treatment

The girl babies have millions of ova (eggs) that are on standby in their ovaries even before they are born, while they are still in their mothers' wombs.

What is Ovary? What is Ovulation?

The ovaries are female reproductive organs connected to the uterus through uterine tubes (tuba). In certain periods of each month, the "ova" are discharged from the ovaries. These ova proceed into the uterus through the tubes. This is called ovulation. The women generally ovulate between the 11th and 16th days that correspond to the middle of their menstrual periods. If these ova sent into uterus meet sperms and are fertilized by them, pregnancy happens. If they do not meet sperms, they are discharged from the body through menstrual bleeding, which we call period, triggered by certain hormones.

The girl babies have millions of ova (eggs) that are on standby in their ovaries even before they are born, while they are still in their mothers' wombs. Within the age range of 9-12, the body makes itself ready for the first menstrual bleeding by using numerous mechanisms. Simultaneously with the first menstruation, hundreds of these eggs on standby shift to the next phase, and the ovulation cycle begins. The ovarian cyst that grows in the ovary that we call follicle cracks in the middle of the menstruation cycle and throws the ovarian cells it contains into the uterus through the tubes. In this period, i.e. on the 11th-16th days of the menstruation, the women may complain about light inguinal pain, and pink, stain-like vaginal bleeding that may last for a few days. Besides, when looking through ultrasonography, some intra-abdominal fluid may also be seen. This is a natural process that shows that your egg has cracked (you have ovulated) and you should not be afraid of. Sometimes, if the cyst we call follicle does not crack but instead continues to grow, the structures we call the ovarian cyst arise.

How Many Types of Ovarian Cysts are there?

Simple Cyst: This is the most frequently observed type of cyst in the ovaries. They are mostly benign ovarian cysts caused by accumulation of fluid in the follicle. They are usually 1-4 cm, well-circumscribed cysts. During the follow-up, they vanish by themselves within a few months.

Hemorrhagic Cyst: The cysts that arise in consequence of clotting of the bleeding in the simple cysts. They can grow up to 4-5 cm depending on the amount of bleeding. In that case, they are called corpus hemorrhagicum cyst. The hemorrhagic cysts are largely seen in a single ovary. Rarely, they may be seen in both ovaries. These cysts are seen widely in the persons who cannot become pregnant naturally and thus receive ovary treatment. Besides, the use of blood thinner medicines may also cause hemorrhagic cyst.

Endometrioma (Chocolate Cyst): It is the cystic structure created in the ovaries by the endometriosis disease. They are well-circumscribed ovarian cysts that contain dark, chocolate-like fluid. They may be seen in one or both ovaries, and they may consist of one or multiple pockets. The risk of these cysts turning into ovarian cancer is under 1%. They may cling to the surrounding tissues and cause severe menstrual cramps (dysmenorrhea) or pain during sexual intercourse (dyspareunia). It is a disease accompanied by chronic pelvic pain and infertility.

Dermoid Cyst: Dermoid cyst is a disease that may contain hair, tooth, bone, or nerve tissue, and must be removed surgically, as they have the rare possibility of turning into cancer. They are the cysts that constitute 60% of the benign ovarian tumors most of which are 5-10 cm when diagnosed. 

Polycystic Ovary Syndrome: It is the existence of numerous very small cysts in the ovary. The reason of this condition is connected with the ovulation period extended for any reason. They arise when the follicles that must crack open every month stop at one stage of their developments and remain in the ovaries in the form of cyst. When this condition repeats continuously, numerous uncracked cystic structures are observed in the ovary.

Ovarian Tumors: The ovarian cancer is a cancer type observed in the ovaries, which are female reproductive organs. They are the tumors that arise from uncontrolled proliferation of the ovarian cells. Although it is mostly seen after menopause, it can be seen in any age range. They mostly develop on the surface layer of the ovaries and are named according to the tissue in which they develop. The most important reason why the treatment of ovarian cancer is started late is the fact that it does not cause any significant complaint in the beginning period of the disease. Although there is usually no symptom at the beginning, loss of appetite, weight loss, abdominal pain, abdominal distension and difficulty in breathing connected to it may be seen at the next stages of the disease. If the disease is diagnosed early, the survival rate is high. 

What are the Symptoms of Ovarian Cysts?

Most of the ovarian cysts do not cause any symptom and are detected incidentally during ultrasonographic examination. 

• Menstrual irregularities (the most frequently observed symptom)
• Abdominal pain and pressure sensation
• Back, waist, and inguinal pains
• Pain during sexual intercourse
• Recurrent pain in menstrual periods
• Abdominal distension and sensation of palpable mass, abdominal circumference enlargement
• Urinary incontinence and feeling of incomplete bladder emptying
• Hairing, hair loss due to hormonal changes
• Infertility
• Difficulty in defecating and chronic constipation (occurs when the cysts press on the intestinal system)

How are the Ovarian Cysts diagnosed?

The Ovarian Cysts are often detected during a routine examination. Most of these cysts are diagnosed through abdominal or vaginal ultrasonography. It is possible to understand whether these cysts are benign or malign with gynecological examination and ultrasonography (the size and shape of the mass, simple cyst or solid mass distinction, papillary extensions, calcifications, its relations with the surrounding tissue, etc.). In addition to examination and ultrasonography, Magnetic Resonance Imaging (MRI) may be requested, and certain tumor markers may be checked in blood analysis. The Cancer Antigen 125 (Ca-125) checked in blood analysis is an important marker of ovarian tumors. The probability of its high levels increases in the advanced-stage ovarian tumors, but its reliability in the early-stage tumors is limited. Unfortunately, Ca-125 is not a marker specific to tumor, and it may be high in 1% of the healthy women as well. Besides, it has a tendency to increase in the cases such as myoma and endometrioma, too. Other than Ca-125, the serum alpha-fetoprotein (AFP), Beta-hCG, carcinoembryonic antigen (CEA), and Cancer Antigen 19-9 (CA 19-9) are some of the tumor markers used.

What is the Treatment for Ovarian Cysts?

1. Follow-up Treatment

Most of the ovarian cysts regress by themselves within 6 months after their detection. Therefore, the shrinkage of the cyst can be monitored by applying only a follow-up treatment to the patient who has no complaints.

The ovarian cancer risk increases with aging, during the menopause period in particular. Nevertheless, these cysts can be monitored in the patients with normal Ca-125 levels, whose cyst is thin-walled, smaller than 5 cm in diameter according to the ultrasonography examination and does not grow during the follow-up.

2. Medicines

Since they accelerate the regression of the cyst, the contraceptive pills (OKS) are used as a treatment option.

3. Surgical Operations

Despite our efforts to categorize the masses radiologically or serologically, the benign and malign masses share similar features. The absolute benign-malign distinction can be achieved only after the masses are removed surgically and examined pathologically.

If the size of the cyst exceeds 10 cm, if the cyst is immobile, i.e. stuck on the surrounding tissues during examination, does not have a smooth surface, includes solid parts, and if both ovaries include cyst, even if it is probably benign, such cysts must be removed surgically due to their potential to turn into malign cysts in time. The probability of being simple cysts is much higher for the cysts that are mobile (i.e. not stuck on the surrounding tissues) during examination, smaller than 6 cm, full with fluid only, and do not include any solid parts according to ultrasonography. These cysts can be monitored for a few months. If the treatment applied cannot shrink or completely terminate these cysts, surgery may become necessary.

We use various surgical methods to remove the cysts:

• Laparotomy (open surgery): This operation technique that allows us to remove the masses that are highly likely to be malign as a whole before they spread into abdomen also provides convenience for us and our patient by providing us with sufficient surgical area to stage the cancer.
• Mini-laparotomy: We can remove small and medium-sized cysts through an incision smaller than c-section. Shorter operation period allows lower rates of cyst rupture (spontaneous burst of the cyst or its being ruptured deliberately by the doctor during the operation). Since our patients have a small incision, they can be discharged the same day.
• Laparoscopy (closed surgery):We peel the cyst off the ovarian tissue and remove it by using tools inserted through 2 or 3 small holes including also the navel. Then, we finish the operation by taking the cyst out of the abdomen with the help of special bags used to take such tissues out of the abdomen. Thanks to smaller incision areas and shorter operation durations, our patients can heal quickly and go back to their daily lives easily.

Do the Cyst Diseases recur after the Operation?

Some malign cysts may recur, as they spread into the neighboring tissues and formations. However, even if it is a malign cyst, if it has been operated so that there will be no malign cell within the surgical borders, or if it is a benign cyst, its possibility of recurring is low. After the cysts have been removed surgically, 6 months constitute appropriate interval for follow-up with examination and ultrasonography.