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 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 uterus begins to thicken itself and prepare for 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). In other words, they have nothing to do with disease. Most ovarian cysts are benign, meaning they are not cancerous, and many disappear on their own in a matter of weeks without treatment. Cysts occur most often during a woman!!!s childbearing years. Ovarian cysts can be categorized as noncancerous or cancerous growths. While cysts may be found in ovarian cancer, ovarian cysts typically represent a normal process or harmless (benign) condition. All of the following conditions are noncancerous, or benign, ovarian growths or cysts. A woman may develop one or more of them.

Follicular cyst: This type of simple cyst can form when ovulation does not occur or when a mature follicle involutes (collapses on itself). It 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. A woman!!!s doctor monitors these to make sure they disappear and looks at treatment options if they do not.

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 an abnormal cyst that usually affects younger women and may grow to 6 inches in diameter. It is a type of benign tumor sometimes referred to as mature cystic teratoma. This cyst is similar to those present on skin tissue and can contain fat and occasionally bone, hair, and cartilage. 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. They can become inflamed. They can also twist around (a condition known as ovarian torsion), causing severe abdominal pain.

Endometriomas or endometrioid cysts: Part of the condition known as endometriosis, this type of cyst is formed when endometrial tissue (the mucous membrane that makes up the inner layer of the uterine wall) grows in the ovaries. It affects women during the reproductive years and may cause chronic pelvic pain associated with menstruation. Endometriosis is the presence of endometrial glands and tissue outside the uterus. Women with endometriosis may have problems with fertility. 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 normal women, and in women with endocrine disorders. An ultrasound is used to view the ovary in diagnosing this condition. 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 to insulin 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. More tests 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 Oral contraceptive/birth control pill use decreases the risk of developing ovarian cysts because they prevent the ovaries from producing eggs during ovulation. 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 therapy for breast cancer 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 spots of blood from vagina Infertility When to Seek Medical Care A healthcare provider 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 as warfarin (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!!!s emergency department: Weakness, dizziness, or faintness, 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 Exams and Tests A healthcare provider 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. 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. 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. 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: The surgeon fills a woman!!!s abdomen with a gas and 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 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 in fact something more harmful.

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

Medical Treatment Ultrasonic observation or endovaginal ultrasound are used repeatedly and frequently to monitor the growth of the 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-inflammatories such as ibuprofen (for example, Advil) may help reduce pelvic pain. Narcotic pain medications by prescription may relieve severe pain caused by ovarian cysts.

Surgery Laparoscopic surgery: The surgeon fills a woman!!!s abdomen with a gas and 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.

Next Steps Follow-up Follow-up depends largely on the type of cyst noted. Cysts in premenopausal women that show no evidence of cancer and are fewer than 4 inches in diameter may be observed for 2-4 weeks.

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 tendency of 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.