Ovarian cysts
Author
Mitchel S Hoffman, MD
Lauri Hochberg, MD Section Editor
Barbara Goff, MD
William J Mann, Jr, MD Deputy Editor
Leah K Moynihan, RNC, MSN
Sandy J Falk, MD
OVARIAN CYST OVERVIEW — Ovarian cysts are fluid-filled sacs that develop in or on the ovary (show figure 1). Ovarian cysts occur commonly in women of all ages. Some women with ovarian cysts have pain or pelvic pressure, while others have no symptoms. Irregular menstrual periods are not usually related to an ovarian cyst.
Fortunately, most ovarian cysts do not require surgical removal and are not caused by cancer. Cysts can vary in size from less than one centimeter (one-half inch) to greater than 10 centimeters (4 inches).
This topic discusses the various causes of ovarian cysts, how ovarian cysts are diagnosed, and what follow up testing and/or treatment might be recommended.
OVARIAN CYST CAUSES — The most common causes of ovarian cysts depend upon whether you are still having menstrual periods (premenopausal) or have stopped menstruating for at least one year (postmenopausal). (See “Differential diagnosis of the adnexal mass”).
Premenopausal women — For premenopausal women, the most common causes of ovarian cysts include:
Ovulation — “Functional” ovarian cysts develop when a follicle (sac) grows, but does not rupture to release the egg. These cysts usually resolve without treatment.
Dermoid cysts — Dermoid cysts are one of the most common types of cysts found in women between age 20 and 40 years. A dermoid cyst can contain teeth, hair, or fat. (See “Overview of ovarian germ cell tumors”, section on Mature cystic teratomas).
Polycystic ovary syndrome (PCOS) — Women with PCOS do not need treatment for ovarian cysts, but may need treatment for other PCOS problems, such as irregular menstrual periods. (See “Patient information: Polycystic ovary syndrome (PCOS)”).
Endometriosis — Women with endometriosis can develop a type of ovarian cyst called an endometrioma, or “chocolate cyst”. (See “Patient information: Endometriosis”).
Pregnancy — An ovarian cyst normally develops in early pregnancy, to help support the pregnancy until the placenta forms. In some cases, the cyst stays on the ovary until later in the pregnancy.
Severe pelvic infections — Severe pelvic infections generally involve the ovaries and fallopian tubes. As a result, pus-filled cysts form in the ovaries and/or fallopian tubes.
Non-cancerous growths
Cancer — Cancer is a relatively uncommon cause of ovarian cysts in premenopausal women; less than 1 percent of new growths on or near the ovary are related to ovarian cancer.
Postmenopausal women — In women who have stopped having menstrual periods, the most common causes of ovarian cysts include:
Non-cancerous growths
Fluid collection in the ovary
In postmenopausal women, new growths on or around the ovary are somewhat more likely to be caused by cancer.
Do I have ovarian cancer? — Although ovarian cancer is not the most common cause of ovarian cysts, many women who are diagnosed with a cyst are concerned that they could have cancer. Ovarian cancer is more likely in women who have:
A genetic predisposition to ovarian cancer (eg, family history of ovarian or related cancers)
A previous history of breast or gastrointestinal cancer
A cyst that appears complex (a cyst with solid areas, nodule on the surface, or multiple fluid-filled areas)
A fluid collection (called ascites) found in the pelvis or abdomen during the imaging test
However, women without cancer may also have these characteristics. In most cases, further testing will be recommended to gauge the likelihood of cancer.
If your doctor is concerned that you could have ovarian cancer, he or she may recommend that you meet with a physician specialist, called a gynecologic oncologist. These physicians have been trained in the surgical treatment of ovarian cancer, and can improve your chances of survival. (See “Patient information: Ovarian cancer treatment”).
OVARIAN CYST DIAGNOSIS — Ovarian cysts can sometimes be detected during a pelvic examination, although an imaging test, usually a pelvic ultrasound, is necessary to confirm the diagnosis. CT scan or MRI are also sometimes used, but less commonly. These imaging tests can also provide information about the cyst’s size, location, and other important characteristics. (See “Sonographic differentiation of benign versus malignant adnexal masses”).
Blood testing — One or more blood tests may be recommended if you are found to have an ovarian cyst. The blood test(s) can help to determine the nature of the cyst.
Pregnancy testing — A blood or urine pregnancy test is often performed in premenopausal women with an ovarian cyst. Ovarian cysts are common during pregnancy.
CA-125 — CA-125 is a blood test that is sometimes drawn in women with ovarian cysts. However, its usefulness in diagnosing ovarian cancer is very limited in women who still have menstrual periods. Many women with early ovarian cancer will have a normal CA-125 level. CA-125 is abnormally elevated in about 80 percent of women with advanced ovarian cancer.
Also, non-cancerous conditions can cause CA-125 to be elevated, including endometriosis, uterine fibroids, pelvic inflammatory disease, heart failure, and liver and kidney disease. As a result, measurement of the CA-125 is not recommended in every case. (See “Patient information: Ovarian cancer screening”).
– CA-125 is often recommended for postmenopausal women with an ovarian cyst.
– CA-125 may be recommended for premenopausal women whose ovarian cyst appears very large or suspicious for cancer on ultrasound.
– CA-125 is not usually recommended for premenopausal women with ovarian cysts that are small and do not appear suspicious for cancer.
Next steps — Depending upon the results of the imaging test, your age, symptoms, results of blood tests, and your family history, your healthcare provider may recommend watchful waiting or surgery. (See “Overview of the evaluation and management of adnexal masses”).
OVARIAN CYST TREATMENT — Ovarian cysts do not always require treatment. In premenopausal women, ovarian cysts often resolve on their own, without treatment, within one to two months. In postmenopausal women, ovarian cysts may not resolve.
If a cyst is large, causing pain, or appears suspicious for cancer, treatment usually involves surgery to remove the cyst or the entire ovary.
Watchful waiting
Premenopausal women — In premenopausal women, watchful waiting usually involves monitoring for symptoms (pelvic pain or pressure) and repeating the pelvic ultrasound after six to eight weeks. If the ovarian cyst does not enlarge or if it resolves during the period of watchful waiting, it does not usually require surgical removal. Some premenopausal women will be advised to take a birth control pill during this time to help prevent new ovarian cysts from developing.
If a cyst decreases in size or does not change, the ultrasound is often repeated at regular intervals until your healthcare provider is certain that the cyst is not growing. If the cyst resolves, no further testing or follow up is required. (See “Ovarian cyst follow up” below).
Postmenopausal women — In postmenopausal women, the decision to undergo watchful waiting depends upon the initial testing (CA-125 and ultrasound). If the cyst does not appear to be cancerous, watchful waiting may be an option, and includes a pelvic ultrasound and measurement of CA-125 every three to six months for one year, or until the cyst resolves. However, ovarian cysts do not always resolve in postmenopausal women.
If the CA-125 levels increase or the cyst grows or changes in appearance, then surgery to remove the cyst may be recommended.
Surgery — Surgery may be recommended in the following situations:
A cyst is causing persistent pain or pressure, or may rupture or twist.
A cyst appears on ultrasound to be caused by endometriosis and is removed for fertility reasons.
Large cysts (>5 to 10 cm) are more likely to require surgical removal compared to smaller cysts. However, a large size does not predict whether a cyst is cancerous.
If the cyst appears suspicious for cancer. If you have risk factors for ovarian cancer or the cyst looks potentially cancerous on imaging studies, your healthcare provider may recommend surgery.
If the suspicion for ovarian cancer is low but the cyst does not resolve after several ultrasounds, you may choose to have it removed after a discussion with your healthcare provider. However, surgical removal is not usually necessary in this case.
Surgery to remove ovarian cyst — If surgery is needed to remove an ovarian cyst, the procedure is usually done in a hospital or surgical center. Whether the surgery involves removing only the cyst or the entire ovary depends upon your age and what is found during the procedure. (See “Oophorectomy and ovarian cystectomy”).
For example:
If there is suspicion of cancer, the whole ovary must be removed since cutting into a cancerous cyst may lead to a more advanced cancer. In some cases, the whole ovary is removed and the cyst turns out to be benign. Having one ovary removed will not cause you to go through menopause and will not cause you to be infertile.
If the cyst appears non-cancerous and is able to be removed through small incisions, it may be removed laparoscopically (through several small incisions) and you may be able to go home the same day.
If the cyst is large or appears suspicious for cancer, it may be necessary to have an open incision (called a laparotomy) and the surgeon may need to remove the entire ovary and surrounding tissues. You will need to stay in the hospital for one or more nights after a laparotomy.
OVARIAN CYST FOLLOW UP — After an ovarian cyst resolves, you will not need further imaging tests if you do not have symptoms.
Some types of ovarian cysts are more likely to recur than others. This includes endometriomas and functional ovarian cysts. If you are premenopausal and are concerned about recurrent cysts, taking a birth control pill or other hormonal form of birth control can help to prevent ovarian cysts from developing. (See “Patient information: Hormonal methods of birth control”).
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two people are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.uptodate.com/patients). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable.
National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
[1-7]
Use of UpToDate is subject to the Subscription and License Agreement .
REFERENCES
1 Modesitt, SC, Pavlik, EJ, Ueland, FR, et al. Risk of malignancy in unilocular ovarian cystic tumors less than 10 centimeters in diameter. Obstet Gynecol 2003; 102:594.
2 Castillo, G, Alcazar, JL, Jurado, M. Natural history of sonographically detected simple unilocular adnexal cysts in asymptomatic postmenopausal women. Gynecol Oncol 2004; 92:965.
3 Myers ER, Bastian LA, Havrilesky LJ, Kulasingam SL, Terplan MS, Cline KE, Gray RN, McCrory DC. Management of Adnexal Mass. Evidence Report/Technology Assessment No.130 (Prepared by the Duke Evidence-based Practice Center under Contract No. 290-02-0025.) AHRQ Publication No. 06-E004. Rockville, MD: Agency for Healthcare Research and Quality. February 2006.
4 ACOG Committee Opinion: number 280, December 2002. The role of the generalist obstetrician-gynecologist in the early detection of ovarian cancer. Obstet Gynecol 2002; 100:1413.
5 Dearking, AC, Aletti, GD, McGree, ME, et al. How relevant are ACOG and SGO guidelines for referral of adnexal mass?. Obstet Gynecol 2007; 110:841.
6 ACOG Practice Bulletin. Management of adnexal masses. Obstet Gynecol 2007; 110:201.
7 McDonald, JM, Modesitt, SC. The incidental postmenopausal adnexal mass. Clin Obstet Gynecol 2006; 49:506.
©2009 UpToDate® • customerservice@uptodate.com
www.uptodate.com