JANE'S PAINFUL OVARIAN CYST
Jane is a 25-year-old women who felt some pain on the right side of her lower abdomen one morning when she awoke. The pain was mild at first, but then became more bothersome over the next few days. The pain seemed to be worse when she was walking or being active and was better when she was still. Even though her job as a secretary allowed her to sit much of the day, the pain bothered her when she had to get up from her desk and lift or move things. She made an appointment to come into the office. During the pelvic examination a small cyst, about the size of a walnut, was felt on her right ovary. The cyst was slightly tender when touched during the examination. We performed a sonogram which suggested a simple-type cyst. Overall Jane's discomfort was not too bad, and she was reassured that nothing serious was going on. I suggested she limit her activity at work to avoid aggravating the discomfort. She made an appointment for another examination in 2 weeks, with the instructions to call if the discomfort got worse. Two weeks later she came back to the office feeling fine, and the examination showed that the cyst was already entirely dissolved. Jane was relieved and has never had another cyst.
An ovarian cyst is simply a collection of fluid within the normally solid ovary. There are many different types of ovarian cysts, and they are an extremely common gynecologic problem. Because of the fear of ovarian cancer, cysts are a common cause of concern among women. But, it is important to know that the vast majority of ovarian cysts are not cancer. However, some benign cysts will require treatment in that they do not go away by themselves, and in quite rare cases, others may be cancerous. A cyst may cause discomfort or may be discovered at the time of a routine examination, when you are feeling absolutely fine. The good news is that almost all ovarian cysts will go away by themselves without any treatment. Since the vast majority of ovarian cysts are benign, the presence of an ovarian cyst is a usually a non-worrisome occurrence.
The most common types of ovarian cysts are called functional cysts, which result from a collection of fluid forming around a developing egg. Every woman who is ovulating will form a small amount of fluid around the developing egg each month. The combination of the egg, the special fluid-producing cells, and the fluid is called a follicle and is normally about the size of a pea. For unknown reasons, the cells that surround the egg occasionally form too much fluid, and this straw colored fluid expands the ovary from within. If the collection of fluid gets to be larger than a normal follicle, about three-quarters of an inch in diameter, a follicular cyst is said to be present. If fluid continues to be formed, the ovary is stretched as if a balloon was being filled up with water. The normally white covering of the ovary becomes thin and smooth and appears as a bluish-grey. Follicular cysts may rarely become as large as 3 or 4 inches. The majority of these cysts, even the large ones, go away after a month or two as the extra fluid dissolves back into the blood stream.
At the time of ovulation, the covering of the ovary tears open in order to release the egg. Within hours, this covering heals, and the cells in the ovary form a structure called the corpus luteum. The corpus luteum produces progesterone, the hormone that prepares the uterine lining cells for the arrival of the fertilized egg. Every menstruating woman, every month, forms a corpus luteum. However, cells can produce fluid within the corpus luteum and form a cyst. While a corpus luteum cyst is usually no larger than a small marble, sometimes so much fluid is produced that a cyst of a few inches results. The good news is that, like follicular cysts, practically all corpus luteum cysts will go away by themselves in a few weeks. Follicular cysts and corpus luteum cysts are collectively referred to as functional cysts.
A number of other types of ovarian cysts can form as a result of the abnormal growth of other cells contained in the ovary. These cysts are less common and are discussed later in this chapter.
The most accurate way to get a picture of the ovary and cyst is with a vaginal sonogram. This test uses a small instrument which is comfortably passed into the vagina. This instrument bounces harmless sound waves off your uterus, fallopian tubes, and ovaries, forming a picture on a monitor. A sonogram allows the doctor to accurately determine the size of the cyst and to "see" inside it in order to detect whether it is filled with fluid or solid areas. This can help determine the type of cyst that is present. Certain types of ovarian cysts, depending on which cells in the ovary are overgrowing, will make fairly reliable patterns on a sonogram. In performing the sonogram, one concern is to look for ovarian cancer. Abnormal cysts often will have an overgrowth of cells that stick out from the inside of the cyst wall, making the inside of the cyst appear jagged on the sonogram. Still, many of these irregularly shaped cysts are benign, but cancer can also appear this way. Unfortunately, the sonogram cannot make a definite diagnosis of benign vs. malignant cysts. So, if the sonogram shows solid areas within a cyst, surgery will be needed to remove it.
Simple ovarian cyst – clear fluid within the cyst appears black on ultrasound. The chance that this is cancer is close to zero.
Endometrioma – small flecks of blood within the cyst usually indicates endometriosis
Dermoid cyst – bright areas indicate fat within the cyst.
Ovarian cancer – cancer causes very irregular growths within the ovary.
Instruments are now available that enable the gynecologist to remove a cyst through small incisions in the abdomen. This type of procedure, known as laparoscopic surgery, provides the benefits of outpatient surgery and a quick recovery. Using a telescope placed through the navel and small instruments placed near the pubic bone, the gynecologic surgeon can remove either the cyst alone or the entire ovary.
An ovarian cyst, which looks like a small balloon filled with water, grows from within the ovary and stretches the normal ovarian tissue over it. Removing the cyst, called a cystectomy, is like taking a clam out of the shell. The thinned out ovarian tissue is cut open, and the cyst is gently peeled away from inside the ovary. The cyst fluid is then removed with a suction device. The cyst now looks like a deflated balloon and can easily be removed through the small laparoscopy incision. If a cyst has destroyed all the normal ovarian tissue, it may be necessary to remove the entire ovary. A number of ways have been developed to allow the removal of the entire ovary with the laparoscope. Using either special sutures or surgical staples, the blood vessels going to the ovary can be tied, and the ovary cut away and removed. In most situations, the operating time for laparoscopic surgery takes no longer than standard surgery. However, the benefit of laparoscopic surgery is that you may leave the hospital the same day and return to normal activity within a week or two.
This is a 6 cm cyst in the left ovary. See ovary on right for comparison.
The surface of the ovary has been cut to reveal the cyst below.
The normal ovary has been peeled off of the cyst.
The cyst has been removed and the entire remaining healthy ovary folds back together.
For more information about whether you should have your ovaries removed, please see: http://www.ovaryresearch.com/
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