Ovarian Cyst Surgery

An ovarian cyst is a fluid-filled sac in or on the ovary. Almost all ovarian cysts of women in reproductive age are benign. They are either simple cysts, known as functional cysts, or benign tumors of the ovary. Functional cysts, generally come and go, and normally shrink on their own or with birth control pills within 1-2months, and do not require surgery. Simple cyst usually occur with normal ovulation or in women with ovulatory dysfunction. Actually, the definition of a simple or functional cyst, is that it does go away on its own. On the other hand, persistent cysts, or benign tumors of the ovary do not go away on there own or with birth control pills, and generally require laparoscopic surgery to remove them. If an ovarian cyst is treated with observation or birth control pills and does not go away after1-3 months, it is known as "persistent". At times, functional cysts do not cause any symptoms and are picked up on a routine gynecologic exam, other times they can cause abdominal discomfort or pain, abnormal bleeding, ovulatory dysfunction and bloating. The same is true for benign tumors of the ovary, like an endometrioma, hemorrhagic cyst, dermoid cyst, serous cyst or mucinous cystadenoma.

Ovarian cysts are either picked up on routine gynecologic examination or the woman is complaining of abdominal and/or pelvic pain or discomfort. ACFS recommends whenever there is any question about the possibility of an ovarian cyst, an ultrasound should be done. That is the best way to be able to differentiate between a functional cyst and a benign tumor of the ovary. A simple cyst is fluid-filled and on ultrasound (US) shows up as an enlarged circumscribed black circle in the ovary. A benign tumor, is generally solid or complex (has a combination of fluid-filled areas and solid areas), and appears on US as an enlarged circumscribed dense area or with a "snowstorm" appearance.

Types of functional (simple) or benign ovarian cysts

1. Functional (physiologic or simple) cysts. The most common type of ovarian cyst is the functional cyst, also called a simple or physiologic cyst. It develops from normal tissue that changes during the process of ovulation. Your ovaries normally grow cystic structures called follicles each month. Sometimes these follicular cysts enlarge, with or without symptoms. Typically, they resolve back to normal ovarian tissue after ovulation. Functional cysts fall into two categories; follicular cyst (from the first half of the cycle before ovulation), and corpus luteumcyst (the second half of the cycle after ovulation).
   1. Follicular cyst. The pituitary gland in your brain stimulates the growth of a follicle by sending it signals, FSH, to start follicle growth, and LH to trigger ovulation. This is called a "LH surge". Normally the egg is released from the follicle and gets picked up by the fallopian tube where fertilization occurs. If the LH surge does not occur, the follicle does not rupture and release the egg. Instead, with continuous FSH, the follicle can grow and can become a cyst. These cysts seldom cause pain and go away on their own.
   2. Corpus luteum cyst. When there is a successful LH surge and the egg is released, the follicle transforms into a corpus luteum (CL) and secretes progesterone, necessary to prepare the lining of the uterus for implantation. Sometimes, the woman can bleed into the CL, causing a corpus luteum cyst. Occasionally, these CL cysts can get quite large and cause abdominal pain, rupture with internal bleeding or twist on itself, known as ovarian cyst torsion. If that is the case, the woman is in a lot of pain and, if surgery is done soon enough, you may be able to "untwist" the ovary and save it; if not, it has to be removed. If it is just a large CL, you can just remove the cyst and preserve the rest of the ovary. You should always try to preserve as much normal ovary as possible in a woman in reproductive age

   With any benign tumor of the ovary, it is important to try to make the diagnosis as early as possible before the tumor gets too big. This is for two reasons. One, is that it is easier to remove through the laparoscope; and secondly, and more importantly, the bigger the ovarian mass gets, the more it "pancakes" the surrounding normal ovarian tissue and destroys it.

   If a benign ovarian tumor gets too big, generally the entire ovary needs to be removed. To goal is always to save as much ovarian tissue as possible, even if it is only a small piece. You never know if the other ovary will develop a large ovarian cyst in the future and need to be removed. Without either ovary, you are now menopausal and "out of eggs". Also, in a woman of childbearing age, some ovary is better than no ovary, because at least it can produce some eggs with stimulation

2. Dermoid cyst. A dermoid cyst, is a benign tumor of the ovary, and consists mainly of hair and sebaceous material. In 50% of dermoids you will find a tooth. A dermoid has microscopic fetal tissue and is thought to be due to auto-fertilization of an egg. They generally grow to 3-7 cm, and have to be removed surgically, usually by laparoscopy, because they will not go away on their own, and can only get bigger in size and increase the risks of the above complications. Very rarely, they can become very large, start to leak or rupture, and cause bleeding into the abdomen.

3. Endometrioma or "chocolate cyst". These are cysts that form when endometrial tissue implants on the ovary and the woman "menstruates" into the ovary each month, forming a blood filled cavity or endometrial cyst (endometrioma). It can slowly grow in size as the endometrial tissue responds to the monthly hormonal cycling. This cyst is commonly called a "chocolate cyst", because when the hemoglobin is removed, the remaining blood is a dark, reddish-brown color. They can be on one ovary, but commonly they can be bilateral (on both ovaries). From ultrasound diagnosis, it can turn out to be either the only finding at laparoscopy, or it can be associated with widespread endometriosis.

   They can be asymptomatic or can present with pelvic pain (especially with a woman's period), painful intercourse and infertility. Generally, an endometrioma greater than one centimeter will not go away on its own, and will need laparoscopic surgery before it gets too large and destroys the entire ovary.

4. Cystadenoma. Cystadenomas are cysts that develop from cells on the surface of your ovary. They are generally benign, and either have clear fluid-known as a serous cystadenoma or be filled with mucin, known as mucinouscystadenoma. Sometimes they can become quite large, causing pelvic pain and loss of the involved ovary due to "pancaking". They will needlaparoscopic surgery to be removed.

5. Multiple cysts - PCOD ovary. Women who have irregular cycles and do not ovulate on a regular basis can develop multiple cysts. In 50% of the women with PCOD, the ovaries are enlarged 2-3 times normal. Women with PCOD are more prone to develop simple ovarian cysts.

Most ovarian cysts go undiagnosed until found on a routine gynecologic examination or present with abdominal/pelvic pain. Although, many will resolve on there own, some become symptomatic. ACFS believes that whenever a woman in reproductive age complains of abdominal and/or pelvic pain, she should have a vaginal ultrasound done to evaluate the ovaries for ovarian cysts. Common reasons to cause an ovarian cyst to become symptomatic are:

1. Rupture with internal bleeding into the abdomen
2. Rapid growth with stretching of the ovarian capsule
3. Bleeding into the cyst but without rupture
4. twisting or torsion of the cyst around its blood supply- which is extremely painful and is a medical emergency

In ACFS opinion, the best way to diagnose an ovarian cyst of any kind is either by abdominal ultrasound or transvaginal ultrasound (US). At ACFS, we do all our ultrasounds transvaginally. With abdominal US, you have to drink 32+ ounces of water before the exam for visualization and, as a result, they are sometimes uncomfortable. With transvaginal US, you have an empty bladder.

Once the diagnosis of an ovarian cyst is made, there are several additional tests that can be done to confirm the diagnosis. Usually, ultrasound is adequate to make the diagnosis. However, if there is doubt as to what type of ovarian cyst it may be, than ACFS recommends getting a MRI. These tests are very helpful in differentiating the type of benign ovarian tumor you are dealing with.

Also helpful is a CA-125, which is a protein marker, that is extremely elevated in ovarian cancer. It can be used as a screening test to "rule in" or "rule out" an endometrioma (endometriosis). It is a simple blood test, and if mildly elevated, it suggests the diagnosis that the mass seen on US is an endometrioma; and if normal, suggests some other benign tumor of the ovary. As a screening test it is not always 100% accurate, and the woman can still have an endometrioma in spite of a normal CA125 level.

Almost all of the time, a "persistent" ovarian mass or benign ovarian tumor can be removed through the laparoscope. Occasionally, the mass is involved in extensive adhesions, or scar tissue, and necessitates an open procedure, orlaparotomy. As with any surgery, the experience and expertise of the reproductive surgeon is very important to the outcome, especially in women who are attempting pregnancy or want to maintain their child bearing potential