Gynaecology (II)

Subtopic:

Ovarian cysts

Ovarian cysts are sac-like structures filled with fluid that develop in or on the ovary’s surface.

Essentially, an ovarian cyst is a pouch within the ovary that can be filled with fluid or be somewhat solid.

Many women will experience ovarian cysts at some point in their lives. Often, these cysts cause minimal or no symptoms and are not harmful. In most cases, they resolve on their own within a few months without any intervention.

Aetiology of Ovarian Cysts

The majority of ovarian cysts arise from the regular functioning of the ovaries as part of the menstrual cycle. These are typically benign and disappear naturally within a few menstrual cycles. However, some cysts are due to unusual cell growth and are not related to the monthly cycle. These can occur both before and after menopause. Conditions contributing to ovarian cysts include:

  1. Hormonal Imbalances:

    • Polycystic Ovary Syndrome (PCOS): This hormonal disorder is characterized by multiple cysts forming on the ovaries. PCOS is the most frequent cause of ovarian cysts.

    • Endometriosis: In this condition, tissue similar to the uterine lining grows outside the uterus, sometimes affecting the ovaries and leading to cyst development.

    • Premature Ovarian Insufficiency (POI): This condition, also known as Premature Ovarian Failure, occurs when the ovaries cease to function properly before the age of 40, resulting in hormonal irregularities and potential cyst formation.

Risk Factors include:

  1. Medications:

    • Fertility Medications: Drugs used to stimulate ovulation can increase the likelihood of cyst formation.

    • Certain Contraceptives: Some hormonal birth control methods, like specific types of oral contraceptive pills, can also be associated with the development of ovarian cysts.

  2. Genetics:

    • Family History of PCOS: Having a family history of Polycystic Ovary Syndrome increases an individual’s risk of developing the condition and its associated ovarian cysts.

Types of Ovarian Cysts

Functional Cysts (Physiological Cysts)

These are cysts that arise as a normal part of the menstrual cycle. They are generally benign, resolve quickly, and are the most frequently encountered type of ovarian cyst.

  • Follicular Cyst: This type develops when an ovarian follicle, which normally holds an egg, fails to open and release the egg. Instead of rupturing, the follicle continues to enlarge, becoming a cyst.

  • Corpus Luteum Cyst (Luteal Cyst): This cyst forms after ovulation. If, after releasing an egg, the follicle seals shut and fluid accumulates inside, it becomes a corpus luteum cyst.

Pathological Cysts (New Growths)

These cysts are less common and are caused by unusual cell proliferation rather than the normal menstrual process.

  • Dermoid Cysts (Teratomas): These are unique cysts that originate from egg-producing cells and can contain various types of tissue, such as hair, skin, and even teeth.

  • Cystadenomas: These cysts develop from the surface tissue of the ovary and can be filled with a fluid that is either watery or mucus-like.

  • Endometriomas (Chocolate Cysts): These cysts are a consequence of endometriosis. They occur when endometrial-like tissue, similar to the lining of the uterus, grows outside the uterus and forms cysts on the ovaries. They are often called “chocolate cysts” because they contain old blood that resembles chocolate syrup.

Signs and Symptoms of Ovarian Cysts

  1. Frequently No Symptoms: Often, ovarian cysts are asymptomatic, meaning many women are unaware they have them.

  2. Pelvic Discomfort: May cause pain in the pelvis, which can be described as sharp or dull, or a general feeling of pressure in the lower abdomen.

  3. Abdominal Fullness or Swelling: Some individuals might experience a sensation of being bloated or notice their abdomen feels fuller or appears swollen.

  4. Menstrual Cycle Changes: Ovarian cysts can interfere with regular menstruation, leading to irregular periods, such as periods that are heavier, lighter, longer, shorter, or unpredictable.

  5. Painful Sexual Activity: Discomfort or pain during sexual intercourse can occur if cysts are present, sometimes referred to as dyspareunia.

  6. Urinary Frequency Changes: Cysts pressing on the bladder can lead to alterations in urination habits, such as needing to urinate more often or feeling an urgent need to urinate.

  7. Digestive System Issues: Larger cysts can exert pressure on the digestive tract, potentially causing symptoms like nausea, vomiting, or changes in bowel habits.

  8. Painful Bowel Movements: Pressure from cysts on the rectum can result in discomfort or pain during defecation.

  9. Low Energy or Tiredness: Some women with ovarian cysts may experience unexplained fatigue or a general lack of energy.

  10. Breast Sensitivity: Ovarian cysts can sometimes be associated with breast tenderness or noticeable changes in breast size.

Signs and Symptoms of Ruptured Ovarian Cysts

  1. Sudden, Intense Abdominal or Pelvic Pain: A ruptured cyst often causes a sharp, severe pain that starts abruptly in the lower abdomen or pelvic region, sometimes radiating to the back.

  2. Vaginal Bleeding or Spotting: Following cyst rupture, some women may notice light vaginal bleeding or spotting.

  3. Abdominal Distension: The abdomen may become bloated or feel full after a cyst ruptures.

  4. Severe Nausea and Vomiting: In certain cases, a ruptured cyst can trigger intense nausea and vomiting.

  5. Feeling Faint or Dizzy: Lightheadedness, dizziness, or even fainting can occur as symptoms of a ruptured ovarian cyst, potentially due to internal bleeding or pain response.

DIAGNOSIS OF OVARIAN CYSTS

  • Medical History and Physical Check-up:

    • Review of symptoms, past health records, and risk factors related to ovarian cysts.

    • A pelvic exam may be conducted to feel for any irregularities or indications of a cyst.

  • Pregnancy Test: A positive test can suggest the presence of a corpus luteum cyst, which is related to pregnancy.

  • Imaging Scans:

    • Pelvic Ultrasound: The most common imaging method to diagnose ovarian cysts. It produces detailed images of the ovaries, helping to assess the cyst’s size, location, and characteristics.

    • Transvaginal Ultrasound: In some instances, this may be used for clearer ovarian views. A small probe is inserted into the vagina to get closer, more detailed images.

  • Blood Analysis:

    • CA-125 Assay: Measures levels of the CA-125 protein in the blood. Elevated levels can be associated with ovarian cysts, including cancerous ones, but it’s not specific for cancer alone.

    • Hormone Level Tests: Blood tests to check hormone levels like estrogen and progesterone can assist in determining the type of ovarian cyst.

  • Laparoscopy (Surgical Visualization):

    • In select cases, this minimally invasive surgery might be advised. A small incision is made in the abdomen, and a laparoscope (thin tube with a camera) is inserted to directly view the ovaries and confirm cyst presence.

  • Biopsy (Tissue Sampling):

    • If ovarian cancer is suspected, a biopsy might be needed. A tissue sample is taken for lab analysis to determine if cancer cells are present.

MANAGEMENT OF OVARIAN CYSTS

Management strategies for ovarian cysts are tailored based on cyst type, size, symptoms, and the patient’s health history.

  1. Observation with Monitoring (Watchful Waiting): Often, cysts disappear naturally without intervention. This approach involves regular follow-up appointments, potentially with repeat ultrasounds, to monitor the cyst and ensure it’s not growing or causing problems.

  2. Medications:

    • Hormonal Contraceptives: Birth control pills may be prescribed to regulate menstrual cycles and prevent new cysts from forming. They can also help shrink existing functional cysts by suppressing ovulation and reducing cyst development.

    • NSAIDs (Nonsteroidal Anti-Inflammatory Drugs): Pain relievers like naproxen, acetaminophen, and ibuprofen can help manage pain associated with ovarian cysts.

  3. Surgical Treatment: Surgery might be considered in certain situations:

    • Large or Symptomatic Cysts: If a cyst is large, persistent, and causing significant symptoms that affect daily life, surgical removal may be recommended.

    • Suspicion of Cancer: If there’s concern that a cyst could be cancerous or have cancerous potential, surgery to remove and examine it may be necessary.

    • Complications: In cases of ovarian torsion (twisting of the ovary) or cyst rupture, emergency surgery may be required to address these acute issues.

  4. Surgical Procedures: Two primary surgical methods are used:

    • Laparoscopy (Minimally Invasive Surgery): This technique uses small abdominal incisions and a laparoscope to remove or drain the cyst. It usually results in faster recovery and less post-operative pain.

    • Laparotomy (Open Surgery): For larger cysts or when malignancy is suspected, a larger abdominal incision may be necessary to remove the cyst. This typically involves a longer hospital stay and recovery period.

  5. Fertility Considerations: When fertility is important, the goal is to preserve reproductive function if possible. Sometimes only the cyst is removed, leaving the ovaries intact. However, in some situations, removing both ovaries might be necessary, potentially leading to early menopause. In such cases, assisted reproductive technologies might be considered for future fertility.

PREVENTIVE MEASURES FOR OVARIAN CYSTS

  1. Routine Pelvic Examinations: Regular pelvic exams are important for early detection of ovarian cysts and monitoring their changes, enabling timely intervention if needed.

  2. Hormonal Birth Control: Using hormonal contraceptives, such as birth control pills, can help regulate the menstrual cycle and reduce the likelihood of developing ovarian cysts.

  3. Maintain Healthy Weight: Obesity and being overweight can increase the risk of ovarian cysts. Maintaining a healthy weight through balanced diet and regular exercise may help in prevention.

  4. Hormone Management: Managing conditions like Polycystic Ovary Syndrome (PCOS), which increase cyst risk, through medication or lifestyle adjustments can be beneficial.

  5. Avoid Smoking: Smoking has been linked to a higher risk of ovarian cysts. Quitting or avoiding secondhand smoke can help lower this risk.

  6. Treat Underlying Conditions: Managing conditions like endometriosis or hormonal imbalances can indirectly help prevent ovarian cysts.

  7. Judicious Use of Hormone Therapy: Certain hormone therapies, like fertility treatments, can increase cyst risk. Discuss potential risks with a healthcare provider before starting any hormone therapy.

  8. Regular Physical Activity: Engaging in regular exercise can help regulate hormone levels and promote overall reproductive health, potentially reducing the risk of ovarian cysts.

COMPLICATIONS OF OVARIAN CYSTS

  1. Ovarian Torsion (Twisting): A large cyst can cause the ovary to twist or move, cutting off its blood supply. This results in severe pain and requires urgent medical attention.

  2. Cyst Rupture: Ovarian cysts can burst, causing sudden, intense pain. Rupture can lead to internal bleeding and increase the risk of infection.

  3. Infection: Risk of infection may increase, particularly postpartum if the woman has recently given birth, and if a cyst becomes malignant.

  4. Hemorrhage: Rupture of blood vessels within a cyst can lead to bleeding.

  5. Intestinal Obstruction: Malignant cysts, especially, can cause the intestines to adhere to them, potentially leading to bowel obstruction.

  6. Pregnancy Complications: Ovarian cysts can be associated with complications during pregnancy, including abortion, abnormal fetal positions (malpresentations), and obstructed labor.