definition of ovarian cyst

8/3/2019 Definition of Ovarian Cyst

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An ovarian cyst is a sac filled with liquid or semi-liquid material arising in an ovary. The number ofdiagnoses of ovarian cysts has increased with the widespread implementation of regular physicalexaminations and ultrasound technology. The finding of an ovarian cyst causes considerable anxietyfor women because of the fear of malignancy, but the vast majority of ovarian cysts are benign.

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Each month, normally functioning ovaries develop small cysts called Graafian follicles.[1] At mid cycle,a single dominant follicle up to about 2.8 cm in diameter releases a mature oocyte.

The ruptured follicle becomes the corpus luteum, which, at maturity, is a 1.5- to 2-cm structure with acystic center. In the absence of fertilization of the oocyte, it undergoes progressive fibrosis andshrinkage. If fertilization occurs, the corpus luteum initially enlarges and then gradually decreases insize during pregnancy.

Ovarian cysts arising in the normal process of ovulation are called functional cysts and are alwaysbenign. They may be follicular and luteal, sometimes called theca-lutein cysts. These cysts can bestimulated by gonadotropins, including follicle-stimulating hormone (FSH) and human chorionicgonadotropin (hCG). A theca-lutein cyst is shown in the sonogram below.

Theca-lutein cysts replacing an ovary in a patient with a molar pregnancy.Despite their size these cysts are benign and usually resolve after treatment of the underlying disease.

Multiple functional cysts can occur as a result of excessive gonadotropin stimulation or sensitivity.In gestational trophoblastic neoplasia (hydatidiform mole and choriocarcinoma) and rarely in multipleand diabetic pregnancy, hCG causes a condition called hyperreactio luteinalis. In patients beingtreated for infertility, ovulation induction with gonadotropins (FSH and luteinizing hormone [LH]), andrarely clomiphene citrate, may lead to ovarian hyperstimulation syndrome, especially if accompaniedby hCG administration.

Neoplastic cysts arise by inappropriate overgrowth of cells within the ovary and may be malignant orbenign. Malignant neoplasms may arise from all ovarian cell types and tissues. By far, the mostfrequent are those arising from the surface epithelium (mesothelium), and most of these are partially

cystic lesions. The benign counterparts of these cancers are serous and mucinous cystadenomas.Other malignant ovarian tumors may contain cystic areas, and these include granulosa cell tumorsfrom sex cord stromal cells and germ cell tumors from primordial germ cells. A clear cell carcinoma isshown in the image below.
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Cross-section of a clear cell carcinoma of the ovary. Note the cystic spacesintermingled with solid areas.

Teratomas are a form of germ cell tumor[2] containing elements from all 3 embryonic germ layers, ie,ectoderm, endoderm, and mesoderm. A mature cystic teratoma is shown in the image below.

A dermoid cyst (mature cystic teratoma) after opening the abdomen. Note theyellowish color of the contents seen through the wall.

Endometriomas are cysts filled with blood arising from the ectopic endometrium. In polycystic ovarysyndrome, the ovary often contains multiple cystic follicles 2-5 mm in diameter as viewed onsonograms. The cysts themselves are never the main problem, and discussion of this disease isbeyond the scope of this article.

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Frequency

United StatesOvarian cysts are found on transvaginal sonograms in nearly all premenopausal women and in up to18% of postmenopausal women.[3] Most of these cysts are functional in nature and benign. Mature

cystic teratomas or dermoids represent more than 10% of all ovarian neoplasms. The incidence ofovarian carcinoma is approximately 15 cases per 100,000 women per year. Annually in the UnitedStates, ovarian carcinomas are diagnosed in more than 21,000 women, causing an estimated 14,600deaths.[4] Most malignant ovarian tumors are epithelial ovarian cystadenocarcinomas. Tumors of lowmalignant potential comprise approximately 20% of malignant ovarian tumors, whereas fewer than 5%are malignant germ cell tumors, and approximately 2% granulosa cell tumors.

Mortality/Morbidity

Benign cysts can cause pain and discomfort related to pressure on adjacent structures,torsion, rupture, hemorrhage (both within and outside of the cyst), and abnormal uterine bleeding.They rarely cause death. Mucinous cystadenomas may cause a relentless collection of mucinousfluid within the abdomen, known as pseudomyxoma peritonei, which may be fatal without extensivetreatment.

Mortality associated with malignant ovarian carcinoma is related to the stage at the time ofdiagnosis, and patients with ovarian carcinoma generally present late in the course of disease. The
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5-year survival rate overall is 41.6%, varying between 86.9% for International Federation ofGynecology and Obstetrics (FIGO) stage Ia and 11.1% for stage IV. [5]Granulosa cell tumors areassociated with an 82% survival rate, whereas squamous cell carcinomas arising in a dermoid cysthave a very poor outcome. Most germ cell tumors are diagnosed at an early stage and have anexcellent outcome. Advanced-stage dysgerminomas are associated with a better outcomecompared to nondysgerminomatous germ cell tumors. A distinct group of less aggressive tumors of

low malignant potential has a more benign course but is still associated with mortality.[6]

The overallsurvival rate is 86.2% at 5 years.

Malignant ovarian cystic tumors can cause severe morbidity, including pain, abdominaldistension, bowel obstruction, nausea, vomiting, early satiety, wasting, cachexia, indigestion,heartburn, abnormal uterine bleeding, deep venous thrombosis, and dyspnea. Cystic granulosa celltumors may secrete estrogen, which leads to postmenopausal bleeding and precocious puberty inelderly patients and young patients, respectively.

Race

Malignant epithelial ovarian cystadenocarcinomas are the only ovarian cysts associated with racialdifferences.

Women from northern and western Europe and North America are affected most frequently,whereas women from Asia, Africa, and Latin America are affected least frequently.

Within the United States, age-adjusted incidence rates in surveillance areas are highestamong American Indian women, followed by white, Vietnamese, Hispanic, and Hawaiian women.Incidence is lowest among Korean and Chinese women.[7]

Among women for whom sufficient numbers of cases are available to calculate rates basedon age, incidence in those aged 30-54 years is highest in white women, followed by Japanese,Hispanic, and Filipino women. For those aged 55-69 years, the highest rates occur in white women,followed by Hispanic and Japanese women. Among women aged 70 years or older, the highest rateoccurs among white women, followed by those of African descent and Hispanic women.

Age

Functional ovarian cysts occur at any age (including in utero), but are much more common inreproductive-aged women. They are rare after menopause. Luteal cysts occur after ovulation inreproductive-aged women. Most benign neoplastic cysts occur during the reproductive years, butthe age range is wide and they may occur in persons of any age.

The incidence of epithelial ovarian cystadenocarcinomas, sex cord stromal tumors, andmesenchymal tumors rises exponentially with age until the sixth decade of life, at which point theincidence plateaus. Tumors of low malignant potential occur at a mean age of 44 years, with a spanfrom adolescence to senescence. The average age is more than a decade less than that forinvasive cystadenocarcinoma. Germ cell tumors are most common in adolescence and rarely occurin those older than 30 years.

History

Most patients with ovarian cysts are asymptomatic but some cysts may be associated with arange of symptoms, sometimes severe.[8]Even malignant ovarian cysts commonly do not causesymptoms until they reach an advanced stage.

Pain or discomfort may occur in the lower abdomen. Torsion (twisting) or rupture may lead tomore severe pain. An ovarian cyst that has undergone torsion is shown in the image below.


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An ovarian cyst that has undergone torsion (twisting of the vascular pedicle).The patient presented with a short history of severe lower abdominal pain. The twisted pedicle can be seen attachedto the cyst, which has turned dusky due to ischemia. No viable epithelial lining was available for histologic diagnosis.

Patients may experience discomfort with intercourse, particularly deep penetration.

Having bowel movements may be difficult, or pressure may develop, leading to a desire todefecate.

Micturition may occur frequently and is due to pressure on the bladder.

Irregularity of the menstrual cycle and abnormal vaginal bleeding may occur. Young childrenmay present with precocious puberty and early onset of menarche.

Patients may experience abdominal fullness and bloating.

Patients may experience indigestion, heartburn, or early satiety.

Endometriomas are associated with endometriosis, which causes a classic triad of painful andheavy periods and dyspareunia.

Polycystic ovaries may be part of thepolycystic ovary syndrome, which includes hirsutism,infertility, oligomenorrhea, obesity, and acne.

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Advanced malignant disease may be associated with cachexia and weight loss,lymphadenopathy in the neck, shortness of breath, and signs of pleural effusion.

A large cyst may be palpable on abdominal examination. Gross ascites may interfere withpalpation of an intra-abdominal mass.

Although normal ovaries may be palpable during the pelvic examination in thinpremenopausal patients, a palpable ovary should be considered abnormal in a postmenopausalwoman. If a patient is obese, palpating cysts of any size may prove difficult.

Sometimes, discerning the cystic nature of an ovarian cyst may be possible, and it may betender to palpation. The cervix and uterus may be pushed to one side.

Other masses may be palpable, including fibroids and nodules in the uterosacral ligamentconsistent with malignancy or endometriosis.

Multiple functional cysts can occur as a result of excessive gonadotropin stimulation orsensitivity.o In gestational trophoblastic neoplasia (hydatidiform mole and choriocarcinoma) and

rarely in multiple or diabetic pregnancy, hCG is the stimulating gonadotropin. The condition iscalled hyperreactio luteinalis.o Patients being treated for infertility by ovulation induction with gonadotropins or other

agents, such as clomiphene citrate or letrozole, may develop cysts as part of ovarianhyperstimulation syndrome.
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Tamoxifen can cause benign functional ovarian cysts that usually resolve followingdiscontinuation of treatment.

Risk factors for ovarian cystadenocarcinoma include strong family history, advancing age,white race, infertility, nulliparity, a history ofbreast cancer, and BRCA gene mutations.

Differential dx

Differentials

Abdominal Abscess

Ectopic Pregnancy

Intra-abdominal abscess continues to bean important and serious problem insurgical practice. Appropriate treatment

is often delayed because of the obscurenature of many conditions resulting inabscess formation, which can makediagnosis and localization difficult.Associated pathophysiologic effects may

become life threatening or lead toextended periods of morbidity withprolonged hospitalization. Delayeddiagnosis and treatment can also lead toincreased mortality rates; therefore, the
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economic impact of delaying treatment issignificant.

A better understanding of intra-abdominalabscess pathophysiology and a highclinical index of suspicion should allowfor earlier recognition, definitivetreatment, and reduced morbidity andmortality.[1] (See image below.)

Percutaneous computedtomography (CT) scanguided drainage of

postoperative

Although multiple causes of intra-abdominal abscesses exist, the following are the most common: (1)perforation of a diseased viscus, which includes peptic ulcer perforation; (2) perforated appendicitisand diverticulitis; (3) gangrenous cholecystitis; (4) mesenteric ischemia with bowel infarction; and (5)pancreatitis or pancreatic necrosis progressing to pancreatic abscess. (See image below.)

Contrast-enhanced computed tomography (CT) scan of infected pancreaticpseudocyst (which can develop from acute necrotizing pancreatitis and give rise to an abscess).

Other causes include untreated penetrating trauma to the abdominal viscera and postoperativecomplications, such as anastomotic leak[1, 2] or missed gallstones during laparoscopic cholecystectomy.
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Microbiology includes a mixture of aerobic and anaerobic organisms. The most commonly isolatedaerobic organism is Escherichia coli, and the most commonly observed anaerobic organismis Bacteroides fragilis.[3] A synergistic relationship exists between these organisms. In patients whoreceive prolonged antibiotic therapy, yeast colonies (eg, candidal species) or a variety of nosocomialpathogens may be recovered from abscess fluids.

Skin flora may be responsible for abscesses following a penetrating abdominal injury. Neisseriagonorrhoeae and chlamydial species are the most common organisms involved in pelvic abscesses infemales as part of pelvic inflammatory disease. The type and density of aerobic and anaerobicbacteria isolated from intra-abdominal abscesses depend upon the nature of the microflora associatedwith the diseased or injured organ.

Microbial flora of the GI tract shifts from small numbers of aerobic streptococci, including enterococciand facultative gram-negative bacilli in the stomach and proximal small bowel, to larger numbers ofthese species, with an excess of anaerobic gram-negative bacilli (particularly Bacteroidesspecies) andanaerobic gram-positive flora (streptococci and clostridia) in the terminal ileum and colon. Differencesin microorganisms observed from the upper to the lower portion of the GI tract partially account fordifferences in septic complications associated with injuries or diseases to the upper and lower gut.Sepsis occurring after upper GI perforations or leaks causes less morbidity and mortality than doessepsis after leaks from colonic insults.

Patho

Intra-abdominal abscesses are localized collections of pus that are confined in the peritoneal cavityby an inflammatory barrier. This barrier may include the omentum, inflammatory adhesions, orcontiguous viscera. The abscesses usually contain a mixture of aerobic and anaerobic bacteria fromthe GI tract.

Bacteria in the peritoneal cavity, in particular those arising from the large intestine, stimulate an influxof acute inflammatory cells. The omentum and viscera tend to localize the site of infection, producinga phlegmon. The resulting hypoxia in the area facilitates growth of anaerobes and impairs bactericidalactivity of granulocytes. The phagocytic activity of these cells degrades cellular and bacterial debris,creating a hypertonic milieu that expands and enlarges the abscess cavity in response to osmoticforces. If untreated, the process continues until bacteremia develops, which then progresses togeneralized sepsis with shock.

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Intra-abdominal abscesses are highlyvariable in presentation. Persistentabdominal pain, focal tenderness, spiking

fever, prolonged ileus, leukocytosis, orintermittent polymicrobial bacteremiasuggest an intra-abdominal abscess inpatients with predisposing primary intra-abdominal disease or in individuals who

have had abdominal surgery. If a deeply


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seated abscess is present, many of theseclassic features may be absent. The only

initial clues may be persistent fever, mildliver dysfunction, persistent GIdysfunction, or nonlocalizing debilitatingillness.

The diagnosis of an intra-abdominalabscess in the postoperative period maybe difficult, because postoperativeanalgesics and incisional pain frequentlymask abdominal findings. In addition,antibiotic administration may mask

abdominal tenderness, fever, andleukocytosis.

In patients with subphrenic abscesses,irritation of contiguous structures may

produce shoulder pain, hiccup, orunexplained pulmonary manifestations,such as pleural effusion, basalatelectasis, or pneumonia. With pelvicabscesses, frequent urination, diarrhea,or tenesmus may occur. A diverticular


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abscess may present as an incarceratedinguinal hernia.[4]

Many patients have a significant septicresponse, suffer volume depletion, anddevelop a catabolic state. This syndromemay include high cardiac output,tachycardia, low urine output, and lowperipheral oxygen extraction. Initially,respiratory alkalosis due tohyperventilation may occur. If leftuntreated, this progresses to metabolicacidosis. Sequential multiple organ

failure is highly suggestive of intra-abdominal sepsis.

The 6 functional compartments in theperitoneal cavity include the following: (1)

pelvis, (2) right paracolic gutter, (3) leftparacolic gutter, (4) infradiaphragmaticspaces, (5) lesser sac, and (6) interlooppotential spaces of the small intestine.

The paracolic gutters slope into the

subhepatic and subdiaphragmatic spaces


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superiorly and over the pelvic briminferiorly. In a supine patient, the

peritoneal fluid tends to collect under thediaphragm, under the liver, and in thepelvis. More localized abscesses tend todevelop anatomically in relation to theaffected viscus. For example, abscesses

in the lesser sac may develop secondaryto severe pancreatitis, or periappendicealabscesses from a perforated appendixmay develop in the right lower quadrant.Small bowel interloop abscesses maydevelop anywhere from the ligament of

Treitz to the ileum. An understanding ofthese anatomic considerations isimportant for the recognition anddrainage of these abscesses.

Ectopic pregnancy presents a major health problem for women of childbearing age. It is the result of a

flaw in human reproductive physiology that allows the conceptus to implant and mature outside theendometrial cavity, which ultimately ends in death of the fetus. Without timely diagnosis andtreatment, ectopic pregnancy can become a life-threatening situation.

Ectopic pregnancy currently is the leading cause of pregnancy-related death during the first trimesterin the United States, accounting for 9% of all pregnancy-related deaths. In addition to the immediatemorbidity caused by ectopic pregnancy, the woman's future ability to reproduce may be adverselyaffected as well.


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Ectopic pregnancy. Laparoscopic picture of an unruptured right ampullary tubal

pregnancy with bleeding out of the fimbriated end resulting in hemoperitoneum

Ectopic pregnancy is derived from the

Greek word ektopos, meaning out of

place, and it refers to the implantation ofa fertilized egg in a location outside of the

uterine cavity, including the fallopian

tubes, cervix, ovary, cornual region of the

uterus, and the abdominal cavity. This

abnormally implanted gestation growsand draws its blood supply from the site

of abnormal implantation. As the

gestation enlarges, it creates the

potential for organ rupture because only

the uterine cavity is designed to expand

and accommodate fetal development.

Ectopic pregnancy can lead to massive

hemorrhage, infertility, or death.

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Multiple factors contribute to the relativerisk of ectopic pregnancy. In theory,

anything that hampers the migration ofthe embryo to the endometrial cavitycould predispose women to ectopicgestation. The most logical explanationfor the increasing frequency of ectopic

pregnancy is previous pelvic infection;however, most patients presenting withan ectopic pregnancy have no identifiablerisk factor. The following risk factors havebeen linked with ectopic pregnancy:

Pelvic inflammatory disease

The most common cause is antecedentinfection caused by Chlamydiatrachomatis. Patients with chlamydialinfection have a range of clinicalpresentations, fromasymptomatic cervicitis to salpingitis andflorid pelvic inflammatory disease (PID).More than 50% of women who havebeen infected are unaware of the

exposure. Other organisms causing PID,
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such asNeisseria gonorrhoeae, increasethe risk of ectopic pregnancy. A history of

salpingitis increases the risk of ectopicpregnancy 4-fold. The incidence of tubaldamage increases after successiveepisodes of PID (ie, 13% after 1 episode,35% after 2 episodes, 75% after 3

episodes).

History of prior ectopic pregnancy

After one ectopic pregnancy, a patientincurs a 7- to 13-fold increase in the

likelihood of another ectopic pregnancy.Overall, a patient with prior ectopicpregnancy has a 50-80% chance ofhaving a subsequent intrauterinegestation, and a 10-25% chance of afuture tubal pregnancy.

History of tubal surgery andconception after tubal ligation

Priortubal surgery has been

demonstrated to increase the risk of
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developing ectopic pregnancy. Theincrease depends on the degree of

damage and the extent of anatomicalteration. Surgeries carrying higher riskof subsequent ectopic pregnancy includesalpingostomy, neosalpingostomy,fimbrioplasty, tubal reanastomosis, and

lysis of peritubal or periovarianadhesions.

Conception after previous tubal ligationincreases a women's risk of developingectopic pregnancies. Thirty-five to 50% of

patients who conceive after a tuballigation are reported to experience anectopic pregnancy. Failure after bipolartubal cautery is more likely to result inectopic pregnancy than occlusion using

suture, rings, or clips. Failure is attributedto fistula formation that allows spermpassage. Ectopic pregnancies followingtubal sterilizations usually occur 2 ormore years after sterilization, rather than

immediately after. In the first year, only


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about 6% of sterilization failures result inectopic pregnancy.

Use of fertility drugs or assistedreproductive technology

Ovulation induction with clomiphenecitrate or injectable gonadotropin therapy

has been linked with a 4-fold increase inthe risk of ectopic pregnancy in a case-control study. This finding suggests thatmultiple eggs and high hormone levelsmay be significant factors.

One study has demonstratedthat infertility patients with luteal phasedefects have a statistically higher ectopicpregnancy rate than patients whoseinfertility is caused by anovulation. The

risk of ectopic pregnancy and heterotopicpregnancy (ie, pregnancies occurringsimultaneously in different body sites)dramatically increases when a patienthas used assisted reproductive

techniques to conceive, such as in vitro


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fertilization (IVF) or gamete intrafallopiantransfer (GIFT). In a study of 3000 clinical

pregnancies achieved through in vitrofertilization, the ectopic pregnancy ratewas 4.5%, which is more than double thebackground incidence. Furthermore,studies have demonstrated that up to 1%

of pregnancies achieved through IVF orGIFT can result in a heterotopicgestation, compared to an incidence of 1in 30,000 pregnancies for spontaneousconceptions.

Use of an intrauterine device

The presence of an inert copper-containing or progesterone intrauterinedevice (IUD) traditionally has beenthought to be a risk factor for ectopicpregnancy. However, only theprogesterone IUD has a rate of ectopicpregnancy higher than that for womennot using any form ofcontraception. Themodern copper IUD does not increase

the risk of ectopic pregnancy.


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Nevertheless, if a woman ultimatelyconceives with an IUD in place, it is more

likely to be an ectopic pregnancy. Theactual incidence of ectopic pregnancieswith IUD use is 3-4%.

Increasing age

The highest rate of ectopic pregnancyoccurs in women aged 35-44 years. A 3-to 4-fold increase in the risk fordeveloping an ectopic pregnancy existscompared to women aged 15-24 years.

One proposed explanation involves themyoelectrical activity in the fallopian tube,which is responsible for tubal motility.Aging may result in a progressive loss ofmyoelectrical activity along the fallopiantube.

Smoking

Cigarette smoking has been shown to bea risk factor for developing an ectopic

pregnancy. Studies have demonstrated


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elevated risk ranging from 1.6-3.5 timesthat of nonsmokers. A dose-response

effect also has been suggested. Basedon laboratory studies in humans andanimals, researchers have postulatedseveral mechanisms by which cigarettesmoking might play a role in ectopic

pregnancies. These mechanisms includeone or more of the following: delayedovulation, altered tubal and uterinemotility, or altered immunity. To date, nostudy has supported a specificmechanism by which cigarette smoking

affects the occurrence of ectopicpregnancy.

Salpingitis isthmica nodosum

Salpingitis isthmica nodosum is definedas the microscopic presence of tubalepithelium in the myosalpinx or beneaththe tubal serosa. These pockets ofepithelium protrude through the tube,similar to small diverticula. Studies of

serial histopathological sections of the


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fallopian tube have revealed thatapproximately 50% of patients treated

with salpingectomy for ectopic pregnancyhave evidence of salpingitis isthmicanodosum. The etiology of salpingitisisthmica nodosum is unclear, butproposed mechanisms include

postinflammatory and congenital as wellas acquired tubal changes such asobserved with endometriosis.

Other

Other risk factors associated withincreased incidence of ectopic pregnancyinclude previous diethylstilbestrol (DES)exposure, a T-shaped uterus, priorabdominal surgery, failure with progestin-only contraception, and rupturedappendix.

Most ectopic pregnancies are located in the fallopian tube.


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Sites and frequencies of ectopic pregnancy. By Donna M. Peretin, RN. (A)Ampullary, 80%; (B) Isthmic, 12%; (C) Fimbrial, 5%; (D) Cornual/Interstitial, 2%; (E) Abdominal, 1.4%; (F) Ovarian,0.2%; (G) Cervical, 0.2%.

The most common site is the ampullary portion of the tube, where over 80% occur. The next mostcommon sites are the isthmic segment of the tube (12%), the fimbria (5%), and the cornual andinterstitial region of the tube (2%). Nontubal sites of ectopic pregnancy are a rare occurrence, withabdominal pregnancies accounting for 1.4% of ectopic pregnancies and ovarian and cervical sitesaccounting for 0.2% each.

Ovarian cyst

Definition of Ovarian CystsAn ovarian cyst is a sac or pouch that develops in or on the ovary. Thecysts may contain liquid, or solid material or a combination of both.Ovarian cysts are very common, particularly in women between the agesof 30 and 60. They may be single or multiple, and can occur in one orboth ovaries. Most are benign (non-cancerous), but approximately 15percent are malignant (cancerous).

Description of Ovarian CystsDuring ovulation (the process during which the egg ripens and is releasedfrom the ovary) the ovary produces a hormone to make the follicles (sacscontaining immature eggs and fluid) grow and the eggs within it mature.Once the egg is ready, the follicle ruptures and the egg is released. Oncethe egg is released, the follicle changes into a smaller sac called thecorpus luteum. Ovarian cystsoccur as a result of the follicle not rupturing,the follicle not changing into its smaller size, or doing the rupturing itself.There are five (5) common types of ovarian cysts: functional cysts,polycystic ovaries, endometrial cysts, cystadenomas and dermoid cysts.Functional Cysts

There are two types of functional cysts - follicle cyst and corpus luteum

cyst. Both of these types of cysts develop as part of the natural functionof the ovary.

Follicle Cyst. This cyst occurs during ovulation when an egg isreleased into the fallopian tube or when a developing follicle fails torupture. These cysts grow from 1 inches to 2 inches in diameter, and will usually dissolve within one to three months.

Corpus Luteum Cyst. This cyst is caused by a malfunction of thecorpus luteum. Unless a woman is pregnant, the corpus luteumdisintegrates. But in the formation of a corpus luteum cyst, it fillswith fluid and remains in the ovary.

Polycystic Ovaries
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Polycystic ovaries (also known as polycystic ovarian syndrome or disease)is a condition in which the follicles never erupt from the ovaries.Under normal circumstances, follicles grow, mature, and rise to thesurface of the ovary, where they burst and release an egg to the Fallopiantube, a process controlled by pituitary hormones. The remnants of the

burst follicle then begin to produce progesterone, which stimulates thelining of the uterus (endometrium) to grow thicker in case it needs tosupport a fertilized egg. The effect on the pituitary of an increase inprogesterone production is to signal it to stop stimulating thedevelopment of eggs.In polycystic ovaries, the follicles grow just under the ovaries' surface,and are produced again and again because the pituitary has not beensignaled to shut off. Both ovaries become filled with tiny cysts and canbecome enlarged.Endometrial Cysts

Endometrial cysts (also known as endometriomas or "chocolate cysts"(filled with dark blood)) form as a result ofendometriosis. Endometriosis isa disease in which the endometrial tissue normally found in the uterusgrows in other areas. After successive menstrual cycles, this misplacedendometrial tissue bleed, gradually forming endometrial cysts. Over timethe cysts grow and can become as large as a grapefruit.Cystadenomas

Cystadenomas are known as neoplasms (new growths). Ovarianneoplasms are new and abnormal formations that develop from theovarian tissue. There are two (2) types of cystadenomas - serous and

mucinous.Serous cystadenoma is filled with a thin watery fluid and can grow to bebetween 2 inches to 6 inches in diameter.Mucinous cystadenoma is filled with a sticky, thick gelatinous material andcan grow to be between 6 inches to 12 inches in diameter. There havebeen rare cases where the cyst measured 40 inches in diameter andweighed over 100 pounds.Dermoid Cysts

Dermoid cysts are also known as ovarian neoplasms and consist of skin orrelated tissue such as hair, teeth or bone instead of fluid like the

cystadenomas. Dermoid cysts develop from the ovary's germ cells (cellsthat produce the egg and the beginnings of all human tissues). Dermoidcysts may be present at birth but are not noticed until adulthood. Theygenerally measure between 2 inches to 4 inches in diameter.Symptoms of Ovarian Cysts

Cysts may grow quietly and go unnoticed until they are found on routineexamination. However, if they are ruptured (by sexual intercourse, injuryor childbirth) and/or become large enough, the following symptoms mayoccur:

Intense abdominal pain (symptom in all types of cysts)
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Menstrual changes such as late periods, bleeding between periodsor irregular periods (symptom occurring in corpus luteum cysts andpolycystic ovaries)

Heavy menstrual flow (symptom occurring in polycystic ovaries) Infertility (symptom occurring in polycystic ovaries and endometrial

cysts) Internal bleeding (symptom occurring in endometrial cysts) Severe menstrual cramps (symptom occurring in endometrial cysts) Pain with sexual intercourse (symptom occurring in endometrial

cysts) Pain during a bowel movement (symptom occurring in endometrial

cysts) Weight gain (symptom occurring in polycystic ovaries and

endometrial cysts)If a cyst becomes twisted, the woman may experience spasmodic pain.

Sudden or sharp pain may mean a cyst has ruptured. The twisting orrupture of a cyst may increase the likelihood of an infection. If the womanis experiencing abdominal pain, fever, vomiting and symptoms of shocksuch as cold, clammy skin and rapid breathing, get help immediately.Diagnosis of Ovarian Cysts

The doctor will take a thorough medical history, perform a physicalexamination, and conduct laboratory and diagnostic tests. During thephysical examination the doctor will do a pelvic exam.During a pelvic exam the doctor will put an instrument called a speculuminto the vagina. This instrument opens the vagina so the doctor can see

the vaginal walls and the cervix, and can get samples of vaginal discharge(called a Pap smear).The doctor will gently clean the cervix with a cotton swab and then collecta sample of cells from the cervix with a small brush, a tiny spatula, or acotton swab. This sample is "smeared" on a glass slide and sent to alaboratory for examination under a microscope by an expert.Once the speculum is removed, the doctor will do a bimanual exam. Thisinvolves inserting two fingers into the vagina and with the other handpressing on the abdomen. This exam allows the doctor to feel the size andshape of the uterus and ovaries.

If an ovarian cyst is present, the ovaries feel larger than normal and theexam itself causes the woman discomfort. If the doctor suspects cysts hewill recommend additional laboratory and diagnostic tests.Laboratory tests include a complete blood count (CBC) to detect infectionand internal bleeding, and a pregnancy test to detect uterine pregnancyor ectopic (tubal) pregnancy.Diagnostic tests include an ultrasound, and if needed, an x-ray andlaparoscopy.Ultrasound uses sound echoes to provide a picture of the tissues andorgans inside the body. Using this technology the doctor can see where,how big, how many and what the cysts are made of.
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If the cyst is composed of solid materials or a combination of fluid andsolid materials, the doctor may recommend an x-ray of the area wherethe cyst resides. This x-ray can reveal whether the cyst is a benigndermoid cyst or a malignant tumor.Doctors will recommend an additional diagnostic test called a laparoscopy

ifendometriosis is suspected, if the cyst is very large, if the cyst is notfluid-filled, or if the woman is over the age of 40 when the risk of cancerbegins to increase.Laparoscopy involves the insertion of narrow tube with a fiberoptic light atone end (called a laparoscope) into the lower abdomen through a smallincision just below the navel to view the ovaries, and if necessary drainthe fluid from the cyst or remove the cyst entirely.Treatment of Ovarian Cysts

Treatment depends on many factors, including the type of cyst, its size,its location, the type of material it contains and the woman's age.

For functional cysts a "watch and wait" approach is taken. Functionalcysts tend to dissolve over time and treatment is not needed. The doctorsdo, however, require the woman to return after two menstrual cycles toget a pelvic exam and/or ultrasound again.If the cyst is still present and growing (over 2 inches) the doctor mayrecommend a laparoscopy to remove the cyst. If the cyst comes andgoes, the doctor may prescribe birth control pills. These pills reduce thehormones that promote growth of cysts and prevent formation of largecysts.For polycystic ovaries the treatment varies. A major symptom of

polycystic ovaries is infertility, and whether the woman is trying toconceive or not determines the treatment.If the woman is trying to conceive and having fertility problems, thedoctor will prescribe Clomid which helps stimulate ovulation. If the womanis not trying to conceive and is having infrequent or no periods, the doctorwill prescribe Provera. Provera restores normal menstrual flows.For endometrial cysts, cystadenomas and dermoid cyststhetreatment is to surgically remove the cyst. If the cyst is small enough thedoctor can remove it via laparoscopy. If the cyst is over 2 inches in diameter the available procedures are:

Ovarian cystectomy- removal of cyst Partial oophorectomy- removal of the cyst and a portion of the

ovary Salpingo-oophorectomy- removal of the cyst, ovary and fallopian

tube. This procedure is done dependent upon the size of the cystand complications encountered such as bleeding, rupturing andtwisting of the cyst.

Total abdominalhysterectomywith bilateral salpingo-

oophorectomy- removal of the cyst, both ovaries, fallopian tubesand uterus. This procedure is rarely used unless the cyst iscancerous.

Questions To Ask Your Doctor About Ovarian Cysts

Are there any tests that need to be done to diagnose the problem?
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What is the cause?

What type of cyst is it?

How serious is the condition?

What treatment will you be recommending?

How effective is this treatment?

Will surgery need to be done?

If so, what is the procedure of the surgery?

What can be expected from the surgery?

Laboratory tests include a complete blood count (CBC) to detect infectionand internal bleeding, and a pregnancy test to detect uterine pregnancyor ectopic (tubal) pregnancy.Diagnostic tests include an ultrasound, and if needed, an x-ray andlaparoscopy.
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definition of ovarian cyst

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