Women normally have two ovaries that store & release eggs. Each ovary is of a size of walnut & located on each side of the uterus. One ovary produces one egg each month. An egg grows in a sac filled follicle in the ovary until oestrogen ( a hormone) signals the uterus to prepare itself for the egg and due to which uterus begins to thickened itself & prepare for pregnancy. This cycle occurs each month and ends when the egg is not fertilized. And contents of the uterus expelled out in the form of menstrual period.

Ovarian cyst is any collection of fluid surrounded by a very thin wall within an ovary when the size is more than 2 cm. Most cysts are harmless and functional in nature but some may cause problems such as rupturing, bleeding or pain and sometime surgery may require to remove the cyst.

Ovarian cyst affect women of all age. About 95% of ovarian cysts are benign, meaning they are non cancerous. There are different kinds of ovarian cysts.

FUNCTIONAL CYST
Majority are functional or physiological and benign in nature means they are non cancerous and disappeares on its own in few weeks without any treatment. Most commonly occurs in women of child bearing years.

(1) Follicular cyst: This type of simple cyst can be formed when ovulation does not occur or when mature follicle collapses. They can grow up to 2-3 inches in diameter. The rupture of this type of cyst can create severe pain. They can disappear by themselves within few months.

(2) Corpus luteum cyst: This occurs after an egg has been released from the follicle. And usually breaks down and disappears if pregnancy does not occur. Sometimes it may remain persistent in the ovary.

(3) Hemorrhagic cyst: This type of cyst occurs when bleeding occurs within a cyst . Patient may have abdominal pain. The rupture of the hemorrhagic cyst is less common and self limiting. Even if it ruptures in many cases it resolves without surgery.

DERMOID CYST
They are made up of different kinds of tissue from other parts of the body such as skin, hair, fat, and teeth. They may be found on both the ovaries. Often they are small and may not cause symptoms unless they become large.

ENDOMETRIOD CYST
These cysts are formed when endometrial tissue grows in the ovaries and this tissue then responds to monthly hormonal changes. This endometroid cyst are also called chocolate cyst as they are filled with dark reddish brown blood.

PATHOLOGICAL CYST
The incidence of ovarian carcinoma is approximately 15 cases per 100,000 women per year.

POLYCYSTIC OVARY
Polycystic appearing ovary is diagnosed based on its enlarged size with small cysts present on the periphery of the ovary. It can be found in normal women and in women with endocrine disorders. Polycystic appearing ovary is different from the polycystic ovarian syndrome, which includes other symptoms in addition to the presence of ovarian cysts, and involves metabolic and cardiovascular risks linked to insulin resistance. These risks include increased glucose intolerance, type II diabetes and high blood pressure. The syndrome is associated with infertility, abnormal bleeding, increased incidence of pregnancy loss, and increase of endometrial cancer later on.
More tests are required to diagnose polycystic ovarian syndrome.

Symptoms
Usually the cysts do not produce symptoms but are found incidentally on routine examination. However the following symptoms may be present:

• Dull aching, severe, sudden, and sharp pain or discomfort in the lower abdomen, pelvis, and lower back.
• Fullness and heaviness in the lower abdomen.
• Irregular menstrual periods.
• Pelvic pain after exercise or sexual intercourse.
• Pain with urination or bowel movements.
• Nausea, vomiting and abdominal bloating.
• Weight gain.
• Infertility.
• Increase level of hair growth ( facial or body hair)

When to seek medical care?

• fever
• Abnormal pain or tenderness in the abdominal or pelvic area.
• Nausea , vomiting.
• Weakness, dizziness, fainting
• Pallor or anemia
• Abnormally heavy or irregular menstruation.
• Abdominal swelling or unusual increased abdominal girth.
• Increased facial hair to male pattern.
• Unexplained weight loss, excessive thirst or urination
• Noticeable abdominal or pelvic mass.
• High or low blood pressure.
• Unexplained shoulder pain combined with abdominal pain.

Examination and the tests
To determine the type of cyst

1. Endo vaginal ultrasound: This is a special type of imaging to examine the pelvic organs & the type of ovarian cyst. Endo vaginal USG resembles a pelvic examination. A thin covered probe is inserted into the vagina & examiner directs the probe towards uterus and ovaries. This type of USG produces a better image than the scan through abdominal wall.
2. Other imaging: CT scanning and MRI Can be used to give detail of the cyst.
3. Laparoscopic surgery: In this procedure surgeon fills the woman‘s abdomen with gas& makes small incision , through which a thin scope ( laparoscope)can pass into the abdomen. The surgeon identifies the cyst & may remove cyst or take biopsy.
4. Serum CA- 125Assay: This is a blood test which checks for a substance called CA- 125 and associated with ovarian cancer.
5. Hormone levels: LH, FSH, Estradiol and Testosterone levels may indicate potential problems concerning these hormone levels.
6. Pregnancy Test : Ectopic pregnancy should be ruled out because some of the symptoms of ectopic pregnancy may be similar to those of ovarian cysts.

MEDICAL TREATMENT
Treatment for cysts depends on the size of the cyst and the symptoms. For small, asymptomatic cyst, the wait and see approach with regular check up will be recommended.

Pain caused by ovarian cyst may be treated with pain relievers, combined methods of hormonal contraception, which may also regulate the menstrual cycle and prevent the formation of follicles that can turn into cyst or possibly shrink an existing cyst.

Cyst that persists beyond 2 to 3 menstrual cycles or occur in post menopausal women may indicate more serious disease and should be investigated thoroughly by USG and laparoscopy, especially in cases where there is a family history of ovarian cancer. Also for large and persisting ovarian cyst surgery is recommended.

LAPAROSCOPIC SURGERY
This kind of surgery is done through key hole incision in the abdomen and surgeon operates under laparascope. This is a minimally invasive surgery. Requires less hospital stay, less medication, early ambulation and less post operative complications. Cyst can be removed (Cystectomy) and if required opherectomy (ovary removal) can be undertaken.

LAPAROTOMY
This is a more invasive surgery in which an incision is made through the abdominal wall in order to remove a cyst.

DR.LATA IYER
ENDOSCOPIC SURGEON – OB/GYNE DEPARTMENT
Gulf Medical College Hospital and Research Centre Ajman