Ovarian Cysts—the Good, the Bad, and the Ugly
By Gerard M. DiLeo, M.D., F.A.C.O.G., C.L.C.P.
Book Title: Ovarian Cysts—the Good, the Bad, and the Ugly
Author: Gerard M. DiLeo, MD
Copyright 2012 by Gerard DiLeo, MD
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Introduction
The future and even the very existence of the human race depend on just a couple of ounces of tissue in a woman's pelvis. For here is where human eggs, hibernating since birth, finally mature and leave their nestled home to accept genetic intermingling from the male of the species. These two important structures are called the ovaries.
For the purposes of clarity, I have broken the subject up into three sections--"the good, the bad, and the ugly"--meaning that I'll talk about function (good), cysts (bad), and malignant tumors (ugly). But first it is necessary to have an understanding of ovarian follicles and ovarian cysts.
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Ovarian Cysts and Follicles and Everything In Between
Every woman after puberty gets them. Every gynecologist feels them. Thankfully, most of them don't really matter at all. They are ovarian cysts and while they often strike fear into a woman's mind, it is up to physicians to tell them not to mind at all.
It's important to understand the most common type of ovarian cyst--the follicle. An ovarian follicle is that little cavity that grows an egg set for release at mid-cycle, or ovulation (medically, called Estrus). The ovarian follicle is both a result of and an integral part of the menstrual cycle. It contains a little puddle of fluid that functions in the development of the egg. The release of the egg, called ovulation, is the midpoint in the menstrual cycle. If ovulation fails to occur in a timely way, the rest of the cycle is often suspended or irregular. The follicle is therefore a product of function, a word which will figure importantly below.
When a follicle gets to be bigger than about two centimeters or so, semantics dictate that it be referred to as a cyst. But it's still just a follicle, and the only difference is the semantics based on the size, greater than 2 cm crossing that semantic threshold. Of course, a cyst can be thought of as an exaggerated follicle, but it is still a matter of normal functioning. Therefore, we speak of theses cysts as "Functional Cysts," and nothing need be done other than wait them out.
Wait them out? But these are cysts!
True, everyone knows a cyst is a term that means something that should not be there normally. And it's also true that ovarian cancer comes from cysts (well, sort of). So shouldn't there be some premium panicking going on here?
Consider this:
Woman who are cycling spontaneously and naturally, that is, not being "hormonally manipulated" with Birth Control Pills (oral contraceptives, or OCs), are seen in the gynecologist's office every day. The law of averages says that if 30 such reproductive-age women with regular cycles are examined on any given appointment day, then the doctor should witness almost every day's phase of the entire menstrual cycle throughout the day. This includes 3-4 in midcycle and the approach to midcycle (another 5-7), when a follicle is brewing toward maturation and ovulation (release of the egg) for, possibly, fertilization (conception, pregnancy). This makes 8-11 women wherein the doctor may feel an ovarian follicle which, if bigger than 2 cm., is called a cyst. So almost half of women of reproductive age, not on OCs, are going to be told they have a cyst. This is common. And spontaneous resolution of a cyst is the usual course of events. The odds are very heavily stacked in favor of this being nothing.
A patient needs this information, so as to walk out of the office without a living will. Of course, if the doctor is from the old school of "what she doesn't know her won't hurt her," which is usually correct, it probably won't hurt her (you). Probably. Hopefully, this type of doctor is extinct by now. But even when a patient is informed of a cyst, another physician attitude, "Don't worry your pretty li'l head about this," won't cut it either. Being told that you have this...this thing...in your body will not settle well.
But you now know ovarian cysts are commonly discovered on physical exams; and you now know it is almost always a fageddaboutit thing. And you now know that most follicles (or even very large cysts) are a matter of normal function, and once release of your egg occurs, your follicle or cyst will vanish into history as a small scar in your ovary (corpus albicans).
You now know that this is the natural cyclic course of things. But...the plot thickens.
Normal functioning cysts can feel the same way a small ovarian tumor can feel. How can any physician blow off such a finding with a good conscience? Is it just the sheer numbers on everyone's side? Yes. But it's other things, too. The size, shape, tenderness, and timing of the cyst can put a patient into a zero-risk category. Any doubt can provoke an ultrasound to reinforce reassurance. And a woman who is prone to cysts that spin everyone's worry wheels can have these cysts suppressed with OCs. After all, that's how birth control pills work, by suppressing ovulation, but more specifically, suppressing follicle formation (and subsequent bigger follicles growing big enough to be called cysts).
But cysts can be painful. (See Pelvic Pain, LINK by Gerard DiLeo.) In fact, it is common for a woman to make an appointment with her gynecologist because of the pain, which will make her doctor keen to feel especially for the presence of a cyst and/or order an ultrasound (sonogram).
Pain from ovarian cysts:
Size, which stretches the lining over the ovaries, which is rich in pain fibers that react to distention, much like colic in a baby with gas distending infant intestines.
Bleeding, which is irritating to the lining of the ovaries, which is the same as the lining of the abdominal/pelvic cavity. Blood is inflammatory. The only time blood doesn't hurt is when it is where it belongs—in the heart, arteries, and veins. (Remember your last bruise?)
Endometriosis can cause enlarging of the ovary with endometriosis—menstrual-like tissue. Besides the size stretching the peritoneum (serosa of the ovarian capsule), the blood-like, menstural-like tissue can leak or come to be adjacent to the peritoneum, irritating it.
If a woman has pain from it, and it not seeking pregnancy*, the temporary use of birth control pills (oral contraceptives, or OCs) can be started. Most women are led to believe that this will "melt away" the cyst, but this is a myth. What OCs will do, though, is suppress additional follicle and cyst formation (suppress the whole cycle) while the problematic cyst withers away over time (2-6 weeks).
*Using OCs with pregnancy desired in the near future, for any reason, is a bad idea. The temptation to quickly melt away the cyst (a myth, as above) so that normal ovulation and conception can occur is fueled by this myth. OCs do not suppress the ovaries directly, but the Pituitary Gland, in the brain, which helps run the hormonal show (the hypothalamus, thyroid, etc., also). In some women, this central suppression can be so stunning to the Pituitary that the time it takes for it to "rekindle" the hormonal cycle and join the cyclic goings-on in the body can vary from woman to woman. Some women can start ovulating right after getting off of the pill, hence unintended pregnancy if one has missed a couple of pills. But a small percentage can take as long as two years to resume normal functioning, which will be heartbreaking if pregnancy was on the docket . Such a delay will also delay periods (menses), so this is called post-pill amenorrhea (without menses).