What are ovarian cysts?
In normal women an egg is produced every month. The egg finds its way to the Fallopian tube, where it may be fertilised if sperm are present.
Sometimes cysts may develop. These are often filled with liquid and are almost always benign.
Cysts can occur from one month to the next and may result from an egg which fails to mature. They may burst and thus disappear on their own.
If you have a simple cyst, there's a 60 per cent chance it will disappear after 12 weeks.
If they're over 6cm in size, they are unlikely to disappear naturally and removal should be considered.
What are the symptoms of ovarian cysts?
Most ovarian cysts produce no symptoms and women are unaware of their presence.However, if a cyst ruptures, twists, or if there is bleeding into the middle of the cyst, then one-sided lower abdominal pain is possible.
Sometimes the cyst can be large enough to put pressure on the bladder (making you feel as they you want to pass urine all the time) or bowel, they may be disturbed during intercourse causing discomfort or pain during penetration.
Ovarian cysts can be associated with other conditions – such as cancer, endometriosis , fertility drugs or early pregnancy.
The risk of ovarian cancer is dependant on the womans age being rare under the age of 40.
The likelihood of cancer is dependant on a number of factors, a combination being more significant than a single feature.
How are ovarian cysts diagnosed?
Ovarian cysts are usually diagnosed on a pelvic ultrasound, but may also be picked up on CT or MRI scan.If they are large, they may be felt at the time of a pelvic[internal] examination.
What will the doctor do?
Depending on the severity of symptoms and what the risk factors are will determine the management options.- If the cyst is likely to be benign, asymptomatic and less than 4cm the doctor will probably reassure you and rescan in 12 weeks.
- If over 6cm removal is usually recommended.
- If more than 4 and less than 6cm, a repeat ultrasound in 4 to 6 weeks to check for a change in size.
Ovarian cysts in postmenopausal women
It is recommended that ovarian cysts in postmenopausal women should be assessed using CA125 and transvaginal grey scale sonography. There is no routine role yet for Doppler, MRI, CT or PET.In order to triage women, an estimate needs to be made as to the risk that the ovarian cyst is malignant. This needs to be done using tests that are easily available in routine gynaecological practice.
At present, these tests are serum CA125 measurement and ultrasound. Serum CA125 is well established, being raised in over 80 per cent of ovarian cancer cases and, if a cut-off of 30 u/ml is used.
Ovarian cysts should normally be assessed using transvaginal ultrasound because this appears to provide more detail and hence offers greater sensitivity than the transabdominal method.
The roles of other imaging modalities, such as magnetic resonance imaging (MRI), computed tomography (CT) and positron emission tomography (PET), in the diagnosis of ovarian cancer have yet to be clearly established.
It's recommended that a 'risk of malignancy index’ should be used to select those women who require primary surgery in a cancer centre by a gynaecological oncologist.
The best prognosis for women with ovarian cancer is offered if a laparotomy and full staging procedure is carried out by a trained gynaecological oncologist.
Most cysts will be benign, gynaecologists in units at more local level will perform the majority of surgery. It should be appreciated, however, that no currently available tests are perfect, offering 100 per cent specificity and sensitivity. Ultrasound often fails to differentiate between benign and malignant lesions, and serum CA125 levels, although raised in over 80 per cent of ovarian cancers, is raised in only 50 per cent of stage I cases.
In addition, levels can be raised in many other malignancies and in benign conditions, including benign cysts and endometriosis.
Those women who are at low risk of malignancy also need to be triaged into those where the risk of malignancy is sufficiently low to allow conservative management, and those who still require intervention of some form.
Non-invasive treatment
Simple, unilateral, unilocular ovarian cysts, less than 5 cm in diameter, have a low risk of malignancy. It is recommended that, in the presence of a normal serum CA125 levels, they be managed conservatively.Numerous studies have looked at the risk of malignancy in ovarian cysts, comparing ultrasound morphology with either histology at subsequent surgery or by close follow up of those women managed conservatively.
The risk of malignancy in these studies of cysts that are less than 5cm, unilateral, unilocular and echo-free with no solid parts or papillary formations is less than 1 per cent. In addition, more than 50 per cent of these cysts will resolve spontaneously within three months.
It's reasonable to manage these cysts conservatively, with a follow-up ultrasound scan for cysts of 2 to 5cm, a reasonable interval being four months. This, of course, depends upon the views and symptoms of the woman and on the gynaecologist’s clinical assessment.
Surgical treatment
Those women who do not fit the above criteria for non-invasive treatment should be offered surgical treatment.Aspiration is not recommended for the management of ovarian cysts in postmenopausal women. Cytological examination of ovarian cyst fluid is poor at distinguishing between benign and malignant tumours.
In addition, there's a risk of cyst rupture and, if the cyst is malignant, there is some evidence that cyst rupture during surgery has an unfavourable impact on disease free survival.
Aspiration, therefore, has no role in the management of asymptomatic ovarian cysts in postmenopausal women.
Laparoscopy
The laparoscopic management of benign adnexal masses is well established. However, when managing ovarian cysts in postmenopausal women, it should be remembered that the main reason for operating is to exclude an ovarian malignancy.If an ovarian malignancy is present then the appropriate management in the postmenopausal woman is to perform a laparotomy and a total abdominal hysterectomy, bilateral salpingo-oophorectomy and full staging procedure.
The laparoscopic approach should therefore be reserved for those women who are not eligible for non-invasive treatment but still have a relatively low risk of malignancy.
Women who are at high risk of malignancy, as calculated using the risk of malignancy index, are likely to need a laparotomy and full staging procedure as their primary surgery.
It's recommended that laparoscopic management of ovarian cysts in postmenopausal women should involve oophorectomy (usually bilateral) rather than cystectomy.
In a postmenopausal woman, the appropriate laparoscopic treatment for an ovarian cyst, which is not suitable for conservative management, is oophorectomy, with removal of the ovary intact in a bag without cyst rupture into the peritoneal cavity.
There is the risk of cyst rupture during cystectomy and, as described above, cyst rupture into the peritoneal cavity may have an unfavourable impact on disease-free survival in the small proportion of cases with an ovarian cancer.
If a malignancy is revealed during laparoscopy or subsequent histology, it's recommended that the woman is referred to a cancer centre for further treatment.
If an ovarian cancer is discovered at surgery or on histology, a subsequent full staging procedure is likely to be required. A rapid referral to a cancer centre is recommended for those women who are found to have an ovarian malignancy.
Secondary surgery at a centre should be performed as quickly as feasible.
All ovarian cysts that are suspicious of malignancy in a postmenopausal woman, as indicated by a high risk of malignancy index, clinical suspicion or findings at laparoscopy, are likely to require a full laparotomy and staging procedure.
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