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Discusses Women's Health

“I had surgery for an ovarian cyst”… a not uncommon statement in the medical histories I get from patients. This is usually followed by the exclamation: “Thank goodness it was benign!” The question is how many of these women underwent unnecessary surgery for something that was benign?

Most cysts in young women (we’re talking reproductive age here) are “functional”, a term used to describe furniture and clothes design…but when used as a gynecologic adjective it connotes a cyst that is formed during the monthly cycle. Follicular cysts develop as the ovary tries to do its duty and create a dominant follicle from one of its primordial oocytes during the first 2 weeks of the cycle. Once ovulation occurs a remnant of that follicle can form a second type of functional cyst termed a luteal cyst. Let me explain:

At the time of puberty the ovaries contain about 400,000 primordial or preformed oocytes (future eggs). Each month one of them usually gets to come forth to fulfill its destiny to grow and develop into a mature egg while thousand more die….sort of depressing, but this is the survival of the fittest egg. (Just consider how many sperm die with every ejaculate and perhaps you won’t feel so bad. But wait, sperm get produced anew every 3 month while we have a fixed number of eggs and once they are used up we can’t make anymore. So there is an ovarian woe in this saga. Our finite number of eggs also explains the hormonal phenomena of perimenopause and menopause, but I diverge…)

A small amount of fluid surrounds the developing egg so that the developed follicle becomes a little cyst on the outer circumference of the ovary. It produces estrogen. At ovulation the follicle ruptures and the egg is extruded. Some women feel this rupture as a mid-cycle pain called by the appropriate onomatopoeic term “mittlesmirz” (pain in the middle). If the cyst becomes large (too much fluid accumulates) and/or grows, it creates a functional follicular cyst.

Once the egg has been released (and potentially may be fertilized by sperm swimming in the tubal vicinity), the emptied follicle changes its identity and becomes a corpus luteum. This too is a small cyst that goes on to produce progesterone and estrogen; hormones that are needed to build up the lining of the uterus so that it can support a developing embryo. In the absence of a pregnancy the corpus luteum dwindles and yes dies; the uterine lining or endometrium is sloughed (the menstrual period) and the entire cycle starts all over again. But if that corpus luteum does not regress and instead swells or bleeds into itself (it has a terrific blood supply) it too can create a functional cyst called a luteal cyst.

Before ultrasound was extensively used, a woman who presented with a mass on the ovary, pain or an enlarged “something” in the area of the tubes or ovaries (called the adnexa), was often subjected to surgery. Even with the advent of ultrasound…if the cyst was big enough or had areas that were not translucent, surgery was often performed either by laparoscopy or an open abdominal procedure. The cyst was removed (cystectomy), or in some cases, the ovary was excised (oophorectomy). After all, the surgeon was already in there and that was the best way to ensure it would be properly diagnosed and “cured”. Any of these procedures could lead to subsequent scarring, pain and/or infertility.

In the 60’s and 70’s doctors noted that women who took oral contraceptives (in doses that were higher than those used today) seemed to have a lower incidence of these functional cysts. The thought was that if ovulation was suppressed there would be no reason for functional cysts to develop. (New data shows that low dose birth control pills do not substantially decrease a woman’s risk of ovarian cyst formation.) This theory that the Pill will stop cyst formation has continued to be used to treat cysts and make then “go away”.

Not so….according to a recent Cochran report that was abstracted in the Journal of the American College of Obstetricians and Gynecologists. The Cochran Review analyses the most relevant and well conducted studies that have been published in peer reviewed journals. The authors then review these studies for accuracy and statistical relevance. Seven randomized controlled trials from four countries were found; the studies included a total of 500 women. The analysis showed that “treatment with combined oral contraceptives (which contain both estrogen and progestin) did not hasten the resolution of functional ovarian cysts is any trial.” And indeed “most cysts resolved without treatment within a few cycles”. This included cysts that developed spontaneously and those that occurred after ovulation induction with fertility medications. (The forced feeding of the ovaries with fertility drugs causes the development of multiple follicles and can result in cysts). They found that most of the cysts that did not regress after a few months of being left alone were endometriomas (blood filled cysts that occur with the disease called endometriosis) or cysts that developed from the fallopian tubes.

So does your physician have to go after those cysts that she or he feels and then “sees” with ultrasound during routine exam? The answer in most circumstances is no. Nor do we have to treat these functional cysts with oral contraceptives to get rid of them. A simple “wait and recheck” in a 2 or 3 months is appropriate.

Bottom line: There is no need to freak at the mention of an ovarian cyst that has developed while you are in your reproductive years. It will probably go away in a month or two. Surgery is indicated only if you develop significant pain (very rarely cysts can twist or bleed) or if the cyst persists.

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