I will often see women about an ovarian cyst. They may have gone to the ER, or the doctor because of pain or, sometimes, they had a scan done for some other reason, and a cyst just happened to be seen-especially if a CT scan was done for some bowel disease.
I guess I will get the shock out of the way right off by saying that your ovary makes a cyst EVERY SINGLE MONTH, from the time you start your periods, until you finally go through menopause! You should see the looks I get when I say that!
I know —- who really paid attention in sex ed class!
So–see those ovaries? They are about the size of a walnut. They are not smooth, like chicken eggs. The outside of the ovaries are covered with bumps (just like a walnut!)–these bumps are because there are little cysts all over the ovary–in 3D.
This is what we would see on an ultrasound of a NORMAL ovary
Every month, about 1000 eggs will start out, hoping to be picked to go “all the way” to ovulation.
Thank goodness, only one will make it—or we’d be having litters! Occasionally, two, or three(twins/triplets), will go all the way to ovulation—and with modern meds we can make octomoms—-insane!!!
These ovulation cysts can range in size from 1 cm to 6 cm. On average about 2.5 cm. It’s like blowing bubbles with bubble gum. Usually we blow small bubbles–but occasionally you’ll get the whopper (6 cm gets our attention)—and when THEY break—well —SPLAT—-more of a mess—more pain. You will have pain for several day and up to 2 weeks and your periods can be screwed up for a couple of months.
By the time you hit puberty, you have about 300,000 eggs left–and they are are used up by about age 50. Fertility does markedly fall off by age 37–but hey–we’ve ALL heard of “change of life babies”—all you need is ONE egg!
The menstrual cycle is the time from one period to the next. When you want to know how long your whole cycle is–you count from the FIRST day of your period, until the day before your next period.
So, if your period starts, say on March 3, and your NEXT period starts on April 2, then your CYCLE runs from March 3-April 1. April 2 would actually be Day 1 of your NEXT cycle. A menstrual cycle can be 21-45 days in length(average is 28 days).
Period time is just the number of days that you actually bleed – typically under 7 days.
So, WHILE you are on your period, a few hundred more eggs are lining up getting ready for the NEXT chance to ovulate. You will have a bunch of tiny little cysts on your ovaries (1-5mm). ONE will go “all the way”–the DOMINANT follicle (foll-ick-cull). Follicle is the fancy medical word for cysts.
See the dominant follicle?
This is what your pelvis looks like when we look inside with keyhole surgery (laparoscopy).
PAIN WITH OVARIAN CYSTS.
So–I get many male partners who accompany women to the hospital, but they don’t know what is going on–“women trouble”–they look down–uncomfortable, and I often get the sense that they are not getting it!
Here’s how I explain the pain to guys.
A woman’s ovaries come from the same tissue as a man’s testicles, when we were just developing in our mother’s womb. Our tissue went up into the abdomen, and became ovaries. Men’s tissues went down into the sac(k).
Now, as Betty White said—we all know how delicate those testicles are–they have to be protected at all times.
Just imagine a cyst being blown up in the testicle (I see them cringe)–and it reaches SIX CENTIMETERS–then —–it bursts!!!! The pain is like getting a swift kick in your delicate area. Understand now??
So, when a cyst rupture (bursts), the pain can literally take you to your knees. You may feel a pressure like you want to move your bowels (do #2), sweat, and even vomit.
The bad pain can last an hour or two, and then will ease—but for the next 1-3 weeks, you will be watching for every pothole in the road–don’t want to jiggle those things–and you will sit very slowly into a chair—there will be no flopping down.
Your period may be late —- remember to keep up with birth control–and your periods may be screwed up for 2-3 months.
If you come in because the pain is so bad, and you get an ultrasound, we will make sure the ovary has not twisted—THAT would require immediate surgery! The pain will be bad enough to get you to go to ER!
If the cyst is 6 cm or under we will have you “ride it out” typically–with a few pain meds to get through next few days.
If the cyst is larger than 6 cm, then the “look” of the ovary will factor into what is done next—we will even watch a cyst up to 8 cm if it looks like a “simple cyst”. We will operate on smaller cysts if they look ‘suspicious’.
We use a scoring sytem, based on tens of thousands of ovarian cysts, to see what the risk is that this cyst is malignant. THIS IS OVARIAN MALIGNANCY SCORING SYSTEM.
You need information that you can only get from discussion with your doctor to do this score–we do it all the time.
You need to look at the ultrasound, and see if it is SIMPLE or COMPLEX
This is an example of a SIMPLE cyst—see the nice smooth walls inside?–and it is only 3.1 cm–quite small. It is only on one ovary. It looks bigger because we blow the picture up, to look carefully!
Now–take a look at THESE cysts—not pretty!
See those growths inside the cysts? WORRISOME and needing urgent care! We would get a blood test called a Ca125–results come back in about 5 days–and at the same time–send your films to a gynecology cancer specialist, who would look at the films, and decide how quickly you need to be seen (typically within 10 days here). If you had THIS cyst, you will be getting surgery–and also likely chemotherapy afterwards!
Now, the thing is with cysts–they do NOT turn into cancer—they would be a cancer right from the get go, if a cancer it is. So the cyst at the top, that is all nice and smooth, will NOT turn into a cancer!
Why don’t we do Ca125 blood test as a screen for ovarian cancer—because it is useless as a screening test.
Studies have been done where Ca125, and an ultrasound show nothing, then 2 months later you can have stage 4 ovarian cancer!!! SCARY EH? We are all just waiting for those little grenades to blow up!
I have heard that testing is being done with DOGS–it seems like they can SNIFF out an ovarian cancer more reliably than the Ca125 blood test. I wonder how they are doing these studies. I am sure the dog has to give some signal to the handler—hmmm. I don’t know if I’d feel too good about walking past the dog and it goes ballistic–or it just sits in front of me quietly—either way–oh no!!!!
There are many types of abnormal cysts–some really huge ones are BENIGN (NOT CANCER)–and some can be small but ARE cancer.
Here are a few cysts–almost certainly BENIGN–some cysts will reach up above your belly button–they can become huge! These enormous cysts are usually benign!
Dermoids are a bit gross—can be full of hair and teeth adn that stuff you squeeze out of pimples—yuck! They are made from the same cells that make skin. Remember we all came from ONE cell–so having skin cells in your ovary–think of it as some just took the wrong path.
We can go in with a laparoscope, and put the ovary or cyst into a kind of ZIPLOC bag (they cost a few hundred dollars), and pull the bag up tight to the abdominal wall, then drain the cyst from outside, so the ovary will come out through the small incision.
For cysts more than 14 cm, we do not have bags big enough! SO—if the cyst is felt to be benign, we can go in and drain the cyst through a laparoscope, until it is small enough that we CAN use a bag! We try not to make a 15 cm cut on your belly!
If your cyst looks like it could be cancerous (even with a NORMAL Ca125), you will be immediately referred to a cancer surgeon who does nothing but operate on female organ cancers. Not all cancers will give a high Ca125 and, actually, you can get a high Ca125 even with BENIGN conditions, such as endometriosis.
If you have TWO close relatives with cancer of breast/ovary under the age of 50, we are really looking at you!
Maybe you have heard of gene testing for the BRCA 1 and 2 gene.
If you are diagnosed with ovarian cancer, you are automatically eligible for BRCA testing–important when you think of your relatives, children, nieces, siblings!
About 5-10% of ovarian cancers are due to a known genetic predisposition—there may be more to be discovered as we figure out our DNA! Typically, we look at first degree(parents, children and full-blooded sisters and brothers), and second degree (granparents, grandchildren, uncles, aunts, nephews, nieces, and half siblings)relatives–but then some women may not HAVE a sister or a daughter so will never have TWO “first degree” relatives with breast cancer. There are studies looking at how to get the best information out of a family history.
Ashkenazi Jewish blood line increases the risk of BRCA 1 and 2 genetic predisposition to cancer.