Ovarian cysts, which are frequently encountered throughout the life of women, are quite common and often occur randomly in gynecological examination and ultrasonography.
I think it should be emphasized that making ovarian cysts as a cause of fear is not quite right and that a significant majority of ovarian cysts are part of the physiological process. Because when women start to worry about physiological cysts that will disappear on their own, I see that they start living with anxiety that cysts can develop in their bodies. Here, we will review the situations that need to be taken into account as well as eliminating this concern.
The Physiology of Ovulation
First, let’s start with the ovulation physiology:
The ovaries do not function as ovulation before puberty (pre-puberty) and after menopause. Ovulation function, which starts with adolescence, continues to menopause by providing menstruation every month. Every month, one ovum (egg) begins to develop in a natural cystic (fluid filled) structure and gets the name of the follicle. When it reaches the size of 18-20 mm, the smooth muscles in the ovarian wall contract, compressing the follicular structure and ensuring its cracking. Meanwhile, the endometrium (intrauterine tissue) thickened with the increasing estrogen hormone in the first half of the cycle. Fluid in the follicle is thrown into the abdominal cavity and easily absorbed through the abdominal membranes in this cavity. The ovum cell, which is thrown together with the liquid, is captured by the fallopian tubes and taken into the tube. With the transformation of the follicular structure, where the follicle is thrown from the ovarian surface, into the corpus luteum, progesterone release continues and if the ovum does not meet with the sperm, progesterone release stops and the woman has menstruation. The corpus luteum, on the other hand, turns into a structure called corpus albicans and disappears. If sperm meets the ovum in the tube, the pregnancy process begins and the progesterone hormone, which provides protection, supports the pregnancy for 10 weeks. At the end of the 10th week, the placenta now takes over and provides the necessary environment for pregnancy health.
When the ovum (egg) in the ovary is completely exhausted, ovulation will no longer occur and menstrual bleeding will no longer occur. However, even if there is no active hormone secretion during menopause, little estrogen and testosterone secretion continues and even this amount provides support in women’s life.
Due to meticulous and detailed biochemical and physiological disruptions between the central nervous system and female genital organs, hormonal problems or drug use, this order may be disrupted and ovulation may not occur. That’s why follicle cysts, the most common benign cysts of the female genital tract, are formed.
The vast majority of follicle cysts do not produce any symptoms and are detected incidentally by gynecological examination or ultrasonography for any reason. They can be one or several. They are mostly unilateral and are monitored under 5 cm. In many tissues and organs other than ovaries, cysts give more findings especially because they cause dysfunction. However, ovarian cysts may not cause dysfunction for a very long time and may not cause symptoms. The most common finding is menstrual irregularities. Apart from this, it can cause pain if it grows too much or bleeds into the cyst. They can feel fullness and pressure in the lower abdomen. Again, depending on their size, they can give pressure findings in the surrounding organs. They can be the cause of frequent urination by pressing the bladder or constipation with bowel compression.
Follicle cysts are monitored in the form of hypoechogenic, thin-walled (less than 3 mm) and no septa (divisions within the cyst) in ultrasonography. Their size is often below 5-6 cm. In diagnosis, gynecological examination and ultrasonography are generally sufficient. However, if the patient’s age continues without growing or growing in the cyst within months, computed tomography (CT), magnetic resonance (MRI) and TM markers (such as ca 12-5, HE4, ca 19-9) can be used for differential diagnosis.
In the meantime, it should not be forgotten that tumour markers are not actually used for diagnosis but used in post-treatment follow-up of ovarian cancers. Because in fact, ca 12-5 is not enough for the differential memory of ovarian cancers. Because, women who have painful menstruation may also have high value during pelvic abscess, endometriosis and especially pelvic tuberculosis.
Approach to follicle cysts is always conservative and operation is not required, except for rare special conditions. Most of them disappear spontaneously within 1-3 months. From time to time, birth control pills can be used to stop hormone stimulation with suppression activities in the central nervous system. However, if they do not cause any obvious complaints or provide symptoms, they can be followed up in women before menopause for up to 1 year and up to 6 months after menopause. Especially in follicular cysts below 5-6 cm, monitoring is sufficient every 2-3 months if the patient is not at the menopause.
In the meantime, if the cyst wall is ruptured due to increased pressure during the follow-up, it may bleed into the abdomen. Follicular cyst rupture is mostly monitored in the hospital, and if the patient’s blood values do not decrease and the vital parameters are not detected, surgery may not be performed despite intraabdominal bleeding. However, if intraabdominal bleeding is very prominent and changes in vital parameters, or if the pain is very severe, laparoscopic surgery can be performed and the bleeding area can be checked, and it is washed with plenty of saline to clean the intraabdominal blood and blood products. This will reduce the likelihood of adhesions in the abdomen. Ovary should always be protected during laparoscopy. However, taking ovaries in pre-menopause and menopause can be considered if there is a risk of cancer.
Corpus Luteum Cysts
The second most frequently encountered physiological cyst is the corpus luteum cyst. It is formed by excessive growth of the progesterone-secreting yellow body (corpus luteum), which is transformed by follicle after ovulation and is often diagnosed by ultrasonography. Bleeding into the cyst is frequently observed. Therefore, it may appear larger and more painful than follicular cysts. Since it continues to secrete progesterone until it disappears, it is most frequently encountered with the complaint of menstrual delay. The disappearance times may be longer than follicle cysts, but they will disappear completely within 2-3 months (mostly spontaneously, with contraceptive pills). If it is ruptured (if the cyst wall bursts into the abdomen and bleeds), it may not be operated by monitoring it in the hospital. However, if the cyst wall also tears the vascular structures formed while tearing, the so-called corpus luteum haemorrhagicum may occur, which requires surgery more frequently due to excessive bleeding within the abdomen.
It should be remembered that corpus luteum cysts may be confused with the diagnosis of ectopic pregnancy, especially in cases of intraabdominal bleeding, and the necessary tests must be performed for differential diagnosis.
Again, laparoscopy surgery should be preferred here and ovarian tissue must be preserved.
In these two most common benign ovarian cysts, if the inside of the abdomen can return with its ovaries due to natural movements and gravity, this table is called ‘ovarian cyst torsion’. Definitive and only treatment in torsion is surgery. The torsion should be corrected laparoscopically and the surgery should be completed after the ovarian colour is expected to return to normal. Contrary to previous applications, evidence-based medicine definitely does not recommend removing ovaries even in very bad colour in ovarian torsions.
Apart from this, the development of infection in the follicular cyst or corpus luteum cyst will also increase the pain finding, and if an early diagnosis is made, using the appropriate combined antibiotics for a sufficient time without going to surgery will be sufficient for problem solving. However, if the abscess has developed, the possibility of surgical treatment increases. Since antibiotics cannot exceed the abscess capsule in the abscess focus in the abdomen, the problem cannot be resolved without surgical treatment. Here, it should be decided completely whether the surgery will be laparoscopy or laparotomy, with the patient’s vital signs and location and width of the abscess focus, and the current conditions should be shared with the patient.
Endometrioma (endometriosis) is one of the rarer but very important cystic structures. The endometrial tissue is the inner tissue of the uterus that is expelled with some blood every month when the woman is not pregnant and should be located only in the uterus. However, in the endometriosis that many theories have been suggested, endometrial tissue can be located on the abdominal membranes, the back of the uterus and the cervix and ovaries. In this case, while the woman is bleeding out during menstruation every month, intraabdominal bleeding also occurs and this explains the menstrual pain (dysmenorrhea) suffered by women with endometriosis very well. If the center is in the ovarian tissue, the bleeding area that occurs every month creates a capsule for itself and prevents bleeding and accumulates in the cyst capsule in the form and appearance of melted chocolate, and these cysts are known as ‘chocolate cysts’.
Endometriosis is most common with menstrual pain, bleeding to pain in certain positions, especially in sexual intercourse, infertility, and chronic lower abdomen and sometimes low back pain. Generally, ultrasonography is sufficient in diagnosis, but as a result, MRI may be inadequate in differential diagnosis and may be required. Surgery is not recommended, especially in endometriomas under 6 cm that do not cause much complaints. However, if the quality of life of the woman is impaired, surgery risks can be made by discussing the operation risks with the patient in detail. In surgery, preference is laparoscopic. The recommended route in couples presenting with infertility in recent years is to benefit from assisted reproductive techniques by avoiding surgery due to the possibility of decreased ovarian reserve during surgery.
Theca Lutein Cysts
One of the more rare ovarian cysts is theka lutein cysts. They are often seen due to excessive hormone activity in women who are treated for ovulation due to multiple pregnancies, mole pregnancies, and infertility. They are mostly bilateral and contain many hypoechogenic, fluid-filled cystic structures and their size can reach up to 20 cm. Bed rest, tight follow-up and fluid electrolyte balance are generally sufficient in treatment. Rarely, if complications develop, they require surgical treatment.
Pregnancy luteoma is a rare solid mass that emerges during pregnancy. Hirsutism (excessive hairiness) may occur in 20-25% of women in pregnancy luteoma due to excessive secretion of secretion secreted from the mass. It will often disappear spontaneously after pregnancy ends. Rarely, surgery may be required. The main problem here is that it is very difficult to make differential diagnosis from other ovarian masses since it is a solid mass.
Among the benign (benign) ovarian tumours, the most common serous cystadenoma is. It often appears in women of reproductive age. These structures are not self-disappearing structures, unlike burst ovarian cysts, and may have 20-30% malignant potential. They can be double-sided, which increases the likelihood of malice. Solid extensions can be seen in the walls of these cystic structures originating in the serosal epithelial cells on the ovarian surface, which increases the probability of malignancy. Although serous cystadenomas are often detected during routine examination and ultrasonography, the woman may also present with pain and swelling in the abdomen and the complaint of the mass. Tumour markers and MRI can be used in diagnosis.
Its treatment is surgical and should be done laparoscopically, taking into account the size of the cyst and the patient’s condition. Whether the patient’s ovary will be preserved, the risk of malignancy before the operation, the rapid pathology assessment called frozen section during the operation, whether the woman has a child’s desire, age and menopause status are determined. All possibilities should be discussed with the woman before the operation.
The second most common benign ovarian tumours that we see after serous cystadenomas are mucinous cystadenomas. They are less likely to be bilateral and contain less malignant potential. The cells secreting mucus in these cystadenomas; Serosa cells on the surface of the ovary are thought to be transformed into cells that secrete mucus in the cervix with metaplasia. The mucus content here is quite clear but not fluid. Inside the mucinous cystadenomas, there are chambers called septa that divide the cyst into many sections. They can reach quite large sizes, such as 10-30 cm.
Mucinous cystadenomas also grow quite slowly and do not cause complaints. Diagnosis is made frequently by gynecological examination or ultrasonography for any reason. Since it can reach very large dimensions, we encounter mass and pain that are handled from time to time. The most dangerous form of application is to rupture when it reaches high pressure and to spread the contents of mucinous cyst around the intestines and abdominal organs. In this picture called pseudomyxoma peritonei, abdominal swelling, abdominal pain, nausea, vomiting and nutritional disorders occur due to the effect of intestinal functions. Although pseudomyxoma peritonei has a cellular-free cell structure, the functional disorder it creates in the abdominal cavity is quite severe and is considered a chronic disease. In the treatment, surgery is tried and mucinous cystic loci are tried to be cleaned one by one. However, it is quite difficult to completely clean the entire abdominal cavity and there is no definitive treatment.
Treatment of mucinous cystadenomas is surgery, and surgery should be preferred before cyst rupture occurs. Laparoscopy can be preferred. However, according to the size of the cyst, open surgery is also a good option to remove the cyst contents without bursting and pouring into the abdomen. Whether the ovary will be preserved should be decided entirely with the age of the woman, the child’s request and her own surgical choice.
Dermoid Cyst (Mature Cystic Teratoma)
An important cystic structure is benign (benign) ovarian tumour, which is a complex origin of dermoid cyst (mature cystic teratoma). Despite many theories in its existence, it is not possible to describe a clear reason for its formation. However, its most important and determining feature is that it contains tissues from all three embryological layers (endoderm, mesoderm, and ectoderm) in the human body. The most dominant tissue in the cyst content is fat and hair tissue. It may also include bone, teeth, and cartilage from time to time. It rarely contains thyroid tissue and this particular condition is defined as ‘struma ovari’. Due to the thyroid hormones secreted by the thyroid tissue in the dermoid cyst, it may present with hyperthyroidism. 10% is bilateral and 1% is likely to have malignancy (malignant cells). The likelihood of malignancy should be kept in mind in pre-adolescent children and women in menopause.
Since the dermoid cyst grows very slowly, it does not produce any symptoms in half of the women. The most common finding is pain, sometimes intermittent bleeding and menstrual irregularities, and the mass that grows in the abdomen because there are very large masses. Although US is sufficient in diagnosis, MRI is also very useful in differential diagnosis.
The most common complication in dermoid cysts is torsion followed by rupture. It is useful to operate both urgently. We can protect the ovarian tissue in the torsion from the possibility of necrosis only by correcting the torsion by surgery. The content poured into the abdominal cavity in rupture is quite irritant (causing severe pain), it is very difficult to clean as it spreads into the abdomen, and it can cause adhesion, and it should be cleaned by washing the abdomen as soon as possible and the dermoid cyst capsule should be completely removed in both torsion and rupture. In case of suspected illness, the operation should be planned and the dermoid cyst capsule should be removed. The cyst is 10 cm up to laparoscopic way. However, laparotomy (open surgery) can be performed for over 10 cm. However, most cysts can be removed laparoscopically, even if they are over 10 cm. During laparoscopy, it is not possible to remove the cyst contents from the laparoscopic way without draining into the abdomen and the inside of the abdomen is washed with plenty of saline. If tumour markers and contrast-enhanced MR results show signs of malignant tumour, it is beneficial to perform the operation by open method. The other ovary must be checked very well before and during the operation. If bilateral and the dermoid cyst in the other ovary is overlooked, dermoid cyst will appear again depending on the growth rate after a while.