A Guide to Ovarian Cysts
Hearing you have an ovarian cyst can be alarming. But not all cysts are created equal! Here’s some mini-med school on ovarian cysts—what causes them, when to worry, and what to ask your doctor.
Here's something I've heard from patients literally thousands of times throughout my career as an OB-GYN:
"I'm freaking out because I was told [usually by a radiologist or emergency medicine physician] that I have a cyst on one of my ovaries!" My response is always the same: “All cysts are not created equally. And ovaries make cysts for a living!” Here's the mini-med school on ovarian cysts, particularly for women in perimenopause and menopause.
What exactly is a cyst?
A cyst is, in fact, the outcome of monthly ovulation. The process of ovulating (releasing an egg) is actually the rupturing of a tiny “cyst” or follicle. When that follicle doesn’t rupture and release its egg, it remains on the ovary and continues to grow.
Ovarian cysts are common: According to the National Institutes of Health, 10 of every 100 women in the U.S. are estimated to have them. Most, however, are harmless; normally, we experience little or no discomfort. And most disappear without treatment within a few months; currently, just 8% of perimenopausal women who develop cysts will require medical treatment.
Traditionally in gynecology, we don't even consider something a cyst until it’s larger than 2.5-3 cm. Sometimes cysts can become quite large and require surgical treatment, but usually this is when they are the size of oranges or grapefruits (larger than 8 cm or so).
Cysts can occur throughout a woman’s reproductive years—and beyond. Let's look at the age groups separately: women younger than 50, then women over the age of 50.
Women Under 50
Women under 50 (and remember that perimenopause can start for some women in their mid-30s) can develop ovarian cysts for many reasons: pregnancy, endometriosis, polycystic ovary syndrome (PCOS), dermoid cysts, or ovarian cancer, to name a few.
If I did ultrasounds on every woman under the age of 50, the vast majority would find something a radiologist could easily describe as a cyst. Most of these would spontaneously resolve within 4-8 weeks; thus, gynecologists wouldn’t normally bat an eye at them.
Here are the questions to keep in mind/ask your doctor if you’re ever diagnosed with a cyst:
- How large is the cyst in actual centimeters?
- Does it appear “simple or complex” on an ultrasound? These are features we look for to help us determine what kind of cyst it is.
- Does it have any features that might indicate malignancy? These include solid components, septations (thin bands of tissue), surface nodularity, and increased/abnormal blood flow.
- Is there an abnormal amount of “free fluid” in the pelvis? All pre-menopausal women have some degree of free fluid in the pelvis, but having a moderate or excessive amount is generally not normal.
- What follow-up is recommended?
Women Over 50
In women over 50, and especially women who have been in menopause for a while, the ovaries are generally NOT active enough to be making cysts anymore. Therefore, if a 58- or 68-year-old woman is told she has a cyst, in addition to asking the questions above, I also recommend blood tests to check for various tumor markers, along with a detailed history and physical exam.
It’s important not to ignore a cyst if you’re a post-menopausal woman—because it could potentially be serious. While there is no accepted screening test for ovarian cancer, the CA-125 blood test can be elevated with some types of this disease. And that’s not the only marker that can be checked: There are several other tumor markers that indicate the presence of ovarian cancer. Ask about adding the following to a blood test panel: AFP, hCG, inhibin A and B, LDH, HE-4, CA 19-9, and CEA.
Keep in mind that some of these values can be elevated even when no cancer is present, just as they might be normal when there IS cancer. Other conditions can cause some values to increase too, so correct interpretation of the blood tests is as important as the interpretation of the ultrasound.
If you are told you have a “cyst” that was found incidentally, don’t panic!
Speak to your gynecologist about what the next steps are and how to interpret what was seen on ultrasound or CT scan. And be aware of the most common symptoms of ovarian cancer: pelvic pain, pressure or discomfort, bloating, increase in urination, early satiety (not feeling as hungry), or change in abdominal girth.
If you notice these symptoms for more than 2 weeks and/or they feel different to you in any way from your previous experience, do not ignore them. See your gynecologist, who will likely order a pelvic ultrasound as a first step.
