Ovarian cysts: part one

“I have pain, don’t you understand? It’s on the right side where the cyst is!” She spit the word out like it had a bad taste. For her it very likely did.

I’d never seen her before, but the family doctor had sent an old ultrasound -done a year ago- along with his consult request letter. Under her critical eye, I read the report: a simple 2.5 cm. cyst in the right ovary. Likely functional, it added…

“I’m tired of this!” she said, and she leaned over the desk menacingly. “And I want it out!” She was twenty-five and she knew what she wanted.

I suggested that I would need to examine her to see if the cyst was still present, but this met with a firm “No! My doctor has already examined me. I don’t want to go through that again.”

It’s hard to know how to proceed under such constraints, but I did manage to talk her into another ultrasound to see if it was still there. She glared at me as if I were calling her a liar.

When she came back to the office a week or so later after the ultrasound had been done, she was no less angry. She sat on the edge of her chair, leaned over the desk again, and pounded it with her fist. “I told you there was a cyst! The ultrasound technician showed it to me! You’ve wasted all this time when I told you I had a cyst…”

I tried to keep smiling while I opened up her chart to look at the new ultrasound report. She had a cyst alright, but this time it was in the left ovary. The right ovary was totally normal. Her pain was not coming from the cyst.

So why the little anecdote? It’s certainly not to belittle the patient, or conclude that she had no pain. It’s just that there are many types of cysts, and not all of them should arouse concern in a young woman. A lot of them don’t cause pain and most of them go away. So I thought I would describe one of the more common types and very briefly outline what I mean.

First of all, the ovary is a very active organ throughout the child-bearing portion of a woman’s life. Each month -if she’s not pregnant or on the birth control pill, for example- a tiny little egg is stimulated to develop by a chemical signal from the brain: the follicle stimulating hormone (FSH).  It does so in a little fluid-filled cavity known as a follicle. This signal gets feedback from the egg so it turns off when the egg is mature, or increases in intensity if the egg is not responding.  As the development proceeds, the follicle gets larger. When the egg is finally mature, the follicle bursts open liberating the egg so it can be picked up by the Fallopian tube.

But suppose the little microscopic egg doesn’t respond very well and never really matures -maybe because of stress, or age -or even because that particular egg is not very sensitive? Well, the follicle gets more and more fluid in it as the FSH increases and pretty soon it’s no longer called a follicle -now it’s a cyst. And because it’s part of the normal functioning of the ovary,  we call it a functional cyst. Or a follicular cyst. Or even a simple cyst. These can get fairly large (up to 4 or 5 cm. diameter) but they’re generally quite temporary and eventually disappear (reabsorb). They seldom cause symptoms although if one bursts, it can be painful for an hour or two. In other words, many people likely have cysts without knowing about them.

What are reassuring features on an ultrasound? Well, think of a tiny balloon filled with water. It would have thin walls -no lumps or thickenings; no ultrasound echoes in the fluid; no increased blood flow to the cyst (they can measure this nowadays using Doppler effects); and a size less than, say, 4 or 5 cm. And if so, what to do? Well, we generally do another ultrasound two or three months later to see if it’s till there or has changed in some way. But otherwise, nothing.

Ovarian cysts should be investigated once they’re discovered, of course, but they don’t all need treatment. They aren’t all bad.

And that patient? I eventually laparoscoped her because of her on-going pain and found endometriosis. Normal looking ovaries, though.

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