Ovarian Cysts and Endometriosis

Ovarian cysts are enlargements of the ovary that appear to be filled with fluid. They can be a simple fluid filled bleb or contain complex internal structures. The term cyst is used to differentiate them from solid enlargements. Simple cysts have no internal structures and are less worrisome than those with complex structures or solid components. A sonogram or ultrasound test can determine if a cyst is simple or complex.

Ovarian cysts are frequently encountered. Every menstruating woman develops an ovarian cyst each cycle. The menstrual cycle requires the coordinated functioning of the pituitary gland, ovary, uterus and the cervix. The pituitary gland in the head produces the hormones, Follicle Stimulating Hormone (FSH) and Luteinizing Hormone (LH). These hormones are released into the blood stream and are the messengers that tell the ovary what to do.

The ovary responds to FSH by maturing an egg. While doing this the ovary makes and releases the hormone estrogen. The maturing egg is in a follicle cyst that grows to about one half inch in diameter. When the pituitary releases a surge of LH the follicle breaks and the egg floats out and eventually enters the tube. The remnant of the follicle cyst is called the corpus luteum and makes the hormone progesterone.

The lining of the uterus is stimulated to proliferate and grow under the influence of estrogen. Progesterone converts the lining of the uterus to become a secretory lining that is prepared to accept a pregnancy. If a pregnancy does not occur that cycle the corpus luteum stops making progesterone. When the progesterone level falls the support for the lining of the uterus is lost and it sloughs. This is the menstrual bleeding. Then the cycle starts all over again: estrogen, ovulation, progesterone and the menstrual period.

Sometimes the ovary does not ovulate and the follicle cyst persists. It will continue to enlarge and can become as big as a baseball. Eventually it will break and the woman may not even be aware that this has happened. The period may be delayed because there is no progesterone phase of the cycle to respond to. The corpus luteum can also become cystic. If these cysts are detected during an examination the woman will be told that she has a cyst. Usually this will cause considerable consternation. Now everybody is upset. Could the cyst be a cancer? Will an operation have to be done? How are these questions to be answered?

If a sonogram shows this to be a simple cyst without any internal structure.
If it is only on one side.
If it is less than 4-5 inches in diameter.
If it occurs in an ovulating woman or an early pregnant woman.
If there are no associated findings such as nodules or fluid in the pelvis.
If there are no major symptoms of pain.

Then wait.

Schedule a reexamination for 4 weeks. If it is gone or getting smaller then it was a functional cyst: either a follicle cyst or a corpus luteum cyst. Nothing more needs to be done. If it persists then a diagnosis must be arrived at surgically.

Women on birth control pills should not develop functional cysts. The function of the pill is to suppress ovulation, although some women ovulate on their pills. Premenarchal and postmenopausal women should not develop functional cysts. Women in these groups with a cyst as well as those with a complex or a solid cyst will have to be evaluated surgically. This is the only way to make sure that the cyst is or is not a cancer. A Ca-125 test is of no value. It can be elevated for a variety of reasons and a normal value is meaningless. A surgical evaluation must be done. Most of the "cysts" will be shown surgically to be things other than cancers.

CAUSES FOR AN APPARENT OVARIAN CYST

Benign neoplastic ovarian cystadenomas Benign teratomas such as a dermoid Cysts of structures next to the ovary Fluid filled Fallopian tubes Infections in the tubes and or ovaries Endometriosis and endometrial ovarian cysts Fibroid tumors of the uterus that are on a stalk Abscess of the appendix Abscess of a colon diverticulum

In many instances, the surgical evaluation can be accomplished by laparoscopy. Laparoscopy is an outpatient procedure, but will in most cases, require a general anesthetic and a trip to the operating room.

Any ovarian or uterine enlargement in a post menopausal woman must be taken seriously. Women in this age group do not develop functional ovarian cysts. If they have fibroid tumors of the uterus these should begin to shrink at menopause. Fibroid tumors are benign tumors of the smooth muscle of the uterine wall and are common in younger women. A newly diagnosed fibroid tumor in a post menopausal woman should be an alarm signal and should be verified surgically.

Endometriosis is a condition in which tissue similar to the lining of the uterus is located outside the uterus. Usually there are implants of this tissue in the pelvis. When the lining of the uterus bleeds during the menstrual cycle, these implants also bleed. This causes pain and scarring in the pelvis. The other pelvic structures react to this bleeding by becoming adherent to each other so that tubes, ovaries and intestine are stuck together. If the endometrial tissue is within an ovary, that ovary will fill with blood. These are called endometriomas and are cysts in the ovary filled with old blood. This old blood has the appearance of thin chocolate or motor oil. They are also called chocolate cysts of the ovary. Endometriomas are frequently found at surgery for ovarian cysts. An elevated Ca-125 is often associated with endometriosis.

The treatment of endometriosis is usually by hormonal suppression of the menstrual cycle. This can be accomplished by using birth control pills. If the symptoms persist during the menses then the pills can be taken in a continuous fashion and not interrupted for menses. This is easily done with monophasic pills where every active pill is exactly the same. Most pills are packaged with 21 active pills followed by 7 empty or "dummy" pills. Taking the empty pills is the same as taking no pill at all. The period only occurs when you stop taking the pill. Normally this occurs on the days when the empty pills are being taken. If the empty pills are ignored and an active pill is taken each day, then every day will be exactly the same. As long as the active pill is being taken there will be no menses. The active pills can be taken daily for as long as a year without any problem and without any bleeding.

Monophasic oral contraceptive pills each contain the same amount of an estrogen and a progestin. The net effect is that of the progestin. A continuous progesterone influence on the lining of the uterus produces thinning or atrophy of the uterine lining. This influence will also atrophy the endometrial implants.

Hormonal suppression can also be accomplished by injection of a long acting progesterone every 2 or 3 months. This drug is called Depo Provera and can be continued indefinitely. There is also a monthly injection of a GnRH type hormone. This is a Gonadotropin Releasing Hormone agonist. It basically stops all pituitary and ovarian function. It is very effective, but is useful for only 9 months at a time. There is a final solution if nothing works which is removal of the uterus and ovaries. Pregnancy also has a beneficial effect on endometriosis because it is a time of high progesterone levels.

William M. Rich, M.D.
Clinical Professor of Obstetrics and Gynecology
University of California, San Francisco
Director of Gynecologic Oncology
University Medical Center
Fresno, California