Ovarian cysts are common findings in women of reproductive age. These fluid-filled sacs on or in an ovary are often benign and resolve without intervention. Many wonder if ovarian cysts can be managed without surgery.
Understanding Ovarian Cysts
Ovarian cysts are sacs filled with fluid or other material that form on or within an ovary. They are broadly categorized into two main types: functional cysts and pathological cysts.
Functional cysts, like follicular and corpus luteum cysts, are the most common and arise from the normal ovulation process. Follicular cysts develop when a follicle fails to rupture and release an egg. Corpus luteum cysts form after an egg is released, but the follicle sac recloses and fills with fluid. These cysts are harmless and often disappear on their own within a few menstrual cycles.
Pathological cysts are less common and include types like dermoid cysts (teratomas), endometriomas, and cystadenomas. Dermoid cysts can contain various tissues like skin, hair, or even teeth, forming from embryonic cells. Endometriomas, sometimes called “chocolate cysts,” are formed from endometrial tissue that grows outside the uterus, often on the ovaries. Cystadenomas are growths on the ovary surface, filled with watery or gelatinous fluid. Cysts are commonly discovered during routine pelvic exams, imaging (ultrasound), or when symptoms prompt evaluation.
Non-Surgical Approaches to Management
Aspiration, a procedure to drain the cyst, is a non-surgical option for specific types. It is reserved for simple, fluid-filled cysts without suspicious imaging characteristics. During aspiration, a thin needle or catheter is guided by ultrasound (often transvaginally) into the cyst to remove fluid. This minimally invasive technique offers benefits like shorter hospital stays, rapid recovery, and reduced discomfort.
However, aspiration has limitations and risks. Recurrence of the cyst is common, with studies showing recurrence rates as high as 75%. While the procedure has a low rate of complications like infection or bleeding, aspiration is not typically used to diagnose malignancy.
Aspirated fluid may be sent for cytologic examination; however, if suspicious features are present or develop, further investigation, including surgery, is often recommended. Aspiration is not suitable for complex cysts, those with solid components, or those raising concern for malignancy.
Other non-surgical strategies are widely employed, particularly for functional cysts. Watchful waiting is the most common approach for asymptomatic cysts that appear benign on ultrasound. This involves monitoring the cyst with follow-up ultrasound scans to confirm resolution or stability, as many functional cysts resolve spontaneously.
Hormonal therapy, such as oral contraceptive pills, may be considered to prevent the formation of new functional cysts. While these medications can suppress ovulation and thus reduce the chance of new cysts developing, they typically do not shrink existing cysts. Studies show hormonal treatment has no significant effect on the resolution rate of existing ovarian cysts compared with expectant management.
When Surgical Intervention is Necessary
Surgery is a necessary or preferred treatment for ovarian cysts under specific circumstances. Persistent cysts (those not resolving after several menstrual cycles or continuing to grow) often warrant surgical removal. Cysts causing significant symptoms, such as severe pain or pressure that impact daily life, are also indications for surgery.
Suspicious features on imaging (ultrasound, MRI, CT scans) are a primary reason for surgery. These features can include solid components within the cyst, internal septations (walls), rapid growth, or abnormal blood flow. Blood tests, such as CA-125, may also be used with imaging, particularly in postmenopausal women, to assess malignancy risk; however, elevated levels can occur in non-cancerous conditions. Emergency surgery is necessary for complications like ovarian torsion (where the ovary twists on its blood supply) or a ruptured cyst causing significant internal bleeding.
Common surgical approaches include laparoscopy and laparotomy. Laparoscopy, or “keyhole surgery,” is a minimally invasive procedure involving small abdominal incisions. A laparoscope, a thin tube with a camera, allows the surgeon to view and remove the cyst, leading to less pain and quicker recovery.
Laparotomy is an open surgical procedure involving a single, larger abdominal incision. This approach is reserved for very large or complex cysts or when cancer is highly suspected, as it provides better surgical access. Surgeons aim to perform a cystectomy, removing only the cyst while preserving the ovary, especially for younger patients or those wishing to maintain fertility. However, if the cyst has extensively damaged the ovary or malignancy is suspected, removal of the entire ovary (oophorectomy) may be necessary.