There are other types of cysts that arise from benign tumors and are more likely to occur in older women. They’re called cystadenomas. These arise from cells on the outer surface of the ovary that secrete a watery or jelly-like fluid. Cystadenomas can become quite large and cause pain. The most worrisome (and largest) are mucinous cystadenomas. They are filled with a sticky, thick, gelatinous material which can seed onto other pelvic and abdominal surfaces causing multiple growths and collections of mucinous fluid. These tend to recur and may ultimately be fatal. 

What about the condition called polycystic ovarian syndrome (PCOS)?  Doesn’t this cause the formation of many cysts?
PCOS is a complicated endocrine condition in which the follicles develop, but don’t normally erupt and extrude an egg. As a result, multiple small cysts remain under the ovary’s surface causing the ovary to become mildly enlarged. These polycystic ovaries appear “hole-ridden” on ultrasound. But contrary to the name, multiple large cysts, measuring more than two and a half centimeters rarely occur. The small cysts of PCOS do not cause pain.

Can other pelvic organs form cysts?
Fluid can accumulate in the fallopian tubes if they become blocked by infection. This condition is termed hyrdosalpinx. Blood collections and swelling of the tube can occur as a result of an ectopic pregnancy. Occasionally growths from the surface of the tube can fill with fluid and cause small cysts (paratubal cysts). All of these diagnoses have to be considered when pain occurs and a cyst is found.

What sort of symptoms are associated with cysts? 
Most cysts don’t cause symptoms and are discovered on routine pelvic exam. However, cysts can cause intense pelvic pain if they rupture, twist, bleed, are pushed around (during intercourse or pelvic exam) or become large enough to press on adjacent structures. If the cyst undergoes torsion and twists or causes the ovary to twist, it can cause spasms of pain.  Sudden or sharp pain may indicate that the cyst has ruptured. Either torsion or rupture of the cyst can also cause fever, vomiting, and even symptoms of shock. 

How is a diagnosis made?
First, on pelvic exam, one or both of the ovaries will feel larger than normal and the exam may illicit unusual discomfort. Sometimes the doctor will feel that a mass fills the pelvis and she or he cannot tell whether it comes from the uterus, tubes or ovaries. Laboratory tests should follow, including a complete blood count (CBC) to check for infection or internal bleeding, a pregnancy test to detect a uterine or ectopic pregnancy. (An early, perfectly normal pregnancy can be associated with a functional ovarian cyst during the first trimester). And ultrasound should be done to “picture” the cyst. The echo pattern allows for assessment of the size of the cyst, whether it is filled with clear fluid or blood and will also detect the presence of internal solid elements. A special ultrasound measuring the flow of blood to and from the ovary and cyst (a Doppler study) may help in deciding if the cyst is actively growing and being fed by the vascular system. If the cyst is found to have solid elements, it’s also helpful to get an x-ray which can detect characteristic teeth, bone and/or cartilage in dermoid cysts. Finally, a CT scan or MRI can help determine whether the cyst is suspicious for malignancy or whether it’s pressing on or invading adjacent organs, lymph glands or blood vessels. 

The words ovarian cyst inevitably cause fear of ovarian cancer. What tests can reassure the patient? 
First, I have to emphasize: Most cysts are benign, especially those that occur during the reproductive years. The incidence of ovarian cancer begins to increase after menopause. If there is no significant family history of ovarian cancer or combinations of certain cancers, such as breast, colon, and prostate cancer, you don’t have a known genetic risk, and if you are younger than 50, you should be reassured. If the cyst appears on ultrasound to be filled with clear fluid ( a simple cyst), it’s less than six centimeters in diameter and you’re not in pain, a wait-and-see approach over the next three months is appropriate. Know that 90 percent of simple cysts are functional and will disappear after five weeks. Your doctor may repeat the ultrasound to make sure the cyst is gone. If, however, you are over the age of 50 and/or the cyst has solid elements and appears complex (with internal walls), further workup is usually done. This includes a blood test for the protein CA125, which may be produced by an ovarian cancer. However, this test is not foolproof. About 50  percent of early ovarian cancers don’t produce detectable amounts of CA125. And non-cancerous diseases such as uterine fibroids and endometriosis can cause mild elevations in the level of the CA125 protein. 

The final diagnosis, especially if the cyst looks suspicious, may have to be surgical via a laparoscopic procedure. The cyst (and sometimes the ovary) will be removed and examined. In women who are menopausal, both ovaries are usually excised in order to prevent recurrences and/or reduce the future risk of ovarian cancer. If the doctor has a very high suspicion of cancer, a laparotomy (an abdominal incision) may be indicated. And if ovarian cancer is found, the surgery usually includes hysterectomy, removal of both ovaries, tubes, adjacent lymph glands and an excision of all visible cancer. This should be scheduled at surgical centers where a specialist in gynecologic cancer surgeries (a gynecologic oncologist) can be present.

Can ovarian cysts be prevented?
Birth control pills can decrease development of functional cysts and may also help issues related to endometriosis. Since ovarian cancer seems, to some extent, to be correlated with “incessant ovulation”, birth control pills (which stop ovulation) have been shown to decrease the risk of ovarian cancer by 40 percent if used for over two years and 80 percent if used for more than 10 years. 

Dr. Reichman's bottom line: Don’t panic if your doctor tells you that you have an ovarian cyst. Chances are it is benign. The proper workup is essential and will often allow you to safely wait, followup and avoid unnecessary surgical intervention. 

Dr. Judith Reichman, the “Today” show's medical contributor on women's health, has practiced obstetrics and gynecology for more than 20 years. You will find many answers to your questions in her latest book, "Slow Your Clock Down: The Complete Guide to a Healthy, Younger You," which is now available in paperback. It is published by William Morrow, a division of HarperCollins.

PLEASE NOTE: The information in this column should not be construed as providing specific medical advice, but rather to offer readers information to better understand their lives and health. It is not intended to provide an alternative to professional treatment or to replace the services of a physician.

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