An ovarian cyst is a sac filled with liquid or semi-liquid material arising in an ovary.

The number of diagnoses of ovarian cysts has increased with the widespread implementation of regular physical examinations and ultrasound technology. The finding of an ovarian cyst causes considerable anxiety for women because of the fear of malignancy, but the vast majority of ovarian cysts are benign.

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Each month, normally functioning ovaries develop small cysts called Graafian follicles.[1] At mid cycle, a single dominant follicle up to about 2.8 cm in diameter releases a mature oocyte. The ruptured follicle becomes the corpus luteum, which, at maturity, is a 1.5- to 2-cm structure with a cystic center. In the absence of fertilization of the oocyte, it undergoes progressive fibrosis and shrinkage. If fertilization occurs, the corpus luteum initially enlarges and then gradually decreases in size during pregnancy. Ovarian cysts arising in the normal process of ovulation are called functional cysts and are always benign. They may be follicular and luteal, sometimes called theca-lutein cysts. These cysts can be stimulated by gonadotropins, including follicle-stimulating hormone (FSH) and human chorionic gonadotropin (hCG). A theca-lutein cyst is shown in the sonogram below.

Theca-lutein cysts replacing an ovary in a patient with a molar pregnancy. Despite their size these cysts are benign and usually resolve after treatment of the underlying disease.

Multiple functional cysts can occur as a result of excessive gonadotropin stimulation or sensitivity. In gestational trophoblastic neoplasia (hydatidiform mole and choriocarcinoma) and rarely in multiple and diabetic pregnancy, hCG causes a condition called hyperreactio luteinalis. In patients being treated for infertility, ovulation induction with gonadotropins (FSH and luteinizing hormone [LH]), and rarely clomiphene citrate, may lead to ovarian hyperstimulation syndrome, especially if accompanied by hCG administration. Neoplastic cysts arise by inappropriate overgrowth of cells within the ovary and may be malignant or benign. Malignant neoplasms may arise from all ovarian cell types and tissues. By far, the most frequent are those arising from the surface epithelium (mesothelium), and most of these are partially cystic lesions. The benign counterparts of these cancers are serous and mucinous cystadenomas. Other malignant ovarian tumors may contain cystic areas, and these include granulosa cell tumors from sex cord stromal cells and germ cell tumors from primordial germ cells. A clear cell carcinoma is shown in the image below.

Cross-section of a clear cell carcinoma of the ovary. Note the cystic spaces intermingled with solid areas.

Teratomas are a form of germ cell tumor[2] containing elements from all 3 embryonic germ layers, ie, ectoderm, endoderm, and mesoderm. A mature cystic teratoma is shown in the image below.

A dermoid cyst (mature cystic teratoma) after opening the abdomen. Note the yellowish color of the contents seen through the wall.

Endometriomas are cysts filled with blood arising from the ectopic endometrium. In polycystic ovary syndrome, the ovary often contains multiple cystic follicles 2-5 mm in diameter as viewed on sonograms. The cysts themselves are never the main problem, and discussion of this disease is beyond the scope of this article.

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Frequency
United States Ovarian cysts are found on transvaginal sonograms in nearly all premenopausal women and in up to 18% of postmenopausal women.[3] Most of these cysts are functional in nature and benign. Mature cystic teratomas or dermoids represent more than 10% of all ovarian neoplasms. The incidence of ovarian carcinoma is approximately 15 cases per 100,000 women per year. Annually in the United States, ovarian carcinomas are diagnosed in more than 21,000 women, causing an estimated 14,600 deaths.[4] Most malignant ovarian tumors are epithelial ovarian cystadenocarcinomas. Tumors of low malignant potential comprise approximately 20% of malignant ovarian tumors, whereas fewer than 5% are malignant germ cell tumors, and approximately 2% granulosa cell tumors.

Mortality/Morbidity
Benign cysts can cause pain and discomfort related to pressure on adjacent structures, torsion, rupture, hemorrhage (both within and outside of the cyst), and abnormal uterine bleeding. They rarely cause death. Mucinous cystadenomas may cause a relentless collection of mucinous fluid within the abdomen, known as pseudomyxoma peritonei, which may be fatal without extensive treatment. Mortality associated with malignant ovarian carcinoma is related to the stage at the time of diagnosis, and patients with ovarian carcinoma generally present late in the course of disease. The

5-year survival rate overall is 41.6%, varying between 86.9% for International Federation of Gynecology and Obstetrics (FIGO) stage Ia and 11.1% for stage IV.[5]Granulosa cell tumors are associated with an 82% survival rate, whereas squamous cell carcinomas arising in a dermoid cyst have a very poor outcome. Most germ cell tumors are diagnosed at an early stage and have an excellent outcome. Advanced-stage dysgerminomas are associated with a better outcome compared to nondysgerminomatous germ cell tumors. A distinct group of less aggressive tumors of low malignant potential has a more benign course but is still associated with mortality.[6] The overall survival rate is 86.2% at 5 years. Malignant ovarian cystic tumors can cause severe morbidity, including pain, abdominal distension, bowel obstruction, nausea, vomiting, early satiety, wasting, cachexia, indigestion, heartburn, abnormal uterine bleeding, deep venous thrombosis, and dyspnea. Cystic granulosa cell tumors may secrete estrogen, which leads to postmenopausal bleeding and precocious puberty in elderly patients and young patients, respectively.

Race
Malignant epithelial ovarian cystadenocarcinomas are the only ovarian cysts associated with racial differences. Women from northern and western Europe and North America are affected most frequently, whereas women from Asia, Africa, and Latin America are affected least frequently. Within the United States, age-adjusted incidence rates in surveillance areas are highest among American Indian women, followed by white, Vietnamese, Hispanic, and Hawaiian women. Incidence is lowest among Korean and Chinese women.[7] Among women for whom sufficient numbers of cases are available to calculate rates based on age, incidence in those aged 30-54 years is highest in white women, followed by Japanese, Hispanic, and Filipino women. For those aged 55-69 years, the highest rates occur in white women, followed by Hispanic and Japanese women. Among women aged 70 years or older, the highest rate occurs among white women, followed by those of African descent and Hispanic women.

Age
Functional ovarian cysts occur at any age (including in utero), but are much more common in reproductive-aged women. They are rare after menopause. Luteal cysts occur after ovulation in reproductive-aged women. Most benign neoplastic cysts occur during the reproductive years, but the age range is wide and they may occur in persons of any age. The incidence of epithelial ovarian cystadenocarcinomas, sex cord stromal tumors, and mesenchymal tumors rises exponentially with age until the sixth decade of life, at which point the incidence plateaus. Tumors of low malignant potential occur at a mean age of 44 years, with a span from adolescence to senescence. The average age is more than a decade less than that for invasive cystadenocarcinoma. Germ cell tumors are most common in adolescence and rarely occur in those older than 30 years.

History
Most patients with ovarian cysts are asymptomatic but some cysts may be associated with a range of symptoms, sometimes severe.[8]Even malignant ovarian cysts commonly do not cause symptoms until they reach an advanced stage. Pain or discomfort may occur in the lower abdomen. Torsion (twisting) or rupture may lead to more severe pain. An ovarian cyst that has undergone torsion is shown in the image below.

An ovarian cyst that has undergone torsion (twisting of the vascular pedicle). The patient presented with a short history of severe lower abdominal pain. The twisted pedicle can be seen attached to the cyst, which has turned dusky due to ischemia. No viable epithelial lining was available for histologic diagnosis.

Patients may experience discomfort with intercourse, particularly deep penetration. Having bowel movements may be difficult, or pressure may develop, leading to a desire to defecate. Micturition may occur frequently and is due to pressure on the bladder. Irregularity of the menstrual cycle and abnormal vaginal bleeding may occur. Young children may present with precocious puberty and early onset of menarche. Patients may experience abdominal fullness and bloating. Patients may experience indigestion, heartburn, or early satiety. Endometriomas are associated with endometriosis, which causes a classic triad of painful and heavy periods and dyspareunia. Polycystic ovaries may be part of the polycystic ovary syndrome, which includes hirsutism, infertility, oligomenorrhea, obesity, and acne.

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Advanced malignant disease may be associated with cachexia and weight loss, lymphadenopathy in the neck, shortness of breath, and signs of pleural effusion. A large cyst may be palpable on abdominal examination. Gross ascites may interfere with palpation of an intra-abdominal mass. Although normal ovaries may be palpable during the pelvic examination in thin premenopausal patients, a palpable ovary should be considered abnormal in a postmenopausal woman. If a patient is obese, palpating cysts of any size may prove difficult. Sometimes, discerning the cystic nature of an ovarian cyst may be possible, and it may be tender to palpation. The cervix and uterus may be pushed to one side. Other masses may be palpable, including fibroids and nodules in the uterosacral ligament consistent with malignancy or endometriosis.

Multiple functional cysts can occur as a result of excessive gonadotropin stimulation or sensitivity. o In gestational trophoblastic neoplasia (hydatidiform mole and choriocarcinoma) and rarely in multiple or diabetic pregnancy, hCG is the stimulating gonadotropin. The condition is called hyperreactio luteinalis. o Patients being treated for infertility by ovulation induction with gonadotropins or other agents, such as clomiphene citrate or letrozole, may develop cysts as part of ovarian hyperstimulation syndrome.

 Tamoxifen can cause benign functional ovarian cysts that usually resolve following discontinuation of treatment. Risk factors for ovarian cystadenocarcinoma include strong family history, advancing age, white race, infertility, nulliparity, a history ofbreast cancer, and BRCA gene mutations.

Differential dx

Differentials

Abdominal Abscess Ectopic Pregnancy

Intra-abdominal abscess continues to be an important and serious problem in surgical practice. Appropriate treatment is often delayed because of the obscure nature of many conditions resulting in abscess formation, which can make diagnosis and localization difficult. Associated pathophysiologic effects may become life threatening or lead to extended periods of morbidity with prolonged hospitalization. Delayed diagnosis and treatment can also lead to increased mortality rates; therefore, the

economic impact of delaying treatment is significant. A better understanding of intra-abdominal abscess pathophysiology and a high clinical index of suspicion should allow for earlier recognition, definitive treatment, and reduced morbidity and mortality.[1] (See image below.)

Percutaneous computed tomography (CT) scanguided drainage of postoperative

Although multiple causes of intra-abdominal abscesses exist, the following are the most common: (1) perforation of a diseased viscus, which includes peptic ulcer perforation; (2) perforated appendicitis and diverticulitis; (3) gangrenous cholecystitis; (4) mesenteric ischemia with bowel infarction; and (5) pancreatitis or pancreatic necrosis progressing to pancreatic abscess. (See image below.)

Contrast-enhanced computed tomography (CT) scan of infected pancreatic pseudocyst (which can develop from acute necrotizing pancreatitis and give rise to an abscess).

Other causes include untreated penetrating trauma to the abdominal viscera and postoperative complications, such as anastomotic leak[1, 2] or missed gallstones during laparoscopic cholecystectomy.

Microbiology includes a mixture of aerobic and anaerobic organisms. The most commonly isolated aerobic organism is Escherichia coli, and the most commonly observed anaerobic organism is Bacteroides fragilis.[3] A synergistic relationship exists between these organisms. In patients who receive prolonged antibiotic therapy, yeast colonies (eg, candidal species) or a variety of nosocomial pathogens may be recovered from abscess fluids. Skin flora may be responsible for abscesses following a penetrating abdominal injury. Neisseria gonorrhoeae and chlamydial species are the most common organisms involved in pelvic abscesses in females as part of pelvic inflammatory disease. The type and density of aerobic and anaerobic bacteria isolated from intra-abdominal abscesses depend upon the nature of the microflora associated with the diseased or injured organ. Microbial flora of the GI tract shifts from small numbers of aerobic streptococci, including enterococci and facultative gram-negative bacilli in the stomach and proximal small bowel, to larger numbers of these species, with an excess of anaerobic gram-negative bacilli (particularly Bacteroidesspecies) and anaerobic gram-positive flora (streptococci and clostridia) in the terminal ileum and colon. Differences in microorganisms observed from the upper to the lower portion of the GI tract partially account for differences in septic complications associated with injuries or diseases to the upper and lower gut. Sepsis occurring after upper GI perforations or leaks causes less morbidity and mortality than does sepsis after leaks from colonic insults.

Patho
Intra-abdominal abscesses are localized collections of pus that are confined in the peritoneal cavity by an inflammatory barrier. This barrier may include the omentum, inflammatory adhesions, or contiguous viscera. The abscesses usually contain a mixture of aerobic and anaerobic bacteria from the GI tract. Bacteria in the peritoneal cavity, in particular those arising from the large intestine, stimulate an influx of acute inflammatory cells. The omentum and viscera tend to localize the site of infection, producing a phlegmon. The resulting hypoxia in the area facilitates growth of anaerobes and impairs bactericidal activity of granulocytes. The phagocytic activity of these cells degrades cellular and bacterial debris, creating a hypertonic milieu that expands and enlarges the abscess cavity in response to osmotic forces. If untreated, the process continues until bacteremia develops, which then progresses to generalized sepsis with shock.

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Intra-abdominal abscesses are highly variable in presentation. Persistent abdominal pain, focal tenderness, spiking fever, prolonged ileus, leukocytosis, or intermittent polymicrobial bacteremia suggest an intra-abdominal abscess in patients with predisposing primary intraabdominal disease or in individuals who have had abdominal surgery. If a deeply

seated abscess is present, many of these classic features may be absent. The only initial clues may be persistent fever, mild liver dysfunction, persistent GI dysfunction, or nonlocalizing debilitating illness. The diagnosis of an intra-abdominal abscess in the postoperative period may be difficult, because postoperative analgesics and incisional pain frequently mask abdominal findings. In addition, antibiotic administration may mask abdominal tenderness, fever, and leukocytosis. In patients with subphrenic abscesses, irritation of contiguous structures may produce shoulder pain, hiccup, or unexplained pulmonary manifestations, such as pleural effusion, basal atelectasis, or pneumonia. With pelvic abscesses, frequent urination, diarrhea, or tenesmus may occur. A diverticular

abscess may present as an incarcerated inguinal hernia.[4] Many patients have a significant septic response, suffer volume depletion, and develop a catabolic state. This syndrome may include high cardiac output, tachycardia, low urine output, and low peripheral oxygen extraction. Initially, respiratory alkalosis due to hyperventilation may occur. If left untreated, this progresses to metabolic acidosis. Sequential multiple organ failure is highly suggestive of intraabdominal sepsis. The 6 functional compartments in the peritoneal cavity include the following: (1) pelvis, (2) right paracolic gutter, (3) left paracolic gutter, (4) infradiaphragmatic spaces, (5) lesser sac, and (6) interloop potential spaces of the small intestine. The paracolic gutters slope into the subhepatic and subdiaphragmatic spaces

superiorly and over the pelvic brim inferiorly. In a supine patient, the peritoneal fluid tends to collect under the diaphragm, under the liver, and in the pelvis. More localized abscesses tend to develop anatomically in relation to the affected viscus. For example, abscesses in the lesser sac may develop secondary to severe pancreatitis, or periappendiceal abscesses from a perforated appendix may develop in the right lower quadrant. Small bowel interloop abscesses may develop anywhere from the ligament of Treitz to the ileum. An understanding of these anatomic considerations is important for the recognition and drainage of these abscesses.
Ectopic pregnancy presents a major health problem for women of childbearing age. It is the result of a flaw in human reproductive physiology that allows the conceptus to implant and mature outside the endometrial cavity, which ultimately ends in death of the fetus. Without timely diagnosis and treatment, ectopic pregnancy can become a life-threatening situation. Ectopic pregnancy currently is the leading cause of pregnancy-related death during the first trimester in the United States, accounting for 9% of all pregnancy-related deaths. In addition to the immediate morbidity caused by ectopic pregnancy, the woman's future ability to reproduce may be adversely affected as well.

Ectopic pregnancy. Laparoscopic picture of an unruptured right ampullary tubal pregnancy with bleeding out of the fimbriated end resulting in hemoperitoneum

Ectopic pregnancy is derived from the Greek word ektopos, meaning out of place, and it refers to the implantation of a fertilized egg in a location outside of the uterine cavity, including the fallopian tubes, cervix, ovary, cornual region of the uterus, and the abdominal cavity. This abnormally implanted gestation grows and draws its blood supply from the site of abnormal implantation. As the gestation enlarges, it creates the potential for organ rupture because only the uterine cavity is designed to expand and accommodate fetal development. Ectopic pregnancy can lead to massive hemorrhage, infertility, or death. _

Multiple factors contribute to the relative risk of ectopic pregnancy. In theory, anything that hampers the migration of the embryo to the endometrial cavity could predispose women to ectopic gestation. The most logical explanation for the increasing frequency of ectopic pregnancy is previous pelvic infection; however, most patients presenting with an ectopic pregnancy have no identifiable risk factor. The following risk factors have been linked with ectopic pregnancy:

Pelvic inflammatory disease

The most common cause is antecedent infection caused by Chlamydia trachomatis. Patients with chlamydial infection have a range of clinical presentations, from asymptomatic cervicitis to salpingitis and florid pelvic inflammatory disease (PID). More than 50% of women who have been infected are unaware of the exposure. Other organisms causing PID,

such asNeisseria gonorrhoeae, increase the risk of ectopic pregnancy. A history of salpingitis increases the risk of ectopic pregnancy 4-fold. The incidence of tubal damage increases after successive episodes of PID (ie, 13% after 1 episode, 35% after 2 episodes, 75% after 3 episodes).

History of prior ectopic pregnancy

After one ectopic pregnancy, a patient incurs a 7- to 13-fold increase in the likelihood of another ectopic pregnancy. Overall, a patient with prior ectopic pregnancy has a 50-80% chance of having a subsequent intrauterine gestation, and a 10-25% chance of a future tubal pregnancy.

History of tubal surgery and conception after tubal ligation

Prior tubal surgery has been demonstrated to increase the risk of

developing ectopic pregnancy. The increase depends on the degree of damage and the extent of anatomic alteration. Surgeries carrying higher risk of subsequent ectopic pregnancy include salpingostomy, neosalpingostomy, fimbrioplasty, tubal reanastomosis, and lysis of peritubal or periovarian adhesions. Conception after previous tubal ligation increases a women's risk of developing ectopic pregnancies. Thirty-five to 50% of patients who conceive after a tubal ligation are reported to experience an ectopic pregnancy. Failure after bipolar tubal cautery is more likely to result in ectopic pregnancy than occlusion using suture, rings, or clips. Failure is attributed to fistula formation that allows sperm passage. Ectopic pregnancies following tubal sterilizations usually occur 2 or more years after sterilization, rather than immediately after. In the first year, only

about 6% of sterilization failures result in ectopic pregnancy.

Use of fertility drugs or assisted reproductive technology

Ovulation induction with clomiphene citrate or injectable gonadotropin therapy has been linked with a 4-fold increase in the risk of ectopic pregnancy in a casecontrol study. This finding suggests that multiple eggs and high hormone levels may be significant factors. One study has demonstrated that infertility patients with luteal phase defects have a statistically higher ectopic pregnancy rate than patients whose infertility is caused by anovulation. The risk of ectopic pregnancy and heterotopic pregnancy (ie, pregnancies occurring simultaneously in different body sites) dramatically increases when a patient has used assisted reproductive techniques to conceive, such as in vitro

fertilization (IVF) or gamete intrafallopian transfer (GIFT). In a study of 3000 clinical pregnancies achieved through in vitro fertilization, the ectopic pregnancy rate was 4.5%, which is more than double the background incidence. Furthermore, studies have demonstrated that up to 1% of pregnancies achieved through IVF or GIFT can result in a heterotopic gestation, compared to an incidence of 1 in 30,000 pregnancies for spontaneous conceptions.

Use of an intrauterine device

The presence of an inert coppercontaining or progesterone intrauterine device (IUD) traditionally has been thought to be a risk factor for ectopic pregnancy. However, only the progesterone IUD has a rate of ectopic pregnancy higher than that for women not using any form of contraception. The modern copper IUD does not increase the risk of ectopic pregnancy.

Nevertheless, if a woman ultimately conceives with an IUD in place, it is more likely to be an ectopic pregnancy. The actual incidence of ectopic pregnancies with IUD use is 3-4%.

Increasing age
The highest rate of ectopic pregnancy occurs in women aged 35-44 years. A 3to 4-fold increase in the risk for developing an ectopic pregnancy exists compared to women aged 15-24 years. One proposed explanation involves the myoelectrical activity in the fallopian tube, which is responsible for tubal motility. Aging may result in a progressive loss of myoelectrical activity along the fallopian tube.

Smoking
Cigarette smoking has been shown to be a risk factor for developing an ectopic pregnancy. Studies have demonstrated

elevated risk ranging from 1.6-3.5 times that of nonsmokers. A dose-response effect also has been suggested. Based on laboratory studies in humans and animals, researchers have postulated several mechanisms by which cigarette smoking might play a role in ectopic pregnancies. These mechanisms include one or more of the following: delayed ovulation, altered tubal and uterine motility, or altered immunity. To date, no study has supported a specific mechanism by which cigarette smoking affects the occurrence of ectopic pregnancy.

Salpingitis isthmica nodosum

Salpingitis isthmica nodosum is defined as the microscopic presence of tubal epithelium in the myosalpinx or beneath the tubal serosa. These pockets of epithelium protrude through the tube, similar to small diverticula. Studies of serial histopathological sections of the

fallopian tube have revealed that approximately 50% of patients treated with salpingectomy for ectopic pregnancy have evidence of salpingitis isthmica nodosum. The etiology of salpingitis isthmica nodosum is unclear, but proposed mechanisms include postinflammatory and congenital as well as acquired tubal changes such as observed with endometriosis.

Other
Other risk factors associated with increased incidence of ectopic pregnancy include previous diethylstilbestrol (DES) exposure, a T-shaped uterus, prior abdominal surgery, failure with progestinonly contraception, and ruptured appendix.
Most ectopic pregnancies are located in the fallopian tube.

Sites and frequencies of ectopic pregnancy. By Donna M. Peretin, RN. (A) Ampullary, 80%; (B) Isthmic, 12%; (C) Fimbrial, 5%; (D) Cornual/Interstitial, 2%; (E) Abdominal, 1.4%; (F) Ovarian, 0.2%; (G) Cervical, 0.2%.

The most common site is the ampullary portion of the tube, where over 80% occur. The next most common sites are the isthmic segment of the tube (12%), the fimbria (5%), and the cornual and interstitial region of the tube (2%). Nontubal sites of ectopic pregnancy are a rare occurrence, with abdominal pregnancies accounting for 1.4% of ectopic pregnancies and ovarian and cervical sites accounting for 0.2% each.

Ovarian cyst

Definition of Ovarian Cysts

An ovarian cyst is a sac or pouch that develops in or on the ovary. The cysts may contain liquid, or solid material or a combination of both. Ovarian cysts are very common, particularly in women between the ages of 30 and 60. They may be single or multiple, and can occur in one or both ovaries. Most are benign (non-cancerous), but approximately 15 percent are malignant (cancerous).

Description of Ovarian Cysts

During ovulation (the process during which the egg ripens and is released from the ovary) the ovary produces a hormone to make the follicles (sacs containing immature eggs and fluid) grow and the eggs within it mature. Once the egg is ready, the follicle ruptures and the egg is released. Once the egg is released, the follicle changes into a smaller sac called the corpus luteum. Ovarian cystsoccur as a result of the follicle not rupturing, the follicle not changing into its smaller size, or doing the rupturing itself. There are five (5) common types of ovarian cysts: functional cysts, polycystic ovaries, endometrial cysts, cystadenomas and dermoid cysts. Functional Cysts There are two types of functional cysts - follicle cyst and corpus luteum cyst. Both of these types of cysts develop as part of the natural function of the ovary. Follicle Cyst. This cyst occurs during ovulation when an egg is released into the fallopian tube or when a developing follicle fails to rupture. These cysts grow from 1 inches to 2 inches in diameter, and will usually dissolve within one to three months. Corpus Luteum Cyst. This cyst is caused by a malfunction of the corpus luteum. Unless a woman is pregnant, the corpus luteum disintegrates. But in the formation of a corpus luteum cyst, it fills with fluid and remains in the ovary. Polycystic Ovaries

Polycystic ovaries (also known as polycystic ovarian syndrome or disease) is a condition in which the follicles never erupt from the ovaries. Under normal circumstances, follicles grow, mature, and rise to the surface of the ovary, where they burst and release an egg to the Fallopian tube, a process controlled by pituitary hormones. The remnants of the burst follicle then begin to produce progesterone, which stimulates the lining of the uterus (endometrium) to grow thicker in case it needs to support a fertilized egg. The effect on the pituitary of an increase in progesterone production is to signal it to stop stimulating the development of eggs. In polycystic ovaries, the follicles grow just under the ovaries' surface, and are produced again and again because the pituitary has not been signaled to shut off. Both ovaries become filled with tiny cysts and can become enlarged. Endometrial Cysts Endometrial cysts (also known as endometriomas or "chocolate cysts" (filled with dark blood)) form as a result ofendometriosis. Endometriosis is a disease in which the endometrial tissue normally found in the uterus grows in other areas. After successive menstrual cycles, this misplaced endometrial tissue bleed, gradually forming endometrial cysts. Over time the cysts grow and can become as large as a grapefruit. Cystadenomas Cystadenomas are known as neoplasms (new growths). Ovarian neoplasms are new and abnormal formations that develop from the ovarian tissue. There are two (2) types of cystadenomas - serous and mucinous. Serous cystadenoma is filled with a thin watery fluid and can grow to be between 2 inches to 6 inches in diameter. Mucinous cystadenoma is filled with a sticky, thick gelatinous material and can grow to be between 6 inches to 12 inches in diameter. There have been rare cases where the cyst measured 40 inches in diameter and weighed over 100 pounds. Dermoid Cysts Dermoid cysts are also known as ovarian neoplasms and consist of skin or related tissue such as hair, teeth or bone instead of fluid like the cystadenomas. Dermoid cysts develop from the ovary's germ cells (cells that produce the egg and the beginnings of all human tissues). Dermoid cysts may be present at birth but are not noticed until adulthood. They generally measure between 2 inches to 4 inches in diameter.
Symptoms of Ovarian Cysts

Cysts may grow quietly and go unnoticed until they are found on routine examination. However, if they are ruptured (by sexual intercourse, injury or childbirth) and/or become large enough, the following symptoms may occur: Intense abdominal pain (symptom in all types of cysts)

Menstrual changes such as late periods, bleeding between periods or irregular periods (symptom occurring in corpus luteum cysts and polycystic ovaries) Heavy menstrual flow (symptom occurring in polycystic ovaries) Infertility (symptom occurring in polycystic ovaries and endometrial cysts) Internal bleeding (symptom occurring in endometrial cysts) Severe menstrual cramps (symptom occurring in endometrial cysts) Pain with sexual intercourse (symptom occurring in endometrial cysts) Pain during a bowel movement (symptom occurring in endometrial cysts) Weight gain (symptom occurring in polycystic ovaries and endometrial cysts) If a cyst becomes twisted, the woman may experience spasmodic pain. Sudden or sharp pain may mean a cyst has ruptured. The twisting or rupture of a cyst may increase the likelihood of an infection. If the woman is experiencing abdominal pain, fever, vomiting and symptoms of shock such as cold, clammy skin and rapid breathing, get help immediately.
Diagnosis of Ovarian Cysts

The doctor will take a thorough medical history, perform a physical examination, and conduct laboratory and diagnostic tests. During the physical examination the doctor will do a pelvic exam. During a pelvic exam the doctor will put an instrument called a speculum into the vagina. This instrument opens the vagina so the doctor can see the vaginal walls and the cervix, and can get samples of vaginal discharge (called a Pap smear). The doctor will gently clean the cervix with a cotton swab and then collect a sample of cells from the cervix with a small brush, a tiny spatula, or a cotton swab. This sample is "smeared" on a glass slide and sent to a laboratory for examination under a microscope by an expert. Once the speculum is removed, the doctor will do a bimanual exam. This involves inserting two fingers into the vagina and with the other hand pressing on the abdomen. This exam allows the doctor to feel the size and shape of the uterus and ovaries. If an ovarian cyst is present, the ovaries feel larger than normal and the exam itself causes the woman discomfort. If the doctor suspects cysts he will recommend additional laboratory and diagnostic tests. Laboratory tests include a complete blood count (CBC) to detect infection and internal bleeding, and a pregnancy test to detect uterine pregnancy or ectopic (tubal) pregnancy. Diagnostic tests include an ultrasound, and if needed, an x-ray and laparoscopy. Ultrasound uses sound echoes to provide a picture of the tissues and organs inside the body. Using this technology the doctor can see where, how big, how many and what the cysts are made of.

If the cyst is composed of solid materials or a combination of fluid and solid materials, the doctor may recommend an x-ray of the area where the cyst resides. This x-ray can reveal whether the cyst is a benign dermoid cyst or a malignant tumor. Doctors will recommend an additional diagnostic test called a laparoscopy if endometriosis is suspected, if the cyst is very large, if the cyst is not fluid-filled, or if the woman is over the age of 40 when the risk of cancer begins to increase. Laparoscopy involves the insertion of narrow tube with a fiberoptic light at one end (called a laparoscope) into the lower abdomen through a small incision just below the navel to view the ovaries, and if necessary drain the fluid from the cyst or remove the cyst entirely.
Treatment of Ovarian Cysts

Treatment depends on many factors, including the type of cyst, its size, its location, the type of material it contains and the woman's age. For functional cysts a "watch and wait" approach is taken. Functional cysts tend to dissolve over time and treatment is not needed. The doctors do, however, require the woman to return after two menstrual cycles to get a pelvic exam and/or ultrasound again. If the cyst is still present and growing (over 2 inches) the doctor may recommend a laparoscopy to remove the cyst. If the cyst comes and goes, the doctor may prescribe birth control pills. These pills reduce the hormones that promote growth of cysts and prevent formation of large cysts. For polycystic ovaries the treatment varies. A major symptom of polycystic ovaries is infertility, and whether the woman is trying to conceive or not determines the treatment. If the woman is trying to conceive and having fertility problems, the doctor will prescribe Clomid which helps stimulate ovulation. If the woman is not trying to conceive and is having infrequent or no periods, the doctor will prescribe Provera. Provera restores normal menstrual flows. For endometrial cysts, cystadenomas and dermoid cyststhe treatment is to surgically remove the cyst. If the cyst is small enough the doctor can remove it via laparoscopy. If the cyst is over 2 inches in diameter the available procedures are: Ovarian cystectomy - removal of cyst Partial oophorectomy - removal of the cyst and a portion of the ovary Salpingo-oophorectomy - removal of the cyst, ovary and fallopian tube. This procedure is done dependent upon the size of the cyst and complications encountered such as bleeding, rupturing and twisting of the cyst. Total abdominal hysterectomy with bilateral salpingooophorectomy - removal of the cyst, both ovaries, fallopian tubes and uterus. This procedure is rarely used unless the cyst is cancerous.
Questions To Ask Your Doctor About Ovarian Cysts

Are there any tests that need to be done to diagnose the problem?

What is the cause? What type of cyst is it? How serious is the condition? What treatment will you be recommending? How effective is this treatment? Will surgery need to be done? If so, what is the procedure of the surgery? What can be expected from the surgery?

Laboratory tests include a complete blood count (CBC) to detect infection and internal bleeding, and a pregnancy test to detect uterine pregnancy or ectopic (tubal) pregnancy. Diagnostic tests include an ultrasound, and if needed, an x-ray and laparoscopy.