My Ultrasound Found An Ovarian Cyst!

There are two types of small ovarian cysts which can be considered "normal". During the first half of the menstrual month ("follicular phase") estrogen stimulates the growth of a dominant follicle. This follicle fills with fluid which is spilled out when the ready egg ("oocyte") is ejected ("ovulation"). After the egg is released, its former follicle closes off and becomes the "corpus luteum" which produces progesterone during the following two weeks ("luteal phase").

If, in either of these phases, larger than normal amounts of fluid collect, one can develop ovarian cysts that will cause pain or menstrual bleeding changes. A normal ovary is about 2 x 3 cm (almond sized). A follicular ovarian cyst, if the egg is not ejected and the amount of fluid continues to increase, can reach sizes of up to 10 cm. Fortunately most follicular cysts are smaller and will resolve within one to three months. If the size is large (eg greater than 8 cm) the heavy cyst can prompt the ovary to twist on itself like a heavy flower on a too fragile stalk. This twisting ("ovarian torsion") causes intense pain as it cuts off the blood supply to the ovary. While follicular cysts are the most common type of ovarian cysts, torsion is uncommon.

In another condition, polycystic ovaries ("polycystic ovarian syndrome/PCOS"), the ovary will contain multiple small follicular cysts. Unlike the cysts described above, PCOS cysts will usually stay small. Yet, like other follicular cysts the egg is not ejected. This lack of ovulations contributes to the fertility problems seen in PCOS.

Normally after ovulation a corpus luteum of less than 3 cm resolves within two weeks. This type of cyst will be maintained, if conception occurs, to produce hormones needed in early pregnancy. If excessive amounts of fluid collect, a corpus luteum cyst can also get large enough to cause pain—or very rarely, ovarian torsion. Occasionally, this type of cyst will have a small blood vessel which continues to bleed into a corpus luteum cyst. This is called a "hemorrhagic ovarian cyst". A cyst of this type can either leak small amounts of blood, or it can rupture, spilling blood into the abdomen. This hemorrhagic ovarian cyst can be linked to prolonged pain, and merits closer follow up.

Each of the cysts described above can start with a normal process and become a medically significant cyst. They are all described as benign cysts. By contrast there are ovarian cysts which are not related to variations in normal processes. Endometriomas are cysts filled with old blood. This gave rise to the nickname "chocolate cysts" as the cyst fluid looked like chocolate syrup. Endometriomas can grow to 6-8 cm. They are formed when bits of uterine lining tissue ("endometriosis") attach to pelvic organs such as ovaries. Dermoid cysts ("cystic teratomas") can contain bits of hair, teeth, or other body tissues. It is still not known why demoid cysts form. At an incidence of 66%, dermoids are most common kind of benign tumors of the ovary. Cystadenomas ("serous cystadenomas") are formed from epithelial cells on the covering of the ovary. These cysts are filled with a fluid or a gel like material. Cystadenomas comprise 20% of benign tumors. The concept of benign tumors sounds like a contradiction in terms. It means that there is a very small chance of this type of ovarian cyst to become cancerous. For example, in one study (Scully, 1973) less than 2% of dermoid cysts showed evidence of malignancy.

What If My Ultrasound Does Not Say What Type of Cyst I Have?

Often, when women get copies of their pelvic ultrasounds there is no definite diagnosis. The ovarian mass may only be described by location, size, and other attributes. The importance of size has been discussed above. The descriptors used can give an indication of the type of cyst that might be present. A cyst described as fluid filled with regular borders is often a simple follicular cyst. The ultrasound term anechoic (no echos) may be used to describe fluid, either cyst fluid or fresh blood.

A complex ovarian cyst generates more concern. A cyst that is a mixture of solid and fluid elements, or is solid, is not a simple follicular cyst. The presence of irregular borders, or septations (internal walls dividing the cyst into separate spaces) are more concerning features found in complex cysts. Other terms which may be linked to complex cysts are: mural nodule, fluid-debris level, retracting blood clot, or a mix of anechoic to hyperechoic appearances.

How Reliable is Ultrasound?

While simple ovarian cysts can usually be diagnosed by vaginal ultrasound, the question arises "How reliable is ultrasound when the cyst is complex?" One well done study (Jermy, 2001), looked at the reliability of ultrasound to make a correct diagnosis for possible endometriosis or dermoid types of complex ovarian cysts. After the mass was removed it was found that ultrasound was successful in predicting 96% of endometriosis cysts and 97% of dermoids. There were no ovarian cancers found.

What Should I Expect for Treatment?

If a simple cyst is suspected, the only treatment may be a repeat ultrasound in six to eight weeks to be sure that it is resolving. If the cyst is very large, and ovarian torsion is a concern, then more frequent ultrasounds may be performed.

Previously, birth control pills (BCPs) were commonly prescribed in an attempt to treat simple ovarian cysts. Studies comparing the use of BCPs to "expectant treatment" (Turan, 1994) began to suggest that "watch and wait" was as effective as treating with BCPs. More recently (Sanersak, 2006) found that low dose monophasic pills were not statistically better at treating functional ovarian cysts than following women with routine ultrasound screening.

In terms of prevention of ovarian cysts, several studies have examined the role for birth control pills. In an older study (Vessey, 1987) there was a 78% reduction in corpus luteum cysts and a 49% reduction in follicular cysts among women who had taken high dose birth control pills within the previous six months. A later study (Lanes, 1992) compared older, high dose mono-phasic pills to lower dose mono-phasic pills, and lower dose tri-phasic pills. This group found that the lower dose pills conferred less protection for functional cysts than did the older types of birth control pills.

Related Topics:

• Your Guide to Menstrual Cramps
• Menstrual Problems: Quiz

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If It's Not Menopause, What Is It?

It's hard to believe, but the first landmark study of women's perceptions of menopause (Neugarten, 1965) found that, "Not knowing what to expect" was midlife women's greatest concern. Since that time there has been an explosion in scientific, and popular, publications pertaining to menopause. Women now are well acquainted with menopausal signs and symptoms. They know what to expect. So the question has shifted to "If it's not menopause, then what is the cause of my menopause-like symptoms?" Let's examine some of the more common symptoms and see what else might be at fault.

Irregular or absent menstrual periods

While a few women will suddenly reach menopause, or the last natural period, most will have sign posts for the upcoming change. The most common sign is marked menstrual changes. The official definition of "perimenopause" is the four to five years before last menstrual period. Perimenopause also includes the first year of no periods following the last menstrual flow. Marked menstrual changes are considered to be: cycle length between flows more than seven days different from normal, and/or more than 60 days of no periods.

There can be other reasons for missed, or irregular, periods. It is possible to conceive right up until the last natural period. If birth control is not being used, pregnancy must be ruled out. If pregnancy is not detected then the next most common cause of menstrual changes is missed, or late, ovulations. In a normal cycle, estrogen is produced all month. Estrogen is responsible for building up the lining of your uterus so you have something to shed each month.

In a normal cycle, progesterone production increases following ovulation and release of an egg.. Progesterone "stabilizes" the uterine lining in preparation for possible implantation of a new pregnancy. If you are not pregnant that month, the levels of estrogen and progesterone fall, triggering the release of the uterine lining--your period. So, if you do not ovulate, the estrogen build up of the lining continues, but without the usual ovulation associated progesterone. Thus, the hormone levels don't decline, and the lining stays up inside the uterus--your missed period.

One can enter a pattern of non-ovulation at any time after menstrual periods first begin. Causes for not ovulating are multifold: thyroid problems, pituitary problems, ovarian cysts, physical stressors (eg sudden increases in exercise, crash dieting), emotional stressors (problems with parents or boyfriends/girlfriends, exams), increased body weight, anorexia, rotating shifts at work, etc. Yet as women move into their 40's one of the most common causes for not ovulating regularly is "old eggs"--the aging of the remaining follicles in their ovaries. This possibility for erratic ovulations can make the diagnosis of menopause more difficult. If one is experiencing irregular or missed periods at any age it is important to check with a GYN, or other healthcare provider, to help make a correct diagnosis.

Hot flashes

Flashes are the second most often reported symptom by perimenopausal women. Hot flashes and night sweats can onset during perimenopause, and generally peak during the first two years after the last menstrual period.

Hot flashes have been linked to abrupt changes in estrogen levels. Typically they are seen during the hormone swings of perimenopause. Yet other medical conditions can prompt flashes and/or night sweats. These include: hyperthyroidism, infections (eg HIV/AIDS, TB, malaria), some types of cancers (eg pancreas, adrenal gland, leukemia), generalized anxiety/panic, and autoimmune disorders. Many women have noted a sensation of flushing when the sympathetic nervous system ("fight or flight" response) is activated. Even being a heavy cigarette smoker can be linked to more hot flash activity as smoking decreases blood estrogen levels. Lastly, some medications (eg serotonin [SSRI]antidepressants, raloxifene, and others) have been noted to prompt flashes. If your flashes appeared after starting a new medication be sure to ask your pharmacist if flashes are noted as a possible side effect.

Sleep disturbances

One study (National Sleep Foundation, 2002) confirmed what many midlife women have suspected. Perimenopausal and postmenopausal women do have less sleep, marred by shortened sleep hours, and more problems with either difficulty initiating sleep or remaining asleep. While night sweats are a prime suspect in the problem of poor sleep, sleep disturbances can arise from other sources.

Physical causes of poor sleep include sleep apnea and other problems with breathing, digestive problems such as gastro-esophageal reflex disorder ("GERD"), painful conditions such as arthritis or diabetic neuropathy, and hyperthyroidism. Some medications (eg asthma drugs, steroids such as prednisone, Dilantin, and stimulants) have side effects which alter sleep architecture. Psychological causes for insomnia can comprise high stress life events, and/or depression, anxiety, or psychosis.

Mood swings

Longitudinal studies, where a large group of women is followed through the transition into menopause, have contributed the best information about mood swings. The women in such studies are not presenting at their doctor's office with specific complaints of mood problems. Rather they are living their daily routines and are surveyed using questionnaires, or interviews. Earlier studies (Kaufert 1992, McKinley 1992, and Woods 1997) found that a prior history of mood disorders, including PMS/PMDD, helped predict who was likely to become depressed during perimenopause. As might be expected, poor health, and increased levels of life stressors, made depression more likely to occur.

Interestingly, when the presence of severe hot flashes/poor sleep, and a history of prior depression were controlled for when analyzing the women's data an interesting fact was found. The greatest incidence of down moods was in the perimenopause, not in pre-menopause (Bromberger 2003) or post-menopause (Freeman 2004). It would seem that there is a time of increased vulnerability to mood swings as one approaches menopause.

Other causes of mood swings can include: unrecognized clinical depression or anxiety, life stressors unique to midlife (eg new medical problems, changes in relationship or parental dynamics, one's aging parents needs, etc.), low thyroid, and endocrine disorders. If one is experiencing mood swings which are impacting her quality of life, it is important to see a healthcare provider for an assessment of physical and psychological causes.

Vaginal dryness

Vaginal dryness can arise at any age. Frequently it is seen in breastfeeding women as low estrogen levels are triggered by the hormone of lactation, prolactin. Some young women using DepoProvera as a contraceptive can also develop lowered estrogen levels and experience vaginal dryness. The sensation of vaginal dryness, when due to lowered estrogen level is marked by both decreased lubrication, and thinner, more fragile vaginal tissues. The vaginal pH will be more alkaline. Fewer of the beneficial, hydrogen peroxide producing lactobacilli will be present.

Other medical conditions which can create vaginal dryness include: benign pituitary mass, diabetes, and Sjogren's syndrome. Medications such as Lupron, antihistamines, diuretics, or drugs which create dry mouth (eg tricyclic antidepressants) have the potential to create vaginal dryness as well. Radiation therapy may prompt vaginal dryness and tissue fragility. Yeast infections, or vulvar dermatology problems (eg lichen planus, or lichen sclerosus), can be interpreted as a dry, uncomfortable feeling in the vagina. Even poor lubrication due to genital pain, or inadequate sexual arousal, can create a subjective sensation of vaginal dryness.

Heart palpitations

It is common with hot flashes to experience an increase in heart rate during the flash. Increased heart rates can also arise when one is stressed, anxious, or having a panic attack. There are cardiac conditions where heart rate can dramatically speed up or actually become quite irregular. If one is experiencing irregular or very elevated heart rates it may necessitate an electrocardiogram (ECG), a treadmill ECG, or a monitor to be worn for 24 hours to detect the arrhythmia.

Is There a "False Negative" on a Test for Menopause?

One can be in perimenopause and have blood tests which do not confirm that diagnosis. This is the reason many healthcare providers chose not to do such tests routinely. There are blood tests (eg inhibin B) used in research settings which are very sensitive indicators of ovarian aging. But the two most common tests FSH, (follicle stimulating hormone) and estrogen (estradiol), are subject to swings in and out of "normal" range.

With ovarian aging it can take much more FSH to push the ovary to produce normal, "young women" levels of estrogen. In general an FSH level greater than 20 mlU/ml suggests approaching menopause. The problem arises when the increasing FSH levels push the ovary to create more estrogen. The resulting spike in estrogen pushes FSH levels back down. This is similar to a thermostat turning off once the heat in the room has returned to an appropriate temperature. Thus, if your GYN were to draw an FSH or estrogen level they would look normal---whereas several weeks before the FSH would be higher than 20 and the estrogen less than 40. This unpredictable variability makes diagnosis of perimenopause less reliable than, say, a blood sugar to rule out diabetes.

Some GYNs will add an additional blood test called LH (lutenizing hormone) which also becomes higher at menopause. However, this increase in LH happens later in the menopause transition so it is not very helpful in early perimenopause.

Finally, the journey into menopause can take a varying amount of time. One source maintains that the range of years during the transition can be from "zero to ten years". Up to 20% of women will enter menopause without significant symptoms. While I would hope that this would be the case for you, any significant symptoms should be assessed before being reflexively attributed to menopause.

Related Topics:

• Too Young for Menopause
• Your Guide to Menopause

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