Ovarian Cysts: Treatments

Treatment depends on many factors, including the type of cyst, its size, its precise location, the type of material it contains, and your age.

Functional Ovarian Cysts: “Watch and Wait”

If you have a small functional ovarian cyst that is not causing any problems, your doctor may recommend a “watch and wait” approach. That is, you may need to return for a follow­up examination or ultrasound after one or two menstrual cycles, when there is a good chance that the cyst will have dissolved. Your doctor may suggest you avoid intercourse during this time, since it can cause a cyst to rupture. If the cyst grows, especially if it becomes larger than about 2 inches, it may need to be removed surgically.

While small functional ovarian cysts generally disappear over time, they also tend to recur with subsequent menstrual cycles. In most cases, functional cysts can be controlled with the use of birth control pills, which reduce the hormones that promote growth of cysts and prevent formation of large, mature follicles that can turn into cysts. If you are already taking birth control pills for contraception, and think you may have an ovarian cyst, see your doctor because it is unlikely to be a functional cyst.

It may take a few months of using birth control pills before your cysts clear up. Your doctor can determine if the pills have been successful by repeating the pelvic exam, the ultrasound, or both. Your cysts may or may not return once you stop taking birth control pills. You can decide with your doctor how long you wish to stay on the pills.

Polycystic Ovaries: No More Surgery

Treatment for polycystic ovaries is more varied. If you have polycystic ovaries and are having problems conceiving, your doctor may recommend that you take clomiphene citrate (Clomid) to stimulate ovulation.

If you are not trying to get pregnant, and you have infrequent periods or no periods due to polycystic ovaries, the treatment is different. Your doctor may start you on the synthetic hormone called medroxyprogesterone acetate (Provera), which is similar to the natural progesterone your body would produce if you were ovulating. Provera fills in for the progesterone that would ordinarily appear after ovulation, allowing you to menstruate. This is important because even if you are not ovulating, your ovaries are still producing the estrogen that causes the uterine lining to grow. Without sufficient progesterone, the lining won't be shed during the menstrual period, and can grow too much. Although you probably feel fine and may not be eager for your periods to return, if your body is exposed only to estrogen without progesterone for long periods of time, the overgrowth of the uterine lining may increase the danger of cancer developing in the uterus.

There are several different schedules used for taking Provera tablets. Most experts agree that one good option is to take one 10­milligram tablet of Provera for 10 days each month. Taking the tablets on the first 10 days of the month makes it easy to remember. You should expect some menstrual bleeding approximately 3 to 5 days after you stop taking the tablets. Don't forget that even though you have polycystic ovaries, you may ovulate occasionally, and it is possible to become pregnant. Provera is not a contraceptive pill. In fact, it is not recommended for use during pregnancy. If you need contraception, you should continue to use your preferred method during your treatment with Provera.

WHAT HAPPENS DURING LAPAROSCOPY

During laparoscopy, the doctor inserts a narrow tube with a fiberoptic light at one end into the lower abdomen through a small incision just below the navel. This minor surgical procedure is used to diagnose many gynecological problems that may not be identifiable with less invasive methods, such as ultrasound or x­ray. For example, laparoscopy can help identify particular types of ovarian cysts, or determine the cause of pelvic pain or fertility problems. Laparoscopy can also be used to treat your cyst. If it's small enough, the surgeon may be able to either drain the fluid from it or remove it through the laparoscope. Use of the laparoscope has eliminated the need for much major abdominal surgery. Though laparoscopy is generally an outpatient procedure, it is usually performed under general anesthesia. This means that you will be required not to eat or drink for at least 8 hours prior to your surgery. You will also have a physical exam and routine blood and urine tests to be certain that you have no underlying illness or infection. Often, using a vaginal speculum, the surgeon will attach a small instrument to the cervix that will allow movement of the uterus as needed during the procedure. The surgeon will then make a one-inch incision just below the navel and insert a small needle to deliver harmless carbon dioxide gas into the abdomen. The gas serves to lift the abdominal wall away from the internal organs and create a space so that the surgeon can see them. The needle is then replaced with the illuminated laparoscope. When the operation is finished, usually after 30 to 60 minutes, the gas is removed through a thin tube placed in the same incision. A few stitches close the incision which will probably be covered with a Band­Aid® type of dressing. After your laparoscopy you will stay in the recovery room until you are feeling awake and alert and until your vital signs (temperature, pulse, blood pressure) are normal. Before you are sent home (usually within 2 hours after your surgery), you will receive instructions on follow­up care from your doctor and nurse. Postoperative pain should be minimal, but your doctor will probably give you a prescription for a mild painkiller. It is not unusual to have some abdominal cramping or shoulder discomfort due to the carbon dioxide gas that filled your abdomen but this should gradually subside over a few days. You will probably be able to bathe and shower as usual, but you may need to avoid strenuous physical activity as well as sexual intercourse for a day or two. Postoperative complications are rare, but be sure to call your doctor if you have bleeding from your incision, severe abdominal cramping or pain, or a fever over 100 degrees. Your doctor will probably want to see you a week or two later to check how you are doing, and to remove any stitches that are not the absorbable type. Though laparoscopic incisions are truly Band-Aid sized, the operation frequently requires more than one puncture. Shown here, the surgeon views an ovary through one incision while manipulating it through another.

Some doctors treat the symptoms of polycystic ovaries with low­dose birth control pills. When you take birth control pills your normal periods will resume, and you'll be protected against pregnancy if that is a concern. Another advantage of birth control pills over Provera is that they decrease the production of the male hormone androgen. Not only does this help control excess hair growth, sometimes a symptom of polycystic ovaries, but it also may reduce the risk of heart disease in women with polycystic ovaries.

The original cure for polycystic ovaries was a surgical procedure called ovarian wedge resection. This involved removing at least one­third to one­half of each ovary in order to return it to normal size. In most women, this operation resulted in resumption of normal periods and normal fertility. The wedge resection is rarely done anymore thanks to the availability of drugs that induce ovulation and restore normal periods.

When Surgery Is Needed

Sometimes, however, surgical removal of a cyst is the only option. Doctors take several factors into account when deciding whether surgery is advisable. One of the most important considerations is the size of the cyst. Because there is a very slight risk of a large ovarian cyst becoming cancerous, the larger your cyst, the more likely the surgery. Although gynecologists differ on the precise “cut­off point,” in most cases if a cyst is at least 2 to 2.5 inches in diameter (about the size of a tennis ball), it will be surgically removed. If your cyst is less than 2 inches, your doctor may want to track it with ultrasound examinations over a period of a few months to see whether it grows to a size that requires surgery.

Another factor doctors consider is your age. Because ovarian cysts are less likely to become cancerous in a woman in her 20s than one in her 40s, or in a woman who has passed menopause, your chance of needing surgical removal of an ovarian cyst increases with age.

The type of cyst is also an important consideration. A “simple cyst,” containing only liquid material, is less likely to require surgery than a “complex cyst,” containing a mixture of materials. However, if a “simple” functional cyst grows quite large or bleeds, surgery may be necessary. Once your doctor has determined the size and type of cyst you have, he or she will discuss with you the advisability of surgery. The common types of cysts that almost routinely demand surgical removal are endometriomas, cystadenomas, and dermoid cysts.

Endometriomas. Because endometrial cysts are caused by endometriosis, you may wonder whether the drugs used to control endometriosis could also be effective in treating endometrial cysts. (See the chapter on “Keeping Endometriosis at Bay” for more on these drugs.) And indeed, these medications may help control the growth of cysts. However, because endometrial cysts can grow quite large and are prone to rupture, perhaps causing internal bleeding, these cysts are often treated surgically.

Cystadenomas. Since cystadenomas are almost always benign, it would seem reasonable to leave them alone unless they are large or cause complications. The problem is that cystadenomas often do become enormous, causing complications simply due to their size. An additional concern is that cystadenomas are “neoplasms,” or new growths of abnormal tissue, and evaluation of neoplasms can be tricky. It is difficult to determine whether a neoplasm is benign or malignant simply by looking at it. Instead, tissue from most types of neoplasms needs to be analyzed under a microscope, and the only way to get a tissue sample is through surgery.

Dermoid Cysts. Dermoid cysts are also neoplasms, and therefore candidates for surgical removal. You may know before surgery that your cyst is a dermoid because if it contains teeth as one­third to one­half of them do, your doctor may have seen them on an x­ray.

What to Expect
When the Doctor Operates

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Once surgery is decided upon, you'll have a meeting with your surgeon to discuss the operation and have a physical exam.

Before Surgery

Your surgeon will review the reason for your operation, the possible risks, no matter how small, and any possible aftereffects. You may find it helpful to bring a written list of questions to the meeting. Feel free to ask your surgeon to explain the operation by drawing a simple diagram of what will be removed.

Although at this point you will probably feel there are no lab tests you have not already undergone, a few basic studies may be ordered to establish that you are healthy enough for surgery:

• A complete blood count (CBC), to make sure that you have no underlying infection and that your body can tolerate loss of a small amount of blood during surgery
• A urinalysis to screen for infection and diseases such as diabetes or kidney problems
• A blood sample to check your blood type, in the unlikely event that you need a transfusion
• A recent chest x­ray or recent electrocardiogram (ECG) if you are over 40 years old

In Surgery

If you have a large cyst, your surgeon will probably remove it through an incision in your lower abdomen. The general term for any operation through the abdomen is laparotomy. If the cyst is small enough, your doctor may be able to remove it with a laparoscope, which requires only a small incision.

The type of operation you will have will depend on the size and nature of your cyst. The goal is to remove only the cyst, leaving the ovary intact. When the cyst alone is removed, the operation is called an ovarian cystectomy. If a portion of the ovary is also removed, the operation is a partial oophorectomy. Occasionally, the large size of the cyst or complications such as bleeding, twisting, or rupture, may require removal of the fallopian tube with the ovary. This operation is called salpingo­oophorectomy. Surgeons make every attempt to preserve the reproductive organs, especially if you have not yet reached menopause since it's still possible to have children when only a small portion of one ovary remains. Removal of the uterus, fallopian tubes, and ovaries ( total abdominal hysterectomy with bilateral salpingo­ oophorectomy or TAHBSO) is very rarely used to treat the types of ovarian cysts described in this chapter, unless there is a reasonable chance that your cyst is cancerous.

After Surgery

If you have a laparatomy, you will probably be in the hospital for a few days after the surgery. During the early recovery and postoperative period, you will receive fluids and medication through your intravenous (IV) line, but you should be eating solid foods fairly quickly. You will receive medication for pain, and you can expect to be walking around the day after surgery. Your wound should heal quickly, and if your incision was closed with staples, the staples and bandage will probably be removed before you leave the hospital. If you have non­absorbable stitches, they will probably be removed 5 to 7 days after your operation.

Before you leave the hospital, you will receive a summary of the type of operation that was performed and the type of cyst that you had. You may wish to ask for a copy of the surgery report for your records. You should also receive complete instructions from your doctor or nurse regarding what to expect in the postoperative period.

You should expect to have some abdominal discomfort for a few days after you return home. You may be given a prescription for a mild pain reliever. You should call your doctor if the medication doesn't help, or if the pain does not improve after a week. You should also contact your doctor if you develop a fever of over 100 degrees, or if vaginal bleeding is heavier than a normal period.

You should expect your incision to look quite red and feel uncomfortable for a few weeks. It is normal to notice some dried blood around the incision, but call your doctor if you see pus oozing from the wound. It's fine to bathe and shower; don't worry about getting the incision wet as long as it's not oozing. The red color of the incision will gradually fade, and eventually the scar will barely be visible.

You may be able to start some non­strenuous physical activity after a week or two. Be sure not to resume intercourse or to use tampons or anything else in the vagina until you have had your postoperative checkup (usually about 2 weeks after surgery). You will probably be able to resume all your normal activities and return to work about 6 weeks after surgery.

Unless you have had both of your ovaries removed, your periods will return to normal, usually by about 4 to 8 weeks after surgery. Remember that if even a portion of one ovary remains, you can still become pregnant if you're of childbearing age. That's one of the many reasons it's important to discuss the specifics of your surgery with your doctor.

Chances are that once the ovarian cyst has been removed, it will not recur. However, the operation does not always guarantee that you'll be cyst­free in the future. As long as you have ovaries, you can have ovarian cysts. It's a good idea to continue any medical treatments your doctor has prescribed to control the cysts and, of course, to have regular gynecological exams. 