• Dr Peter Chew

Ovarian cyst

Her face grimaced in pain and her hands clutched her belly. She staggered into my consultation room. “Doc, help me. I am suffering from my usual menstrual cramps again.” She cried.


G, 23, has been suffering from menstrual pain for the past 5 years.  “I had my first period at 11 and experienced the menstrual cramps every month. The pain wasn’t too bad at first. It usually lasted a few hours and was relieved after a hot shower. Mum said it was quite common among teenagers. She gave me some Chinese herbal tonics after my menses and the pain was gone for a few years. But by late teens, the pain returned. It lasted longer than the usual one day and became more severe.  I had to take Panadol regularly,” she recalled.        


“Soon panadol and other pain killers such as ponstan and synflex were not effective. Mum brought me to see the family physician who suggested that I took oral contraceptive pills. I   did not take them as I was afraid of the side effects. The cramps became worse . I was completely incapacitated. On one occasion, I almost passed out.”



When I examined G, her womb was tender to the touch and relatively immobile. An ultrasound scan showed a left ovarian cyst about 7 cm in diameter. I discussed the various options of treatment with her. She finally agreed to have the cyst removed by the key-hole surgery. This was done using a telescope with a lighted camera (laparoscope) and delicate surgical tools which were inserted through several small cuts - 0.5 to 1 cm in diameter in the abdominal wall. The operation was performed by viewing the organs through through a video screen. It went smoothly and G was discharged well the next day. Microscopic examination revealed that the cyst was an endometriotic cyst or “blood cyst”.


 What is ovarian cyst?


An ovarian cyst is a collection of fluid surrounded by a thin wall within or on the surface of an ovary. The ovary -about the size and shape of an almond –is located on either side of the womb (uterus). It is the organ where eggs develop and mature and are released every month during the childbearing years.


Many women have ovarian cysts at some time during their lives. Majority of ovarian cysts present little or no discomfort and are harmless. Most are functional cysts which are formed during ovulation and they usually disappear without treatment.


There are two types of functional cysts, the follicular cyst and corpus luteal cyst.


Follicular cyst: The ovaries normally grow cyst-like structures called follicles each month. The follicle produces the hormones oestrogen and progesterone and release an egg around the middle of the menstrual cycle.  Sometimes the follicle does not rupture or release its egg and keeps on growing into a functional cyst called follicular cyst.


Corpus luteal cyst: After a follicle releases its egg, it is called the corpus luteum. Sometimes, the exit opening of the egg seals off and fluid accumulates inside, causing the corpus luteum to expand into a cyst called corpus luteal cyst.


Other types of ovarian cysts are not related to the normal function of the menstrual cycle.


They include:


Endometriotic cysts (blood cysts): These cysts are also called chocolate cysts because it contains thick and old clotted blood. They are due to the backflow of the menstrual blood in the pelvic cavity and the ovary   . They will grow with time and cause severe menstrual cramps and pain during sexual intercourse. Occasionally, it may rupture causing sudden, severe abdominal pain mimicking that of appendicitis and requiring emergency operation. Very rarely, it may become cancerous.


Dermoid cysts (hairy cysts): These cysts are usually non- cancerous .They are often filled with fatty cheesy contents with hairs , teeth and bones. They are often small and may not cause symptoms. When they become large they can have complications.


Cystadenomas. These cysts develop from ovarian tissue and may be filled with a watery liquid (Serous cyst) or a mucous material (Mucinous cyst). Both types of cyst can become cancerous.


What are the symptoms and complications of ovarian cyst?


Most ovarian cysts do not have any symptoms.  They are usually discovered during routine pelvic examination .They may cause problems if complications develop such as torsion (twisting), bleeding ,infection, rupture and cancerous changes. Ovarian cancer is often “silent” and spreads widely before it is detected.


Symptoms of ovarian cysts include:

•         Severe abdominal Pain

•        Feeling of fullness (bloatedness) in the abdomen

•         Difficulty and frequent urination

•         Dull ache in the lower back

•         Pain during sexual intercourse

•         Painful menstruation and abnormal vaginal bleeding

•         Sudden loss of weight

•         Nausea or vomiting

•         Loss of appetite

•      Low grade fever


Ovarian cancer usually does not have any symptoms in the early stage. There may be non-specific symptoms such as loss of appetite, loss of weight and having abdominal  bloatedness. In the late stage, there may be swelling of the abdomen with fluid and swelling of legs and feet.


Diagnosis


Some of the ovarian cysts are found during the annual gynaecological check-up by vaginal examination.


Some of them are discovered by ultrasound examination in which sound waves are used to create an image of the ovaries. This helps determine the size and location of the cyst as well as its contents. If the cyst contains a mixture of fluid and solid components, it may be  an indication that the cyst may be cancerous


Dermoid cysts are occasionally detected by X-ray of the abdomen because of the teeth or bones they contain.


Other imaging tests include Computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography (PET). These are highly detailed imaging scans and help in assessing the extent of spread of the ovarian cancer.


Blood tumour marker test such as CA-125 has been used for women with higher risk for ovarian cancer. It is a protein and its level tends to be high in some women with ovarian cancer. But this test is non-specific as patients with non-cancerous conditions such as endometriosis and pelvic infection may also have raised levels.


Treatment


Once the cyst is found, a repeat scan during or soon after the period should be done. A functional cyst will shrink or disappear. If the cyst persists and appears benign on account of ultrasound and CA125 findings, a laparoscopic removal (key-hole surgery) may be done.

If the cyst is too large or suspicious of being cancerous, the conventional laparotomy is performed under general anaesthesia. A large vertical or horizontal incision is made in the abdomen. The cyst is then removed and sent for a frozen section (a microscopic test in the operation room). This may indicate whether the cyst is cancerous or benign.


If it is benign, the cyst is then removed and the normal structure of the ovary restored by suturing.


If it is cancerous, a more extensive operation called debulking is done where as much of the tumour tissues as possible is removed. Depending on how far the cancer has spread, the ovaries, uterus, fallopian tubes, omentum -- fatty tissue covering the intestines -- and nearby lymph nodes will also be removed.


Other treatments for ovarian cancer include:


•             Chemotherapy : The drugs are given through a vein (Intravenous), by mouth, or directly into the abdomen to kill the cancer cells. They can have side effects such as nausea , vomiting, hair loss, kidney damage, and increased risk of infection. These side effects usually go away after the treatment is over.


•             Radiation : High-energy X-rays can  kill or shrink cancer cells. This treatment can cause side effects, including redness on the skin, nausea, vomiting, diarrhoea, and fatigue. Radiation is not often used as most ovarian cancers are not radio-sensitive.


Surgery in combination with chemotherapy is the usual mode of treatment. If recurrence occurs, further surgery may be necessary.


Although there is no definitive way of preventing the growth of ovarian cysts, annual gynaecological check up with pelvic examinations , ultrasound scan and blood tumour marker test are methods  of early detection of  changes in the ovaries. In addition, one should pay attention to changes in the menstrual cycle like irregular bleeding and other nonspecific symptoms such as bloatedness, gastric discomforts and loss of weight. Talk with your doctor about any changes that concern you.

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