What to Know About Ovarian Cysts

A gynecologist breaks down the difference between common types of ovarian cysts, and when they may be cause for concern.

About 10% to 30% of women will experience ovarian cysts in their lives. While the small sacs that form on the ovaries are common and usually benign, painful symptoms can develop and cause concern.

“When patients are diagnosed with a cyst, I don’t want them to panic,” says Dr. Sierra J. Seaman, a gynecologic surgeon at NewYork-Presbyterian/Columbia University Irving Medical Center. “Most ovarian cysts of reproductive aged women are harmless, and some may require specific treatment or therapy, but they are very treatable.”

Health Matters spoke with Dr. Seaman to find out more about ovarian cysts, including the different types of cysts, their symptoms, and treatments.

Dr. Sierra Seaman

What are ovarian cysts, and why do they occur?
Dr. Seaman: A cyst is a thin-walled sack that contains liquid. An ovarian cyst, specifically, is a usually benign, non-cancerous growth or mass on the ovary, and there are different types: some simple and some complex. Some cysts are stimulated by hormones in the body, especially reproductive hormones. Other types of cysts are caused by conditions in the pelvis, such as endometriosis. Some are simply created by changes in the way that our cells divide and grow.

What are the signs and symptoms?
Many patients won’t feel anything at all. In those cases, a cyst can even be discovered incidentally on a routine pelvic exam or a CT scan for appendicitis, for example.

But when symptoms do arise, they can include bloating, pelvic pressure, and pelvic pain, which patients usually describe as an achiness or a sharp pain low in the pelvis, usually on one side. It can sometimes be difficult to even distinguish what side the pain is coming from. In addition, patients who have ovarian cysts often report that the pain becomes worse with intercourse.

Sometimes patients can experience even more severe symptoms when there is a medical emergency related to a cyst, such as an ovarian rupture or torsion, which occurs when the ovary or fallopian tubes twist around the surrounding tissue. These conditions usually present with an intense, very sudden sharp stabbing or twisting pain in the pelvis, and sometimes nausea and vomiting.

The Different Types of Ovarian Cysts

Functional Cysts: Every month, a woman’s body recruits multiple follicles into the ovary, and one of them becomes a dominant follicle that grows, ruptures, and releases an egg. “If it doesn’t rupture or it doesn’t rupture completely, it can grow large enough (greater than three centimeters) that we would consider it a functional or physiologic cyst,” says Dr. Seaman. “Many, many women experience these types of cysts during their life, and they usually resolve on their own.”

Dermoid Cyst: These are the most common germ cell tumor, which are formed by abnormal cells. This type of cyst can grow a variety of organ systems within itself, including hair, skin, teeth, and bones.

“Depending on the size and if it’s causing any symptoms, some patients can live with these types of tumors forever,” says Dr. Seaman. “It’s very rare for them to turn into a cancer or a more concerning problem. But if they become large enough that they might put the patient at risk for complications, such as torsion, they should be surgically removed.”

Endometriomas: A common type of cyst in patients with endometriosis, a condition that causes the tissue that makes up the uterine lining (endometrial tissue) to grow outside of the uterus in the abdomen or pelvis. The treatment for an endometrioma is dependent on symptoms and goals. “It could require medication or surgery to help control endometriosis as a disease, and sometimes surgery specifically to address the cyst itself,” says Dr. Seaman.

Hemorrhagic Ovarian Cyst: A functional cyst that is filled with blood. “It can be painful, but most of the time it will resolve with time,” says Dr. Seaman. If it ruptures and continues to bleed, it may need surgical intervention.

Cystadenomas: These are another very common benign (non-cancerous) ovarian tumor that are simple in appearance but can grow to be very large. These are often treated with surgery.

Who is most at risk for getting ovarian cysts?
In general, ovarian cysts mostly affect women of reproductive age, which means after menstruation begins and before menopause; dermoid cysts tend to be diagnosed between ages 10 to 30. Also, people with endometriosis are at higher risk of forming ovarian cysts.

What about PCOS?
Polycystic ovarian syndrome (PCOS) is a bit of a misnomer because those with this condition do not necessarily have ovarian cysts. PCOS is a syndrome associated with excess androgen, or male sex hormone, and irregular menstruation due to ovulatory dysfunction. Some patients which PCOS have enlarged ovaries with multiple follicles, but others have normal appearing ovaries.

How are ovarian cysts treated?
Usually, ovarian cysts are asymptomatic. With small cysts, especially simple cysts, patients may have some discomfort, but it’s usually mild. It’s rare for patients to need any kind of intervention for small functional cysts because they tend to go away on their own over the course of weeks or months.

Taking hormonal birth control pills may help some patients who experience discomfort from recurrent functional cysts; since birth control prevents ovulation, it should theoretically be a perfect way to prevent the formation of functional cysts, but it hasn’t shown perfect success. The pill isn’t right for everyone, and it won’t prevent all types of cysts. For example, it can’t prevent dermoid cysts.

Treatment for dermoid cysts is a bit different. If you’re in a reproductive age and have a dermoid cyst, we usually conduct annual ultrasounds to make sure they’re not getting larger. If you have a stable dermoid cyst that doesn’t get much bigger and doesn’t cause discomfort, you may never need surgery. But if you have a dermoid cyst that grows to six centimeters or more, you become at risk for torsion. This is when you should see a doctor about next steps, which may include surgical removal.

Sometimes ovarian cysts can become emergencies. The two emergencies we worry about the most are ovarian torsion and ovarian cyst rupture. Both present with sudden onset pelvic pain, which we take very seriously. If a torsion occurs, it can cut off the blood supply to the ovary, and over a longer period of time, could actually cause the ovary to die completely. It can cause extreme pain, and usually nausea and vomiting. With torsion, we need to surgically untwist the ovary and remove the ovarian cyst.

When an ovarian cyst ruptures, it can present similarly to torsion, but the treatment is different. And as long as their blood count is stable, most patients are able to be managed with close medical supervision. Their pain gets better quite quickly in a matter of hours, and we are able to treat with pain medication and observe to make sure that they’re not experiencing internal bleeding (which is luckily rare).

Can an ovarian cyst be a sign of cancer?
Although the vast majority of ovarian cystic masses in women before menopause are benign, we are always looking for signs that could point to cancer. For women over 45, the risk of an ovarian mass being cancerous is about 33%, so we treat these patients a bit differently than younger patients, sometimes with closer follow up or special blood work.

Can ovarian cysts affect fertility?
Most cysts don’t affect fertility, although certain cysts such as endometriomas may. Functional cysts, and for the most part, dermoid cysts have very limited effect, if any, on fertility. The exception would be if a dermoid cyst causes torsion, for example.

If someone suspects they might have an ovarian cyst, when should they seek help?
If you’re having symptoms, such as discomfort in the pelvis or pain with sex, you should go and see a gynecologist. If you’re having such severe pain that over-the-counter pain medication like ibuprofen isn’t helping at all, or if you’re having associated nausea, vomiting, or fevers, it’s advisable to go to the emergency room. Most patients will describe the feeling of torsion, for example, as worst pain of their life. Any sudden onset sharp, severe pain in the pelvis should be treated as an emergency, and you should seek help.

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