Ovarian Cysts

He wasn't looking at me as he said it, but Dr. Alter is a straight-shooter and when he told me "You have an ovarian cyst," and that it was common and benign, I believed him. After all, if he saw cancer, an oncologist would leap into action; more than that, he was reading off a page in a binder balanced on a windowsill.

So I became curious about this new thing growing inside me. I've had babies grow inside me, and I've had adenocarcinomas grow inside me, and now I've got a cyst. The first is self-explanatory; the second was explained to me in great detail; now this one owes me an explanation.

What is it and how did it get there?

Ovaries, the almond-sized glands flanking the uterus, secrete hormones and release eggs at specific times in the monthly cycles that are life for a woman of childbearing years. Cysts are a by-product of the maturing and releasing process of eggs. The truth about bodily processes is that there is one way for the process to conduct itself correctly, and many ways for it to go wrong and cause problems.

The correct thing for an ovary to do each month is to surround several immature eggs with a sac, called a functional cyst. One egg matures fully in its sac, at that stage called a follicular cyst. When the hormonal balance is right, the follicular cyst bursts and the egg enters the fallopian tubes and either encounters sperm or doesn't. The sac then becomes a corpus luteum. It secretes progesterone, and eventually dissolves into something called a corpus albicans.

There are several opportunities for error in this process. First, the sac may not burst. This causes an enlarged follicular cyst, which engorges itself with fluid and then, on its own, disengorges and goes away. The corpus luteal cyst comes when, rather than dissolving itself into a corpus albicans, the sac reseals itself and continues to fill with fluid. This type of cyst will also go away on its own.

Or they don't. Sometimes, a cyst will become quite large, bleed, or twist the ovary; it might do all three. This causes the woman pain. As a point of interest, a woman might be slightly luckier if the cyst is in her left ovary rather than her right. The relatively rigid rectosigmoid colon cushions and holds the ovary in place. On the right side is the softer ileocecal region of colon, which does nothing to stop the twisting, bleeding, and subsequent pain. These types of cysts, fortunately, are almost never associated with cancer.

Of course, the processes of the ovaries are so much more complicated than alluded to here, so there is so much more room for something to malfunction. Sometimes tissue from inside the uterus forms outside the uterus, and sometimes it forms on the ovaries. The resulting cysts are called "endometriomas". Sometimes the cells on the outside of the ovaries grow without regard to their proper purpose, and these form "Cystadenomas". (I didn't like learning about those because the mango-sized lump growing in my colon was called an "adenocarcinoma". I'm sure, however, that "adeno" switching from prefix to base in the words has an impact on the seriousness of the diagnosis, as is the absence of the base "carci". ) "Dermoid cysts" develop from the cells in the ovaries that can develop teeth, hair, and other tissues. All of those cysts grow very large and cause pain.

Polycystic ovaries have functional cysts that are not, well, functional. The follicular cysts never burst to release the mature eggs. This is a very different condition and should be treated as a separate issue.

Why me? How did this happen?

The processes go wrong; this much we know. But why? Well, other processes going wrong, it seems. One reason is "disordered follicelogenesis", which is usually a function of the pituitary gland. Another reason is "hormonal imbalances" that can be caused by any number of things. Ovarian cancer and metastatic cancer can cause ovarian cysts, which hide the malignant process. (I don't want to think about those!!!)

Some studies found that smoking causes a two-fold increase in the likelihood of developing ovarian cysts. Other studies failed to reproduce those results. Body mass is aparently inversely related to ovarian cyst development. Early menarche, or onset of menstruation, is another risk factor.

How do I know whether I have an ovarian cyst?

If you are female, you could have an ovarian cyst right now and not know it, and may in fact never know it. The most common types of ovarian cysts grow and dissolve without symptoms and without intervention.

Usually, a woman discovers she has an ovarian cyst while being checked for another condition. This is how I found out. During a CT scan for recurrence of colon cancer and for blood clots, they found the cyst. The first time it appeared it was not mentioned in the follow-up visit because these things so often go away on their own. It was only mentioned because it got larger instead of smaller. Sometimes a gynecologist will feel the cyst during a pelvic exam. When I visited my gynecologist, she did feel it and asked if I felt pain. Actually, she was confirming that my "ow, ow, ow," was because of the placement of her hand.

Cysts do sometimes display symptoms. These will include abdominal pressure or pain, an aching in the lower back, a bladder that doesn't empty completely, pain during sex, weight gain, painful periods, nausea, vomiting, and breast tenderness. Of course, all these can be symptoms of other conditions. For example, I have had pain during sex since March of 2004, but that's because I had a half a yard of colon removed and colostomized in January, and then ten months later had it put back together. I gained weight, but that could have been the steroids during chemo and my love of chocolate and cake. There are always alternative explanations for symptoms, and so seeing doctors regularly is a great way to get the truth.

If I have an ovarian cyst, what can I do?

The primary means of treatment is "watchful waiting". The doctor will prescribe an ultrasound, usually a "transvaginal" ultrasound. This means that the ultrasound tech will lubricate a small wand and place it into the vagina, for the better viewing of the ovaries. If the cyst is merely a fluid-filled sac, the doctor will prescribe another ultrasound two months hence and tell you to beware of the symptoms of a burst ovarian cyst. These are fever, vomiting, acute pain in the abdomen, tachycardia and dizziness. The doctor may also prescribe birth control pills so that while the other cyst is dissolving, you won't ovulate and create more cysts. If you have no pain and can bear to wait, this is the preferred option.

A blood test for CA-125 proteins may be indicated. This protein is present in women with ovarian cancers, but is also present in women who have fibroids, endometriosis, or indeed nothing wrong with them, and may be absent in a woman who has ovarian cancer. As another indicator, however, the test is performed.

Another option might be surgery. This is indicated if the ultrasound shows that the cyst is something other than a small, fluid filled sac.

A Laparoscopy is indicated if the cyst is not going away, but seems small (defined as "less than plum-sized") and benign. The scope is inserted somewhere above or below the navel, and if the surgeon wishes to remove the cyst, a small incision is made in the bikini line, through which the cyst is removed.

If, after viewing the cyst, the doctor sees that it is abnormally large or suspicious, a Laparotomy might be performed. Through a slightly larger incision, the cyst is removed and tested for cancer. If the test is positive, the ovary, lymph nodes, uterus or other organs may be removed.

So?

Yes, like all growths or lumps in the body, an ovarian cyst is worrisome. It might be this, it could be that, you may have this that or t'other in your future. Trust, however, that if something is suspicious, or painful, or anything, a doctor is going to do something rapid and effective. It is seldom that a doctor will not act, and to think otherwise is useless. So until next Tuesday, I will imagine a tiny water balloon in my pelvis and distract myself with chocolate and cake.

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