Normal women have small white organs called ovaries placed by the side of the womb.   They are normally about half a lemon in size and are responsible for the production of hormones called oestrogen and progesterone in the body. They extrude human eggs or ova every month by a process called ovulation.  Sometimes the follicles which harbour these ova get filled with a watery fluid or even blood .  This gives rise to what are called ovarian cysts.  They are basically membranous sacs in the ovary filled with fluid.  More often than not, these ovarian cysts are harmless and could be left alone.  But there are situations where surgical intervention will be needed.

The various types of ovarian cysts generally found are described below:

Harmless functional cysts:

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Due to the routine use of ultrasonography for a myriad of conditions, ovarian cysts are normally found in many womenThey could be harmless cysts which are called ‘’functional cysts”.  They normally appear and disappear by themselves.

By and large simple cysts that are less than 5-6 cm in size do not need any intervention. A repeat ultrasonography after

3 months may show disappearance of the cyst.  If the cyst persists, it is better to have the cyst removed

surgically by a procedure called ovarian cystectomy.

If a woman has a simple cyst of 5-6cm size, should she take any precautions?

In women with 5-6cm cysts, it would be better to avoid sudden movements like dancing, jumping etc for a couple of months, as the cysts may twist and cause pain. Once twisted, if it worsens, surgery may be required. After a couple of months, the cyst may disappear by itself. If the cyst has twisted, there may be vomiting,with severe abdominal pain. Twisted ovarian cysts:

Sometimes the cysts turn around or undergo a twist, so to say. This is usually associated with intermittent abdominal pain,.  The pain is usually more in certain positions, like turning on to one side.  Sometimes it may be accompanied by vomiting.

In the first picture, you can see the beginning of a twisted ovary. In the second picture, you can see laparoscopic untwisting of a twisted ovarian cyst.  A twisted ovarian cyst, if left alone, will have a jeopardised blood supply and this will lead to gangrene of the ovary.In the picture, you can see a blackened ovary which has undergone gangrene twist for a long time.

So whenever there is acute pain in the abdomen and an ovarian cyst is diagnosed, the woman is subjected to surgery, usually ovarian cystectomy. It can be done laparoscopically in places there are facilities to do the procedure or by open surgery.. If surgery is delayed and the ovary has undergone gangrene, the ovary will have to be sacrificed.

Can twisted ovaries untwist?

Sometimes an ovarian cyst may twist badly with the patient getting severe symptoms. When the symptoms are severe, the doctor may advice surgery. Meanwhile with some sudden movement the cyst may untwist and the pain may go off. Thus a woman who was advised surgery is suddenly relieved of her symptoms without needing surgery. this leads to doubts in the minds of the patients and her helpers that the doctor had ordered unnecessary surgery. However, as far as the doctor is concerned,it is difficult to take the chance that the twist may go off. If the twist does not go off, the ovary will undergo gangrene and become useless. Therefore, the doctor would rather be safe in the presence of severe symptoms.

to see a video of laparoscopy in ovarian cyst in twisted ovarian cyst by Dr.Shobhana Mohandas, view  https://www.youtube.com/watch?v=em6gNVX4J-4

If a schoolgoing or college going girl develops a twisted ovary, will surgery for the twist jeopardise her potential for fertility in future?

Generaly, ovarian cysts that twist are harmless functional ovarian cysts. Untwisting such cysts with ovarian cystectomy will not jeopardise her potential for fertility in future. There is no need to be guilty of having a less perfect ovary just because one has undergone ovarian cystectomy in a twisted ovary.

Will the cysts recur?

Functional cysts may seldom recur, though it is very uncommon. Taking medications like oral contraceptive pills can prevent ovulation and thereby cyst formation for a while.However, it is strogly recommended that young girls should not get their ovaries removed just because they are scared that there may be a recurrence of cyst in the ovary.Ovaries are valuable organs and should not be destroyed by any means.

If a woman gets ovarian cyst after the age of 40 is it not better to remove the uterus also?

In this age group, special tests like ultrasonography and CA125 can determine if the cyst is cancerous or not. If there are no indications that the cyst is cancerous,it is better to remove only the cyst. Hysterectomy, the surgery for removing the uterus is a more complicated surgery and should not be undertaken unless the uterus has some problem in it requiring removal. In certain cases, the ovary may be removed on the whole.

What if a woman gets a cyst after menopause?

If the cysts are just 3-4 cm in size , simple, and there are no indication that the cyst is harmful, it is better to wait to see if the cyst will disappear. 

Endometrioma:

Sometimes the ovarian cyst is filled with dark, chocolate coloured fluid, which is old blood.  This is caused in women who suffer from a disease called endometriosis.  In endometriosis, a tissue called endometrium, which normally lines the uterus,is found in places outside the uterus.  The uterus, normally sheds this endometrium outside at the time of menstruation.  Instead, if the endometrium is found in the abdomen , the woman is said to have endometriosis.  A collection of endometrium along with blood, in the ovary, which enlarges to  form a cyst, is called an Endometrioma or Chocolate cyst.  If it occurs in women who do not have children, it may cause infertility.  The ideal treatment for endometrioma is laparoscopic ovarian cystectomy, 

for a video on laparoscopic ovarian cystectomy by Dr.Shobhana Mohandas in endometriosis, go to.

Endometriomas,  in  spite of  very good  surgery  do  tend  to  recur,  as, the  basic disease  Endometriosis,with  retrograde menstuation, where the menstrual blood goes retrograde into the abdomen, is not cured.  Repeated ovarian cystectomies in such patients will lead to loss of precious ova. Infertile patients with recurrence of endometrioma should think in terms of undergoing  procedures like Artificial Reproductive Technonlogy  instead of  undergoing repeated surgeries.

Benign ovarian tumours: Sometimes ovarian cysts are caused by noncancerous benign tumours like serous cystadenoma, mucinous cystadenoma, etc.  These cysts  do not regress and need surgical removal.  The cyst can be removed by cystectomy through laparoscope or open surgery.  Once removed , there is not much chance of recurrence.

Dermoid   cysts:  Sometimes, the ovarian cyst is filled with many tissues like hair, teeth, bone, fatty sebacious material, etc.  These are called Dermoid cysts.  These are called germ-cell tumours.  Usually this occurs in the younger age group.  Treatment is by cystectomy. There is very little chance of recurrence.  In one  study, after Dermoid resection, 3.4% patients were seen to have a recurrence within the study period of 6 years.  Dermoids could also occur bilaterally and there is a small risk of malignancy in untreated patients.  It is possible to get pregnant even after removal of Dermoids.

For a video on laparoscopy in dermoid cyst by Dr.Shobhana Mohandas, view: https://www.youtube.com/watch?v=2Xrxl9h8AY8

Malignant ovarian cysts: Malignant ovarian cysts usually occur bilaterally, although it could also occur unilateally.  Ultrasonogram in such patients show solid elements in the ovarian cysts, besides the usual fluid that is seen in non-cancerous cysts.  Tumour markers like CA -125 are raised in such patients.  This could be detected by testing the blood.  Special ultrasound examination like colour Doppler ultrasonography can show increased blood flow in the cyst.

If the cyst is malignant, in young patients, in some particular cases, it may suffice to remove only the affected ovary.  In most cases, in the older age group the uterus along with both the ovaries will have to be removed .  Open surgery is the preferred  modallity of surgery in these patients.

 Indications for surgery in ovarian cysts:

1. The cyst  persists after 3 months;   Persistent ovarian cysts could be caused by benign ovarian tumours and need removal.

2. The cyst  is associated with pain or increase in size: Pain could be due to a twist in the ovary, which may lead to loss of blood supply to the ovary and subsequent death of the ovary.

3. Endometrioma: A common cause for ovarian cysts is an endometrioma.  In this condition, menstrual blood collects over the ovary, finally ballooning it into a blood filled sac. This is called an endometrioma and the blood inside the sac is usually old blood.

4. Cancerous cysts:   Cancerous cysts usually have solid components besides the usual liquid contents of simple ovarian cysts.  These differences could be detected by ultrasonography.  A special type of ultrasonography called colour doppler ultrasonography could detect the presence of increased blood flow in the ovary suggestive of malignancy in the ovarian cyst.

Some blood tests like CA125 levels could also be useful in the detection of malignancy.

Ovarian cysts in pregnancy: 

Ovarian cysts may occur during pregnancy.  If seen in the first 3 months it could be a functional cyst and could be left alone.  If severely symptomatic, immediate surgery may be needed. Otherwise, doctors wait till the 4th month to see if the cyst disappears.  If it persists, ovarian cystectomy may be done

Laparoscopic ovarian cystectomy is possible in pregnancy and is safe in pregnancy in experienced hands. We have done 10 cases of laparoscopic ovarian cystectomy in pregnancy in our unit and all of them had good obstetric outcome.

To view laparoscopic surgery for ovarian cyst in pregnancy by the author, view https://www.youtube.com/watch?v=9QueTojJNuA