Facts, myths and solutions
By Dr Joe Kabyemela, MD
Consultant Gynaecologist and Honorary Clinical Lecturer in Obstetrics and Gynaecology
Please note...
Every part of this book has been scrupulously checked for factual accuracy and confirmed to be so. However, whilst it is aimed at giving clear and comprehensive information on the subject of ovarian cysts, it is not meant to replace your doctor or their opinion. The author, being an experienced and practising specialist, is fully aware that, on occasions, unique individual circumstances may make it necessary to depart from standard practice. This is a very detailed book demystifying ovarian cysts, answering most questions on the subject and, just as important, bursting a number of prevalent myths. All this is done in plain English, avoiding unnecessary medical jargon, thereby maximising accessibility.
Copyright 2012 Joe Kabyemela, MD. All rights reserved
Smashwords Edition
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This book is dedicated to Jordan, my son; my buddy. For the inspiration.
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Common ultrasound terms explained
Benign ovarian cysts (non-physiological)
Cystadenomas (serous and mucinous)
Malignant (cancerous) ovarian cysts
Ovarian cysts after the menopause
Ovarian cysts in infants and children
Polycystic ovarian syndrome (PCOS)
‘Natural’ cures for ovarian cysts?
Let’s start off on the right foot: This book is not about perpetuating a myth. In fact, the opposite is true. The main aim is to burst the myth that has a lot of people imprisoned in unjustified anxiety and fear about a problem that may be non-existent. It is a myth that has been cynically exploited by unscrupulous individuals to peddle ‘remedies’ for ovarian cysts, quite often shamelessly labelled as ‘natural cures’. When seeking a solution to a problem one might have, it is logical that the first thing one does is to understand the problem. This book seeks to do just that. A solemn promise I make is that, when finished with this book, you will have a clear understanding of ovarian cysts as an entity. That understanding will be a giant step towards clarity on whether you have an ovarian cyst problem or not and if you do; what your options for a solution are.
Ovarian cysts are (largely) normal
The most basic fact that needs to be understood is that most ovarian cysts are completely normal. Ovaries do form cysts. It is one of their physiological functions. It is natural. It is difficult to over-emphasize this fact. Ovaries forming cysts is as natural as noses smelling and eyes seeing.
Simple and Complex cysts
Now that this is clearly understood, it is also true that some cysts are not physiological and therefore cannot be described as normal. In this category of non-physiological cysts, the majority are what are described as simple and certainly benign. Most of these are completely harmless. I shall expand on this aspect a little later. A smaller percentage of ovarian cysts are described as ‘complex’. Some of the complex cysts are benign and others are malignant (cancerous). Again, this distinction will be made clear a little later.
Simple and complex cyst is a descriptive categorisation. It is based on appearances on ultrasound and other imaging tests. As said earlier, simple cysts are almost invariably benign. Complex cysts, on the other hand, could be either. Still, the majority are non-cancerous.
A cyst is a fluid-filled sac. Ovaries are not the only part where cysts form. A typical ovarian cyst is usually fairly small, measuring less than 5 cm across and is filled with clear fluid. An ultrasound scan will show it is a uniformly dark round structure. Normal physiological cysts (and these are the majority) will come and go throughout a woman’s reproductive years.
At this early stage, it is worthwhile to look at some of the medical terms used to describe a cyst. These terms are commonly found in ultrasound scan reports, this being the commonest imaging technology used for the diagnosis of cysts. A typical report could read like this:
A thick-walled multiloculated lesion measuring 5 x 3 x 2.5 cm in the left adnexa. It appears to arise from the left ovary. The septae appear thin and most loculi are hypoechoic. There is a small echogenic focus in the centre of the cystic lesion. This appears to be a multiloculated complex left ovarian cyst.
For a non-medic, such a report can seem impenetrable and leave you bemused. Most of the words are descriptive and are very useful in interpreting the report and forming an opinion on the likely specific diagnosis. Once you know what those words mean, it all makes a great deal of sense. So, let’s look at the commonly used terms.
Hyperechoic: Ultrasonography (ultrasound) employs sound waves. These are beamed into the tissues and, depending on their density, the sound waves will bounce back to varying degrees. On solids such as bone and even muscle, most of the sound waves bounce back giving a solidly white or almost white image. That will be described as hyperechoic. Comes from the word ‘echo’. The alternative term for hyperechoic is hyperechogenic (or simply ‘echogenic’). This also explains the other two terms (below) originating from the same word:
Hypoechoic: Little sound wave reflection and therefore few internal echoes. This is seen in soft tissues such as fat. However, the term hypoechoic is frequently used as a relative term to describe difference in echogenicity of structures next to each other. For instance, muscle may be described as hypoechoic next to another solid structure such as bone or even a tumour. Another term used to mean the same thing is ‘echo-poor’.
Anechoic: Clear fluid such as water, amniotic fluid or normal urine allows the sound waves to pass through un-reflected, giving a solidly black image. It means there are no internal echoes. That is described as anechoic.
Unilocular: If fluid is contained within a single pocket or chamber, it will be described as unilocular as opposed to:
Multilocular: The cyst is sub-divided into multiple pockets (loculi) or
Bilocular: The cyst is divided by a wall (septum) into two chambers
Septum: A wall that bisects the cyst
Septated: Divided (the dividing ‘walls’ are what are known as ‘septae’.
Adnexa: This is a description of the structures to the side of the uterus where you find the ovary and fallopian tube
These are really just some of the terms used to describe an ultrasound image. It allows the doctor reading the report to get a vivid mental image of what things look like. This allows for forming an opinion as to what the nature of the lesion might be. There are many more terms used but not as frequently and those may not be relevant for this topic.
Let’s address the issue of pain and ovarian cysts. Contrary to popular belief, cysts are usually painless. Even when they grow significantly bigger, sometimes up to a size of big orange or bigger, the tendency is to remain painless. Every practising gynaecologist will have encountered a situation where a woman presenting with pelvic pain whose scan shows an ovarian cyst will sit down convinced that this is the source of her problem.
Sadly, in the vast majority of cases, that is not so. It can be very difficult to persuade her otherwise, especially when you are not in a position to immediately give her a credible alternative explanation.
It needs to be stated again and very firmly that ovarian cysts do not normally cause pain.
Functional Cysts
Functional or ‘normal’ cysts are so called because they result from a normal physiological process. They are expected to happen and it will be regarded as an anomaly if they didn’t. Functional cysts come in two forms. These are called:
Follicular cysts
Corpus luteum
A woman is born with all the eggs she will ever have. No eggs are made after a child is born. The two ovaries, each the size of a small thumb, contain all of the eggs a woman she will ever have. The total number of eggs a woman is born with varies a great deal. The average is quoted to be around 180,000 – 200,000. Some newborns will arrive with a number much less than this and others could have up to a million. These eggs remain biologically inactive for the first 10-12 years of a girl’s life. When a girl reaches the age of puberty, around 12 years old, give or take a year or two, eggs start maturing. Every month or so, a few eggs start this process. In most months, only one egg will complete the process of maturation and eventual release (ovulation). This cyclical process will continue throughout the woman’s reproductive life, stuttering towards the end about 30-35 years later as she approaches menopause. At that point, there will be only around 1,000 follicles remaining. The only times this monthly process does not happen is when she is pregnant, breast feeding, on hormonal contraception or when she has a medical condition interfering with this process
A follicle is the part of the ovary that will normally develop an egg, usually released half way through a menstrual cycle. The follicle measures around 2-2.5 cm across at the time ovulation takes place. Sometimes the follicle does not release the egg. Instead, it continues to fill with fluid, gradually increasing in size. This can get up to 5 cm (2 inches), sometimes slightly larger than this. It can persist for several weeks, even months. It is typically painless. That is what is known as a follicular cyst. Every woman will develop these numerous times throughout their reproductive lives. The ultrasound image below shows a typical follicular cyst. This one measured 3.2 cm (11/4 inch) across. The image may look dramatic (it is a close up) but this is a completely normal, usually transient, cyst. The uniformly black colour inside the cyst is confirmatory that the cyst contains only clear fluid. (On ultrasound, solids appear white).