Healthcast 635 - Ovarian Cysts: Diagnosis and Treatment After Menopause

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At Biobalance® Health we often find cysts or masses on the ovaries of women who are menopausal quite by accident. We order an ultrasound before we treat a menopausal woman with estradiol to see if there is a thickened lining that might cause bleeding under the influence of estrogen replacement, or to make sure there is no uterine cancer before we treat a new patient.

We also incidentally find ovarian masses or cysts when we are investigating pelvic pain or postmenopausal bleeding on our patients who are already on estrogen replacement. In general, since BioBalance's female patients have their own GYN we don't do pelvic exams in the office, therefore we don't find a mass by palpating (feeling) the pelvic structures, however ovarian cysts and masses can be found by ultrasound as well as by physical exam. We generally find ours by vaginal ultrasound.

Why do we get ovarian cysts?

Before menopause we make an egg every month (if we are not on birth control) that grows within a fluid filled sack. This egg will grow to about 18 mm, or 1.8 cm before it ruptures and releases the egg. That is the miracle of ovulation. It is normal to see one or two of these small cysts on the ovaries of ovulating, fertile women. These small sacks are not cysts because of their size.

Ovarian cysts are fluid filled sacks attached to the ovary that are over 2.5 cm. They often occur secondary to a trapped egg that won't ovulate for some reason, and the cyst will remain until the next period. If the cyst doesn't dissolve before the next cycle, it can grow larger with the surges of hormones and it can prevent future ovulation, or it can cause pain from the stretching of the outer covering of the ovary. If a cyst is less than 2.5 mg. we don't re-ultrasound in cycling women. If it is larger or continues to cause pain, we follow up an ultrasound in 6 weeks to see if it is growing. If it is growing but is still clear, depending on the size and the pain involved, we might do a laparoscopy to remove the cyst from the ovary. If it is growing and looks unusual in shape or density, we order 2 blood tumor markers for ovarian cancer. If those are negative, we follow up with another ultrasound in 3 more months.

In some patients, multiple ovarian cysts are the norm. Those patients with polycystic ovaries create multiple cysts each month and rarely ovulate. It helps to use the drug Metformin ER to improve ovulation in PCO patients (and the rupture of cysts). Some patients require laparoscopy to punch holes in all the cysts especially if she is trying to get pregnant.

What does a postmenopausal ovarian mass or cyst mean indicate?

Now for postmenopausal patient's ovarian cysts and masses are much more worrisome but much rarer. Because the ovary is not metabolically active, and therefore not ovulating the menopausal ovary should look small without cystic structures, however there are some exceptions! The menopausal ovary that has a fluid filled cyst 2.5 cm or less can have been there since the patient stopped ovulating and it never deflated, or ovulated. This type of cyst doesn't grow and is not malignant.

Ovarian cysts in postmenopausal women that are fluid filled and larger than 2.5 cm, or solid, or partially fluid filled and partially solid are suspicious for malignancy. In this case your doctor may order an MRI, a CT scan of the pelvis, and order cancer tumor markers. In most cases these masses are benign, or early in a malignancy and can be treated with surgery. Sometimes we find a suspicious mass that needs confirmatory ultrasound or MRI by a GYN Oncologist, tumor markers, and surgery would be scheduled to take the uterus tubes and ovaries and sometimes the omentum and lymph nodes.

When will a patient know that her mass if not malignant and if she needs surgery?

The surgeon may do a frozen section in the operating room to see if more than the ovary itself must be removed or your GYN may wait for the final pathology report to determine if it is malignant. That takes several days to a week.

How common is ovarian cancer?

Ovarian cancer is very rare and tends to run in families. If you have not had a relative with ovarian cancer, then you are not likely to have ovarian cancer if you have a suspicious mass. That does not mean you won't' need surgery, it just means the outcome has a high chance of being benign.

What can be mistaken for an ovarian mass on ultrasound?

There are several pelvic structures that might be confused with an ovarian cyst/mass. The most common is a pedunculated fibroid that hangs down from the uterus and looks like it is coming from the ovary. These muscle masses from the ovary are generally benign, but they can grow under the influence of estrogens. There are cysts called para-ovarian cysts that can originate from the fallopian tube. They are fluid filled and can actually grow, looking like an ovarian mass, but they are benign, and most are sedentary and don't grow or become a problem. In my 25 years of operating on women I only had one of the next types of cysts that was thought to be a malignancy at first. It was a very large cyst, 12x 12 inches in diameter and I asked a general surgeon to come in and work with me to help with the surgery if it was a malignancy. In the end, it was a cyst in the retroperitoneal space, called a peritoneal cyst, that was totally benign, and the patient did not require any further treatment after the surgery.

Postmenopausal women who have had an ovarian cyst or ovarian mass you know that it can be an anxiety producing situation, however the great majority of the simple ovarian cysts in postmenopausal women are benign and surgery is not necessary. Most ovarian cysts are likely to remain unchanged or disappear during the follow-up period. The malignancy rate of these cysts is about 1 in 10,000, so worry is usually unnecessary. In my 25 years of private practice, I only operated on 5 patients with an ovarian cyst or mass that turned out to be malignant.

As gynecologic surgeons we are trained to investigate any ovarian cysts that are suspicious through ultrasound, or surgically even if there is a very slight chance that they might be malignant. We are expected to remove any ovary that is suspected to be cancer, even if the chance is minimal that the cyst is malignant. In our practice we send all our patients with suspicious ovarian masses to their gynecologist for evaluation and treatment.

American College of Obstetricians and Gynecologists' Committee on Practice Bulletins—Gynecology. Practice Bulletin No. 174: evaluation and management of adnexal masses. Obstet Gynecol 2016;128:e210–e226. doi: 10.1097/AOG.0000000000001768