Ovarian Follicles, Cysts, and Malignancies

   Every woman after puberty gets them.  Every gynecologist feels them.  Thankfully, most of them don't really matter at all.  They are ovarian cysts and while they often strike fear into a woman's mind, it is up to us physicians to tell them when to mind at all.

    It's important to understand the most common type of ovarian cyst--the follicle.  An ovarian follicle is that little cavity that grows an egg set for release at mid-cycle, or ovulation. The ovarian follicle is both a result of and an integral part of the menstrual cycle.  It contains a little puddle of fluid that functions in the development of the egg.  The release of the egg, called ovulation, is a midpoint in the cycle.  If ovulation fails to occur, the rest of the cycle is often suspended or irregular.  The follicle is therefore a product of function, a word which will figure importantly below.

    When a follicle gets to be bigger than about two centimeters or so, semantics dictate that it be referred to as a cyst.  That's the difference--semantics.  Of course, a cyst can be thought of as an exaggerated follicle, but it is still a matter of normal functioning.  Therefore, we speak of theses cysts as "Functional Cysts," and nothing need be done other than wait it out.  If a woman has pain from it, or if she doesn't want to wait it out because she's not seeking pregnancy, it can be melted away usually with the temporary use of birth control pills.

    After all, how do birth control pills work?  By suppressing ovulation and therefore the cysts that may develop from it.

    Waiting, admittedly, can be a bit nerve-wracking, because a period is usually delayed in all of the "functional" confusion.  Still, regardless of management, the condition is usually harmless and doesn't require surgery, unless the cyst becomes really huge, bleeds, or twists on itself ("torsion") causing tissue damage.

And then there are the rest of the ovarian cysts.

    Pre-cancerous cysts don't go away with birth control pills, so a failure here may indicate that there's something more dangerous than a functional cyst.  This is when gynecologists start discussing laparoscopy to either make a diagnosis or to shell it out, saving the ovary it's in if possible.  A test called "CA-125" is a blood test that could raise the index of suspicion if abnormal.  And ultrasound is helpful to indicate whether the cyst is a simple sack (encouraging) or complex (worrisome).

    Family history also plays a part in how aggressive a doctor may be.  If a patient's mother or sister had cancer of the ovary, we worry over any cyst, resolved to prove it functional or not.  A family history is when things start to get a little creepy, because one out of seventy women will get ovarian cancer; but if a mother had it, a daughter's chances are anywhere between one in twelve to one in twenty.  If two close members of her family have it, the chances can get as ridiculously high as one in two!  No wonder we worry.

    New laparoscope techniques make surgical cyst management easier on the patient, and good diagnostics can ensure we don't get carried away with mere functional cysts, which are the vast majority of them.  But a suspicion of malignancy or even pre-malignancy is never taken lightly and poses one of the most important exclusions of every routine GYN exam.

    This is the beginning of a series on the ovary and things that can go on within it. In the next links I will go into more detail, a series called, "The Good, the Bad, and the Ugly."

© 2000 Gerard M. DiLeo,M.D., F.A.C.O.G.