Ovarian cysts and endometrioma

Types of cyst

• Functional cysts: related to ovulation and usually resolve on their own.
• Dermoid cyst (teratoma): common between the ages of 20 and 40; may contain tissues such as fat and hair. Almost always benign.
• Endometrioma (chocolate cyst): a cyst containing old blood, caused by endometriosis.
• Polycystic ovaries: many small follicles; surgery is not needed.
• Other benign tumours and, rarely, cancer.

Symptoms and diagnosis

Most cysts cause no symptoms. When they do, there is usually pelvic pain or pressure on the side of the cyst. Rupture of a cyst or twisting of the ovary (torsion) can cause sudden, severe pain and needs urgent assessment.

The diagnosis is made by transvaginal ultrasound, with MRI when needed. For cysts with a suspicious appearance and after the menopause, blood tumour markers are checked in addition to ultrasound. There is no single marker; which tests are requested depends on the patient's age and which type of cyst the ultrasound suggests:

• CA-125: the most commonly used marker; it can be raised in tumours arising from the surface (epithelium) of the ovary. However, it can also be raised in benign conditions such as endometriosis and endometrioma, fibroids, menstruation, pregnancy and abdominal inflammation, so it is not diagnostic on its own, especially before the menopause.
• HE4: when assessed together with CA-125 (ROMA index), it helps estimate the likelihood that a mass is benign or malignant.
• CEA and CA 19-9: may be raised in mucinous (sticky fluid-containing) tumours. CA 19-9 can also be high in dermoid cysts. CEA also helps assess whether a mass originates from another organ such as the bowel.
• AFP, beta-hCG and LDH: may be raised in germ cell tumours, which occur especially in children, adolescents and young women; they are added for solid-looking masses in this age group.
• Inhibin and AMH: used to assess hormone-producing granulosa cell tumours.

Tumour markers are not screening tests; a normal result does not completely exclude cancer, and a raised result does not on its own mean cancer. Results are always interpreted together with ultrasound and examination findings. If markers are raised before surgery, they are also used in follow-up after treatment.

Monitoring or surgery?

Before the menopause, simple-looking cysts are usually rechecked by ultrasound after 6–8 weeks. Surgery is recommended in the following situations:

• Persistent pain or a risk of torsion
• A large cyst or one that keeps growing
• An ultrasound appearance or risk factors suggesting cancer
• Symptomatic endometriomas

Which patients with a dermoid cyst need surgery?

Unlike functional cysts, dermoid cysts do not disappear on their own and do not shrink with medication; they may grow slowly over time. However, not every dermoid cyst needs immediate surgery. Surgery is generally recommended in the following situations:

• Cysts causing symptoms such as pain or pressure
• Large cysts or cysts seen to grow during follow-up
• Risk of ovarian torsion: dermoid cysts are among the most common causes of torsion
• Cysts whose ultrasound or MRI appearance is uncertain and cannot be distinguished from another tumour
• In women planning a pregnancy, when the likelihood of the cyst causing problems during pregnancy is assessed
• Cysts found after the menopause: the rare risk of malignant change at this age is taken into account

For small dermoid cysts that cause no symptoms, especially in young women, regular ultrasound follow-up is also a suitable option. When surgery is needed, the aim is to remove the cyst without rupturing it and to preserve healthy ovarian tissue; a special bag is used so that the cyst contents do not spread within the abdomen. The decision is individual and takes into account the size of the cyst, symptoms, age and pregnancy plans.

Laparoscopic cyst surgery

For cysts that appear benign, surgery is performed laparoscopically (keyhole). The aim is to remove the cyst and preserve healthy ovarian tissue (cystectomy). This is especially important for protecting the egg reserve in women who wish to have children; unnecessary surgery is therefore avoided for small endometriomas that cause no symptoms.

Cysts suspected to be cancer are removed without rupture, together with the ovary if necessary, and sent for pathological examination. Removing one ovary does not cause the menopause and does not end fertility.