Complex ovarian cysts are very rare but they can cause many serious problems and complications, including emotional isolation because of the condition. To manage this condition in the ovary, you need to understand what it is and how it affects you.

The ovary is an organ that is located on both sides of the uterus. It resembles the size and shape of an almond and is responsible for releasing an egg every month and for producing the sex hormones, estrogen and progesterone. An ovarian cyst is a sac or pouch filled with fluid or semi-liquid material found on the surface or inside an ovary.

What is Complex Ovarian Cyst?

An ovarian cyst occurs commonly in women during the childbearing years, the period from puberty to menopause. It is referred to as a functional cyst and is usually formed as part of the menstrual cycle and therefore occurs less commonly after menopause. A woman can have one cyst or many cysts and she may not be aware of it. In most cases it is harmless and does not affect a woman's ability to get pregnant. Ovarian cysts usually disappear even without treatment.

An ovarian cyst can also contain both fluid and solid material, and this is known as complex cyst. It occur less frequently and are not related to the normal menstrual cycle. These are generally harmless (benign). There are three types of complex ovarian cysts: dermoid cysts, cystadenomas, and endometriomas.

• Dermoid cysts -Theseare the most common type and develop during the childbearing age. The cysts contain structures such as the teeth, hair, nail, bone, or sweat glands. It is a slow growing and rarely cancerous. It causes significant pain when the cyst twists.
• Cystadenomas - Cystadenomas are benign cysts that develop from cells that cover the outer layer of the ovary. There are two types, mucinous and serous cystadenoma. Mucinous adenoma contains a sticky, thick fluid. It can grow up to 30 cm (12 in) in diameter and weigh up to 100 pounds. It can fill up the abdomen and cause pressure on other structures such as the bladder and bowel. It can also block the blood supply in the ovaries and cause twisting or torsion of the ovaries. Serous cystadenoma contains a thin, watery fluid. It does not grow as big as mucinous cystadenoma but can cause symptoms when it ruptures.
• Endometriomas - Endometriomas are blood-filled cysts that arise from endometriosis. Endometriosis is a condition wherein the cells that are normally found inside the uterus grow outside the uterus, such as the ovaries, fallopian tubes, bladder, or bowel. Endometriomas care also called chocolate cysts. This is because the cells that grow in the ovaries bleed and become brown over time and result in a brown-colored cyst.

Patients with ovarian cysts are often concerned about malignancy. Complex ovarian cysts are generally benign. The risk of malignancy is generally higher among postmenopausal women, occurring in 0.3% of cases. It has been reported that a malignant change occurs in small percentage of women with dermoid cyst and endometrioma. Cystadenoma has not been reported to become malignant.

Causes of Complex Ovarian Cyst

The cause or causes have not been identified. There are several risk factors known to be associated with its formation:

• genetic predisposition
• early onset of menstruation (younger than 12 years)
• history of irregular menstrual cycles or previous ovarian cysts
• hypothyroidism
• obesity or increase in upper body fat
• infertility and infertility treatment (clomiphene or letrozole)
• tamoxifen (for treatment of breast cancer)
• cigarette smoking

Symptoms of Complex Ovarian Cyst

A cyst does often not present with any symptom. If symptoms occur, the most common complaint is pain or discomfort in the lower part of the abdomen. The pain is often due to a very large cyst. Pain may also be due to bleeding, rupture, or torsion of the cyst, being bumped during sexual intercourse, or when the blood supply to the ovary is interrupted.

The pain of a large cyst is described as a dull, heavy sensation while rupture or torsion is associated with sudden, severe, and sharp pain. Pain is also present before and after the menstrual period and during intercourse and bowel movement. There may be a feeling of fullness or bloating in the abdomen. Symptoms similar to pregnancy, such as nausea, vomiting, and breast tenderness may occur and menstruation may become irregular. A large cyst may also press on the bladder and cause increased frequency of urination.

Diagnosis of Complex Ovarian Cyst

• Ultrasound test - Cysts are often asymptomatic, they are usually diagnosed during a pelvic examination or incidentally while doing an ultrasound test for a different condition, such as pregnancy. An ultrasound is the primary imaging test used to diagnose a cyst. It shows the size, shape, location and makeup of the cyst.
• CT scan and MRI - Other tests used are computerized tomography (CT) scan or magnetic resonance imaging (MRI). CT scan is a helpful in identifying presence of blood in the abdominal cavity (hemoperitoneum) due to rupture of a cyst. MRI is better than the CT scan at visualizing soft tissues. It is indicated if the ultrasound and CT scan cannot identify a mass as an ovarian cyst. Doppler flow studies show the presence or absence of blood flow to an organ.
• Other laboratory tests - These include urinary pregnancy test, hormone levels, and cancer antigen 125 (Ca-125) test. A urinary pregnancy test should be done in all women of childbearing age. Hormones to be determined include luteinizing hormone (LH), follicle stimulating hormone (FSH), estradiol (estrogen), and testosterone. Cancer antigen 125 or Ca-125 is a blood test done in menopausal women. It is a tumor marker, a tool that is for detecting ovarian cancer.

Treatment for Complex Ovarian Cyst

The management of ovarian cysts requires a gynecologist, a specialist trained in diseases of a woman's reproductive organs. Treatment will depend on the age of the patient, type and size of the cyst, presence or absence of symptoms, and whether the patient has had menopause. The doctor may recommend watchful waiting, use of birth control pills, or surgery.

• Ultrasound test - Most ovarian cysts disappear in 8 to 12 weeks. Watchful waiting is recommended at any age if there are no symptoms, and the ultrasound test shows a simple fluid-filled cyst. Because of the risk of ovarian cancer is higher among women who had menopause, regular ultrasound and blood tests are required until the cyst disappears.
• Birth control pills (oral contraceptive) - These are prescribed if the woman has frequent episodes of ovarian cysts. They do not decrease the size of the cyst but are helpful in decreasing the risk of ovarian cancer.
• Surgery - Surgery is recommended if the cyst is large, causes symptoms, does not disappear after two or three menstrual cycles or continues to grow, in women who are near menopause or has had menopause, and those with complex ovarian cyst that does not disappear. The types of surgery are exploratory laparotomy and pelvic laparoscopy. Exploratory laparotomy is a procedure where a cut is made in the abdomen and the abdominal organs are examined. The whole cyst and ovary is removed and sent to the laboratory to check for the presence of cancer. Pelvic laparoscopy is done for smaller cysts. A small, tube-shaped microscope with a light at the end is inserted into the abdomen. The abdominal organs are visualized and through a tiny instrument the cyst is removed.