New Horizons...........Living Well, Feeling Great

Ovarian Disorders 

The following questions will be addressed in this section:

I was told I have a cyst. What is that?
Why do I have pain from my ovarian cyst?
Do I need surgery if I have a cyst?
What type of surgery is done for ovarian cysts?
How do you know my cyst is not cancerous?
The doctor says I have an ovarian tumor. Does that mean I have ovarian cancer?
Does ovarian cancer run in families?
Are there screening tests for ovarian cancer?
What symptoms will I have if I develop ovarian cancer?
If the tumor is on my ovary, why does the doctor want to perform a hysterectomy?
The doctor says all the cancer was removed. Why does he want to give me chemotherapy?
I know people who had chemotherapy and died anyway, so why should I take chemotherapy?
Why get sick from the chemotherapy?
How long will I get chemotherapy?
The doctor says he wants to look inside me again after the chemotherapy. Why?

I was told I have a cyst. What is that?

Any fluid filled structure seen in the ovary is referred to as an ovarian cyst. Your doctor may discover an ovarian cyst when he examines you, or it may be detected by a radiologic scan (most often on ultrasound scan). Radiologists often call any fluid filled structure in the ovary a cyst, but in premenopausal women this term should be reserved for structures greater than 2 centimeters. The follicle containing the egg to be released at ovulation is a cystic structure. It increases to about 2 centimeters (slightly less than 1 inch) before ovulation. Because follicles are normally seen in the ovary, they should not be referred to as cysts. Postmenopausal women no longer develop follicles so any fluid filled structure in the postmenopausal ovary is abnormal (but not necessarily dangerous, see below).

The most common cysts seen in the premenopausal ovary are “functional ”cysts. Sometimes a follicle doesn’t rupture in the middle of your cycle. It continues to increase in size, evolving into a follicular cyst. Sometimes the follicle does rupture, and blood collects in the corpus luteum (the follicular structure after ovulation). This is referred to as a corpus luteal, or hemorrhagic, cyst. Follicular and luteal cysts are “functional” because they relate to the normal function of the ovary. They comprise 90% of all of premenopausal and perimenopausal ovarian cysts. Functional cysts resolve spontaneously. Your doctor may place you on oral contraceptives to suppress ovarian function. Some physicians believe this decreases the amount of time it takes for resolution of a functional cyst, although studies do not back up that assertion.

Polycystic ovaries (PCOS) represent a variation of functional cysts. In this condition, there is a buildup of unruptured follicular cysts within the ovaries. This abnormality is associated with infrequent ovulation that may cause infertility. Infrequent periods, obesity, and masculinizing traits (such as increased facial hair) may also develop.PCOS is also associated with a metabolic syndrome that includes type 2 diabetes, hypertension (high blood pressure), and dyslipidemia (abnormal levels of cholesterol and triglycerides).

Another type of ovarian cyst is an endometrioma. Before menopause, little bits of endometrium can reflux out of your fallopian tubes and land on the surface of your ovaries and other pelvic organs. If the capsule of the ovary envelops these "endometrial implants", then each month they bleed and the blood cannot escape from the ovary. This produces a cyst filled with old blood, sometimes referred to as a "chocolate cyst". Associated with this there may be other symptoms related to endometriosis such as pelvic pain or infertility. After menopause endometriomas tend to shrink, but often they do not disappear. They do not necessarily need to be removed.

There are many types of benign (noncancerous) cystic tumors that can evolve from ovarian tissue. Cystadenomas are cystic tumors that emerge from the cells that cover the surface of the ovary. Dermoid cysts are particularly unique. They may contain many types of tissue within the cyst including skin, hair, and teeth (Yes, they look as disgusting as they sound!). Because most benign tumors are removed (see below), it is not known how many of them would become cancerous if not treated.

Malignant tumors of the ovary may also be cystic. The most common of these are referred to as cystadenocarcinomas. Fortunately, malignant (cancerous) tumors comprise a small minority of ovarian cysts. Ninety-five percent of all ovarian tumors in women under age 45 are benign. The chances of a cyst being malignant increases with age, although the majority of cysts are benign even after menopause.

Why do I have pain from my ovarian cyst?

An enlarged cystic ovary may twist and turn causing intermittent, sharp pain. If the ovary is enlarged sufficiently to press on other pelvic structures it may be felt as a dull, continuous pain. You may also feel pain with intercourse, particularly on deep penetration. A very large cyst may be first noticed as abdominal swelling.

Occasionally a cystic ovary undergoes continuous twisting until it cuts off its blood supply. This is called ovarian torsion. You develop profound, unrelenting pain with ovarian torsion. We’re talking about the kind of pain that brings you to the emergency room any time, day or night. Ovarian torsion is treated through surgery. Most doctors now approach ovarian torsion using laparoscopic techniques (surgery using a telescopic instrument and small incisions). Traditionally, doctors removed the ovary if there was torsion. More recently, physicians are untwisting the ovary. In a premenopausal woman, particularly a woman who wants to have more children, the ovary is untwisted and preserved, as long as the torsion has not destroyed the blood supply to the ovary. Ovarian torsion is less common in menopausal women, but when it does occur, the ovary will usually be removed.

Rupture of an ovarian cyst also produces pain. This presents with a sharp pain as the cyst ruptures. The pain then decreases in intensity but may persist as a continuous “achy” feeling in the pelvis. The diagnosis is suspected when an ultrasound examination demonstrates “free” fluid in the pelvis. This represents the contents of the cyst lying free in the pelvis. If there is continuous bleeding from the ruptured cyst (demonstrated by repeatedly checking your blood count), surgery is required. However, most of the time ruptured cysts can be observed without treatment. Most ruptured cysts occur in premenopausal women, are functional in nature, and will resolve spontaneously. Your pain usually resolves quickly (anywhere from hours to several days). Any ruptured cystic structure in a postmenopausal woman must be further investigated to exclude cancer.

Do I need surgery if I have a cyst?

Most ovarian cysts do not require surgery. In the premenopausal or perimenopausal patient, the majority of cysts are functional (see above) and will resolve spontaneously over 1-3 months. You need surgery for your cyst in the following situations:
1. Your cyst does not resolve after several months, particularly if you have been placed on oral contraceptives.
2. Your cyst is exceptionally large. Functional cysts are usually under 10 cm. If your cyst is larger than 10 cm., surgery may be recommended.
3. You are menopausal. After menopause, your ovaries no longer function. Therefore, functional cysts are not possible after menopause. If your cyst is small and has benign (noncancerous) characteristics on ultrasound scan, your doctor may be willing to follow it conservatively. You must meet the following criteria for conservative management:
• Your cyst should be no larger than 5 cm.
• Your cyst must be purely cystic (fluid filled). There can’t be any solid areas within the cyst.
• The walls of the cyst must not be thickened.
• There must not be thick septations (walls going through the cyst).
• You must not have other evidence of cancer on your scan such as ascites (free fluid in the abdomen), enlarged lymph nodes, or other tumor masses.
• You must have a normal CA-125 test. CA-125 is a blood test that screens for ovarian cancer.
• You must be willing to undergo frequent ultrasound scans (initially every 3-6 months).
All menopausal cysts that do not meet these criteria should be removed. Some doctors feel that all menopausal cysts should be removed if you are otherwise healthy (at low risk for undergoing surgery), but gradually doctors are willing to be more conservative. Very few postmenopausal cysts with a benign appearance will ever develop into cancer.
4. Your symptoms are severe. If the pain you have cannot be adequately controlled, surgical intervention may be justified.
5. You develop ovarian torsion (see above).
6. Your cyst causes internal bleeding that does not spontaneously abate.

What type of surgery is done for ovarian cysts?

Historically, ovarian cysts were removed by laparotomy, which requires a larger incision through the abdomen. Today, laparoscopic approaches for ovarian surgery are commonly used.  A telescopic instrument is inserted through a tiny incision near your navel. Operative instruments are introduced through additional small incisions and either the cyst is removed from the ovary (ovarian cystectomy) or the entire ovary is removed (oophorectomy). Laparoscopic surgery for an ovarian cyst is only appropriate if the cyst is benign. The contents of a cyst may spill into the abdomen during laparoscopic removal, which is not ideal if the cyst is malignant. Rarely, an ovarian cyst appears benign on imaging studies such as ultrasound but looks suspicious at the time of laparoscopy. When this happens, the laparoscope is removed and your surgery will be performed through a laparotomy. The ovary will remain intact, and more extensive surgery is performed if the ovary is found to be malignant on frozen section examination by a pathologist. Laparotomy for a suspicious ovary may be rescheduled so that a gynecologic oncologist (GYN doctor that specializes in cancer) is present for the procedure.

How do you know my cyst is not cancerous?

There is no way of knowing for sure. This can be very upsetting. Many women overreact when informed of an ovarian cyst. You may assume that it is malignant and have yourself “dead and buried”. In reality, it is far more likely that the cyst is benign, particularly if you are premenopausal. If the ultrasound criteria mentioned above indicate that the cyst is benign, and your CA-125 test is normal, then you have at least a 95% chance that your cyst is not cancer. If you are premenopausal, wait to see if the cyst will resolve.

The doctor says I have an ovarian tumor. Does that mean I have ovarian cancer?

Words like “tumor” and “neoplasm” are tossed around cavalierly by health professionals. Without further definition, they are likely to be misinterpreted by patients. A tumor, or neoplasm, is an abnormal mass of tissue that grows more rapidly than normal. It may be noncancerous (benign) or cancerous (malignant). The word tumor is usually used for ovarian growths that appear to have a solid component. Fluid filled ovarian masses that do not appear to be functional cysts are referred to as cystic tumors or neoplasms.

The majority of ovarian tumors are benign. The incidence of ovarian cancer increases with age, but even after menopause more ovarian tumors are benign than malignant. Certain ultrasound characteristics help your doctor decide if the tumor is likely to be cancerous. The CA-125 blood test is also helpful. However, until the tumor is removed surgically, there is no way of being sure that your tumor is benign.

Does ovarian cancer run in families?

Most ovarian cancer is sporadic. It occurs without the patient having a family history of ovarian cancer. However, there are familial genetic syndromes which can increase a woman's chance of developing breast, ovarian, endometrial, and colon cancer. The most common of these familial syndromes is Hereditary Breast and Ovarian Cancer Syndrome, related to a BRCA1 or BRCA2 mutation.

In the general population, ovarian cancer occurs in approximately 1 out of every 70 to 80 women. It occurs more frequently in white women than black women and is most common between the ages of 50-75. Your chances of developing ovarian cancer are increased if you have a history of infertility. It is also higher if you have not had children. Your chances are decreased with childbearing and usage of birth control pills. Tubal ligation may also have a protective effect.

If there is one relative in your family who has had ovarian cancer, your risk is increased, but no more than 3-5%. If there are multiple relatives (particularly first degree relatives such as your mother and sisters), your risk is increased substantially. In this situation, there is a reasonable likelihood of Hereditary Breast and Ovarian Cancer Syndrome and your risk of developing ovarian cancer may be as high as 25 to 50%. Genetic testing should be strongly considered under these circumstances (first testing the family members who have actually had ovarian cancer). With a BRCA1 or BRCA2 mutation most gynecologists and oncologists will recommend prophylactic removal of the ovaries between ages 35 - 40. Early detection of ovarian cancer is difficult, even with screening. Your ovarian hormones can be replaced until you are closer to the age of natural menopause.

Are there screening tests for ovarian cancer?

Screening tests for ovarian cancer include pelvic ultrasound and a blood test called CA-125. Routine pelvic exams will detect some ovarian cancers, although early detection by pelvic exam is uncommon. Your Pap smear does not screen for ovarian cancer. It is valuable for the detection of cervical cancer but does nothing to detect ovarian problems.

A pelvic ultrasound scan is good at detecting ovarian cysts and growths. So, why aren’t we getting pelvic scans every year? First, the scans are relatively expensive, approximately $500 per scan. That is a large amount of health care dollars to detect a disease that occurs in only 1.3% of women. We perform mammography annually in women over 40-50 years of age, but breast cancer develops in more than 10% of women. Even if we had unlimited finances, there are other problems. Ovarian cancer can progress rapidly. For early detection, we would have to screen women at least every six months. Also, ovarian cancer tends to spread to other areas in the abdomen fairly early in its course. Although screening will detect some cancers still confined to the ovary (which have a good prognosis), many will have already spread. It is therefore debatable how many lives can be saved with ultrasound screening. Finally, the ultrasound scan cannot precisely determine if your ovarian growth is cancerous. Many benign ovarian cysts and tumors detected by the scan would be removed for every one that actually is malignant.

There are also problems using the CA-125 blood test. Not all ovarian cancers increase the CA-125 level. No more than 50% of early ovarian cancers will have an elevated CA-125. On top of that, many benign conditions raise the CA-125 level (fibroids, endometriosis, pelvic infection, pregnancy). False positive elevations create anxiety and may lead to unnecessary surgical procedures. The noncancerous conditions that raise CA-125 usually occur before menopause. It is not recommended to screen premenopausal women with the CA-125 test because of this high “false positive” rate. It is more reliable when used after menopause.

So, where does this leave us? Opinions vary among gynecologists as to the value of screening for ovarian cancer. It is probably not cost effective. However, if you are the one who develops the cancer, there will be little solace gained by someone telling you that screening wasn’t cost effective. Studies are continually underway to decide if screening can actually decrease the death rate from ovarian cancer. So far, the results have been mixed. If you have a positive family history of ovarian cancer, consider screening with ultrasound and CA-125 every 6-12 months. If there is a strong family history, consult your doctor regarding the possibility of genetic testing, or if this is not feasible, ask whether you should have your ovaries removed.

What symptoms will I have if I develop ovarian cancer?

Unfortunately, you probably won’t have any symptoms while your cancer is early. Ovarian cancer tends to be assymptomatic until your abdomen begins to swell. By that time your cancer has often spread into the abdomen. The abdominal swelling is either from free fluid in your abdomen, called ascites, or the tumor itself which at this point is very large. Early ovarian cancers may cause pelvic pain or painful intercourse in similar fashion to ovarian cysts. Occasionally the cancer will alter ovarian hormone secretion and cause abnormal bleeding. Advanced ovarian cancer may create indigestion, abdominal cramps, or bloating.

Whatever you do, don’t assume you have an ovarian cancer if you have any of the above symptoms. They all are quite common and usually caused by conditions that are totally unrelated to cancer. On the other hand, don’t ignore persistent, unusual symptoms. Consult your doctor and let him decide if further investigation is warranted.

If the tumor is on my ovary, why does the doctor want to perform a hysterectomy?

OK, you’re told there is an ovarian growth that needs to be removed. That makes sense. “But why in the world does he want to remove my uterus, and why does he need to remove the other ovary?” Ovarian cancer can spread to the uterus and may also involve the other ovary. If it is obvious that your tumor is malignant (either by appearance at surgery, or on “frozen section”), the uterus and other ovary should be removed. If you still desire childbearing and the cancer appears to be confined to one ovary, the uterus and opposite ovary are sometimes preserved. However, a second operation is usually recommended after you have completed your family to have the uterus and other ovary removed. If you are beyond menopause, your doctor may recommend removal of your uterus and other ovary even if he feels that the tumor is benign. Until your tumor is analyzed, you can’t be sure that there is no cancer. If the tumor appears benign, but is found to be malignant on further evaluation, a second operation would be required. Removal of the uterus and opposite ovary also eliminates them from developing benign or malignant tumors in the future. If both ovaries are removed in a premenopausal woman, hormone replacement can be temporarily given in order to prevent premature menopausal symptoms.

Ovarian cancer surgery also entails removal of the omentum. The omentum is a fatty drape that lies over your intestines. It can be safely removed without any repercussions and is a frequent site for metastasis (spread of cancer cells). Your doctor should also take biopsies throughout the abdomen and sample lymph nodes to see if there has been any spread of the cancer. Your doctor may consult a gynecologic oncologist for this more extensive surgery. If the cancer has spread to involve your bowel, he may have to resect a section of the bowel to optimize your chances of doing well after the surgery.

The doctor says all the cancer was removed. Why does he want to give me chemotherapy?

Even when all of the gross tumor (tumor your doctor can see) is removed, there are microscopic cancer cells that remain in the pelvic and abdominal areas. If these are not treated, your cancer will definitely recur. In certain situations, radiation will be used to treat the remaining cancer cells. However, for most types of ovarian cancer, chemotherapy is more effective. If there is no evidence of your cancer progressing beyond the ovary, chemotherapy may not be necessary. Unfortunately, only 25% of ovarian cancers are confined to the ovary when first diagnosed. Most women with ovarian cancer will need chemotherapy in addition to their surgery.

I know people who had chemotherapy and died anyway, so why should I take chemotherapy?

The success of chemotherapy is predicated upon many factors. Not all types of cancers are sensitive to chemotherapy. Fortunately, most ovarian cancers respond well to chemotherapy. Therefore, you can’t compare someone else’s situation to your own. Your response to chemotherapy depends on the following factors:
• The extent of your cancer when it is first discovered -- if the cancer is limited, your chances of success with chemotherapy are better than if the cancer is widespread.
• The type of ovarian cancer -- some varieties of ovarian cancer respond better to chemotherapy than others.
• The grade of your cancer -- cancers with a very atypical, or bizarre microscopic appearance (higher grade) have a poorer prognosis.
• The success of your surgery -- If all of the visible tumor can be resected at surgery, your chances are better than if tumor is left behind.
If your doctor can successfully resect all the visible cancer at the time of surgery, your chances of surviving at least 5 years after chemotherapy is 50% (referred to as the 5 yr. survival rate). The benefit of chemotherapy in this situation clearly outweighs any risks associated with its use. If the cancer was initially confined to the ovary, your 5 year survival can be as high as 90%.

As the extent of the cancer increases, your chances of survival decrease. If your cancer cannot be optimally resected at the time of surgery, your chance of surviving to 5 years is very low (under 10%). In this situation you must weigh the benefit of chemotherapy extending your life against the side effects you will experience with the chemotherapy. Most patients will begin chemotherapy to see if their cancer responds (noted by a decrease in the size of the tumor when followed by scans). If the tumor shrinks and the side effects from the chemotherapy are tolerable, it is continued. If there is no response or the chemotherapy is not tolerated well, it is discontinued.
Chemotherapy is not always recommended with ovarian cancer. If your cancer appears to be very early and confined to the ovary, chemotherapy may not be recommended. Other types of tumors referred to as “borderline” have a good prognosis without chemotherapy. Some types of ovarian cancer are more successfully treated with radiation. Each case of cancer is unique. Openly discuss the pros and cons of recommended treatments so that you can make an informed decision. Ask your doctor to be honest with you regarding your prognosis. If you have trouble getting information, consult a gynecologic oncologist.

Will I get sick from the chemotherapy?

Side effects from chemotherapy vary depending on what agent is used. Probably the most common side effects from chemotherapy are nausea, vomiting, decreased appetite, change in bowel function, fatigue, and hair loss. Nowadays, patients are pre-medicated to limit some of the side effects.

Most chemotherapeutic agents suppress your bone marrow. This can lead to anemia, poor blood clotting, and an increased susceptibility to infections. Your blood counts are monitored very closely during chemotherapy, and sometimes special drugs are administered to boost the bone marrow.

In addition to those effects mentioned above, each chemotherapeutic drug has its own unique profile of toxicity. Chemotherapy is administered by doctors who specialize in this area (usually either a gynecologic oncologist or medical oncologist). The doctor will review possible side effects from any chemotherapeutic drug that is recommended.

How long will I get chemotherapy?

Duration of chemotherapy ranges from 4-12 months. It is given in cycles, with most patients receiving 6-9 cycles. Each cycle is 3 weeks. You are given the chemotherapeutic agents either as an outpatient or during a very short hospitalization. The following three weeks allow your body to recover from the effects of the drugs. Throughout the course of therapy, your response to the chemotherapy will be monitored using scans. The CA-125 level (and possibly a new tumor marker HE4), will also be followed if it was elevated when your cancer was initially diagnosed. Tumor markers should decrease with successful treatment, and they tend to rise again if there is a recurrence.

Sometimes chemotherapy is injected directly into the abdominal cavity through a catheter. Higher concentrations of chemotherapy reach the cancer when it is placed directly into the abdomen, but side effects from treatment may be more severe than chemotherapy given intravenously.

Occasionally, very large cancers, or cancers that appear to have extensive spread within the abdomen, may be treated with chemotherapy for several cycles before surgery. The hope in this situation is that the cancer will shrink to a point that makes surgery more successful.

The doctor says he wants to look inside me again after the chemotherapy. Why?

This is referred to as a second-look operation. It is the most accurate method of assessing whether any cancer remains after your chemotherapy. CT scans can detect bulky tumor, but rarely will identify small tumor nodules. Laparoscopy does a better job than scans of detecting persistent or recurrent tumor but some areas in the abdomen are not inaccessible with this procedure. In the past, doctors would perform second look procedures in order to decide whether more chemotherapy was indicated.

There is much controversy regarding second-look operations. It is difficult to subject a patient to a second major operation unless the benefits are clear. Proponents of the procedure feel that it is the only reasonable method of determining if chemotherapy should be continued. However, ovarian cancer commonly recurs even when there is no evidence of persistent tumor during second-look surgery. Survival is poor in patients who have chemotherapy continued because of persistent tumor found on second-look. Therefore, it is not clear that substantial benefit is to be gained from second-look surgery. With the advent of newer scans (ex. PET scan) and tumor markers (HE4) and the lack of a clear survival advantage, initial enthusiasm for second look procedures has waned.

Can I be cured, or will my cancer come back?

You have a good chance of a “cure” if the cancer is confined to the ovary when it is discovered. Unfortunately, early ovarian cancer is usually assymptomatic. It doesn’t take long for tumor cells to slough off the ovary and implant elsewhere in the pelvis and abdomen. Tumor masses evolve from the implants and are often present at the time of initial diagnosis. Most women treated at this stage will eventually have a recurrence of their cancer. However, many will have prolonged disease free intervals.
If you develop a recurrence after a disease free period, reoperation and/or additional chemotherapy may be recommended. If the cancer responded well to chemotherapy previously, it may do so again, placing you in remission.

For more information on ovarian cancer:

National Cancer Institute

American Cancer Society