Post-menopausal ovarian cysts
Ovarian cysts
An ovarian cyst is a fluid-filled sac which forms in or on the ovaries. Cysts are usually 1-2cm wide but can be bigger. They are more commonly diagnosed before menopause but are becoming more frequently diagnosed in post-menopausal patients, often incidentally when patients are being investigated for another condition. Studies suggest that ovarian cysts can affect 5-17% of post-menopausal people. Most ovarian cysts in post-menopausal patients are benign, though they can cause worry for patients.
Your medical team will ask questions about your symptoms, personal medical history and family history. Of relevance is any family history regarding ovarian, breast, bowel, stomach, urinary tract, endometrial (lining of the womb) cancers, and if you or any close relatives are known to carry BRCA gene mutations.
Symptoms of ovarian cysts
Ovarian cysts can be asymptomatic but in patients who do report symptoms, these are common:
- Dull ache or pain in the lower abdomen/back
- Pressure, bloating, swelling in the lower abdomen
- Pain during intercourse
- Weight gain
- Feeling full or loss of appetite
- Needing to urinate more frequently, or with new urgency
Sometimes cysts can rupture or twist, which can cause acute abdominal pain, sometimes associated with nausea, vomiting, dizziness or feeling faint.
Investigations
If you are diagnosed with an ovarian cyst in the post-menopausal period, the medical team will organise some investigations to help determine which cysts are benign and less cause to worry, and which cysts might be cancerous and require further investigation or management.
Common tests for ovarian cysts include:
- Imaging tests – the most common kind is a pelvic ultrasound. This test uses sound waves to make a picture of your uterus and ovaries. The pictures can show if you have cysts. If can also show where they are and how big they are. Your doctor may also recommend an MRI or a CT scan.
- Blood tests (tumour markers) to check the possibility of cancer. This is called CA125 and can be raised in other conditions, so it is important to discuss the results with your doctor.
Your medical team then calculate the risk of your ovarian cyst being cancerous using the results of these investigations and discuss them in a multi-disciplinary team meeting with radiologists and pathologists before discussing management options with you.
Management of ovarian cysts
Conservative management
Sometimes called ‘watchful waiting’ – this means no immediate action and usually a repeat evaluation in 4-6 months with repeat investigations.
This is appropriate when the ultrasound shows a small cyst (<5cm) without concerning features and the CA125 blood test is normal, and when patients do not have any significant symptoms associated with the cyst. In this situation, there is a very low risk of ovarian cancer and cysts can often resolve spontaneously.
If after 1 year the cyst has not increased in size and blood tests remain normal, patients can be discharged from further follow-up.
At 2 years, patients with asymptomatic cysts were shown to:
- Disappear (53%)
- Remain static in size (28%)
- Enlarge (11%)
- Decrease (3%)
- Fluctuate in size (6%)
Laparoscopy (keyhole surgery)
Laparoscopy is minimal-access surgery which might be an option for patients who have symptoms associated with an ovarian cyst. You might be offered a laparoscopic salpingo-oopherectomy, which is removal of the affected ovary and fallopian tube. Guidance suggests bilateral surgery to be more beneficial to reduce risk of cancer, but this can be discussed with your doctor.
Guidance suggests removal of the entire ovary and tube is safer than removal of just the cyst in the post-menopausal period.
Laparotomy
This is open surgery reserved for patients who are at high risk of ovarian cancer after further investigation. These patients will usually be referred to a gynaecology cancer centre for this procedure.
Aspiration
Aspiration of an ovarian cyst (an injection to remove some of the fluid inside the cyst) is not usually recommended for definitive management but is sometimes considered for symptomatic relief in patients who are unable to undergo surgery for various reasons.
Further information
NHS Ovarian Cyst: https://www.nhs.uk/conditions/ovarian-cyst/
Up-to-date Patient education: Ovarian cysts (Beyond the Basics): https://www.uptodate.com/contents/ovarian-cysts-beyond-the-basics/print