Post-Menopausal Ovarian Cysts: A Guide by Dr. Anu Vij

Post-Menopausal 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 attain 7-10 cm dimensions as well. They are more commonly diagnosed before menopause, as they are related to menstrual cycle, 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; but risk of transformation to malignant is more in post -menopausal women. Family history of malignancies like ovarian, breast, bowel, stomach, urinary tract, endometrium, is important to elicit. Also if any close relatives are known to carry BRCA gene mutations.

Symptoms:

Ovarian cysts are usually asymptomatic but in patients who do report symptoms, these are common:

• • Dull ache or pain in the lower abdomen/back
• • Pressure, bloating, acidity, dyspepsia, 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 fain

Investigations are needed to determine which cysts are benign and hence less cause of 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. A trans vaginal US is always preferred to a trans abdominal US ; however a TAS gives additional and complimentary information in cases of very big sized cysts which are beyond the field-of-view of TVS. An MRI or a CT scan can be advised in certain select conditions.

Blood tests(tumor markers) to check the possibility of cancer. This is called CA125. It can also be raised in other medical conditions, so it is important to interpret the results with caution and keeping the whole clinical picture in mind.

Malignancy risk calculation is done by taking into account the age/ menopausal state of the woman, imaging scores and tumor marker levels.

Management of Ovarian Cysts:

When the cyst is small, <5cm, without features suggestive of malignancy and the CA125 blood test is normal, and when patients do not have any significant symptoms associated with the cyst, there is a very low risk of ovarian cancer and cysts can often resolve spontaneously.These patients are kept under ‘watchful expectancy’, this means no immediate action and usually a repeat evaluation in 4-6 months with repeat investigations.

If after 1 year the cyst has not increased in size and blood tests remain normal, patients can be called for annual check- ups.

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.Evidence suggests removal of the entire ovary and tube is safer than removal of just the cyst in the post-menopausal period.Evidence suggests bilateral surgery to be more beneficial to reduce risk of cancer.

Laparotomy

This is open surgery reserved for patients who are at high risk of ovarian cancer after further investigation.

Aspiration

Aspiration of an ovarian cyst (putting in a needle and suction removal of some of the fluid inside the cyst) is not usually recommended for definitive management but is sometimes considered for temporary symptomatic relief in patients who are unable to undergo surgery for various reasons.