Treatment of Ovarian Cysts: For Rural Patients

What are ovarian cysts?

Ovarian cysts are fluid-filled sacs that develop in the ovaries. Women have two ovaries, and one of them produces an egg every month. The egg is enclosed in a sac with fluid, and the sac is called a follicle. At the appropriate time, the egg is released when the follicle ruptures. The egg then travels down to the uterus, and it is expelled if it is not fertilized.

simple ovarian cystSometimes, the follicle fails to rupture, and the fluid remains, which is called a functional cyst. They are covered by a very thin wall. These small cysts rupture and release the contents into the peritoneal cavity. In ultrasounds, these small cysts are seen like bubbles. These cysts are not abnormal, however, sometimes they might not rupture and can become large. Rarely, cancers and other conditions cause the ovarian cysts.

What are the types of ovarian cysts?

The following are the types of commonly seen ovarian cysts (1).

  1. Follicular cyst: As mentioned earlier, this is a simple cyst that is present at the time of ovulation. It can grow up to 2 inches, and its rupture can cause sudden, sharp pain. It occurs when an egg is not released into the follicle or gets destroyed in the follicle.
  2. Corpus Luteum cyst: This is also a functional cyst. After releasing the egg, the cyst remains instead of breaking down and disappearing. It can contain fluid or blood. It is called a hemorrhagic cyst if it contains blood, and this can be painful.
  3. Dermoid cyst: These are benign tumours. In other words, they are tumours that are not cancers. They are aberrations of normal tissue or developmental abnormalities, and they tend to occur in younger women. They contain various parts of the body like hair, fat, bone, cartilage, etc.
  4. Endometrial cyst: These are endometrial tissue (the inner lining of uterus) occurring in ectopic sites, meaning sites where they are not supposed to be. They also act like normal endometrial tissue with menstruation, and hence contain altered blood in them. Ovaries are a common site, but they can occur anywhere in the pelvis. These are sometimes called chocolate cysts.
  5. Polycystic ovaries: They contain many cysts in the ovaries. They are also associated with other abnormalities like obesity, insulin resistance, infertility, etc.
  6. Cystadenoma: These are again benign or non-cancerous cysts that contain thick mucus-like secretions.
  7. Ovarian cancers: They can also have a cystic appearance. However, 99% of the cysts are not cancers.

What are the symptoms of ovarian cysts?

Ovarian cysts are often asymptomatic and are diagnosed by ultrasound examination. Ultrasound examinations are carried out for lower abdominal pain, menstrual irregularities and for infertility. However, when complications occur, the cysts are associated with nausea, vomiting, severe lower abdominal pain, etc. If the cysts are very large, they can cause bloating, indigestion, incomplete defecation, etc. Urgency and increased frequency of voiding could be present too (2).

How are ovarian cysts diagnosed?

As mentioned earlier, the most common mode of diagnosis is ultrasound examination. Sometimes with huge ovarian cysts in thin women, just clinical examination is sufficient to diagnose it. In urban centers, a blood test like CA–125 could be carried out, to rule out malignancy. However, they are not very sensitive or specific and are not necessary in rural areas.

What should be done with ovarian cysts?

The answer to this depends on several factors. About 60 percent of the cysts that are less than 4 cm in size disappear within 12 weeks (3). In premenopausal women with a cyst less than 4 cm in size, all that is required is watchful waiting.

Single incision gasless laparoscopic surgery for ovarian cystThe risk of complications increases significantly when the size is greater than 6 cm (4). Risk of torsion is about 17% for cysts greater than 4 cm in size. Hence, with the advent of minimally invasive surgeries, especially the single incision gasless laparoscopic surgeries (6), it is easier to offer surgical treatment for cysts greater than 4 cm, especially if they are symptomatic. In women who need more children, it is possible to leave behind some ovarian tissue, thanks to the modern energy sources.

Even very large ovarian cysts could be removed with single incision surgeries, after removing the fluid from the cyst. Larger dermoid cysts might be difficult to remove through the single umbilical incision, and these could be removed through the posterior fornix (vaginal route).

In the rare event of the cyst being malignant, extensive surgery is required to entirely remove the ovaries, tubes, uterus and the surrounding fatty tissue (omentum). Chemotherapy might be required, too.

What are the options available at SEESHA medical services?

A variety of treatment options are available at the SEESHA Karunya community hospital at Karunya Nagar Coimbatore and at the SEESHA surgical camps at Bethesda Hospital Aizawl, Sielmat Christian Hospital at Churachandpur at Manipur, Family Health Hospital at Dimapur and the other places.

The single incision gasless laparoscopic surgeries are available in all the places with modern energy sources, so that preservation of ovarian tissue is possible. Extensive surgeries for malignancies and chemotherapy are also available at these places.

gnanaraj Dr. J. Gnanaraj MS, MCh [Urology], FICS, FARSI, FIAGES is a urologist and laparoscopic surgeon trained at CMC Vellore. He has been appointed as a Professor in the Electronics and Instrumentation Engineering Department of Karunya University and is the Director of Medical Services of the charitable organization SEESHA. He has a special interest in rural surgery and has trained many surgeons in remote rural areas while working in the mission hospitals in rural India. He has helped 21 rural hospitals start minimally invasive surgeries. He has more than 150 publications in national and international journals, most of which are related to modifications necessary for rural surgical practice. He received the Barker Memorial award from the Tropical Doctor for the work regarding surgical camps in rural areas. He is also the recipient of the Innovations award of Emmanuel Hospital Association for health insurance programs in remote areas and the Antia Finseth innovation award for Single incision Gas less laparoscopic surgeries. During the past year, he has been training surgeons in innovative gas less single incision laparoscopic surgeries.

References (click to show/hide)

  1. Available from: http://www.karunya.edu/krch/ovarian_cysts.php
  2. Available from: http://www.medicinenet.com/ovarian_cysts/page3.htm
  3. Available from: http://www.netdoctor.co.uk/diseases/facts/ovariancysts.htm
  4. Bottomley C, Bourne T. Diagnosis and management of ovarian cyst accidents. Best Pract Res Clin Obstet Gynaecol. 2009;23 (5): 711-24.
  5. Available from: https://en.wikipedia.org/wiki/Ovarian_cyst
  6. Available from: http://mdcurrent.in/primary-care/low-cost-laparoscopic-surgeries-taking-modern-surgery-poor/

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