Ovarian cyst pain is an unpleasant symptom and fairly common.
Women who have recently been diagnosed with an ovarian cyst and are having symptoms from it can be reassured that these are usually easy to treat.
Other women may be suffering from pelvic pain and may be worried about the possibility of an ovarian cyst or other condition?
This article aims to cover ovarian cyst pain and symptoms in detail.
To start with – How common are ovarian cysts?
They are extremely common in premenopausal women. Among functional cysts, follicular cysts are the most common type, and small cystic follicles are found in virtually all premenopausal ovaries. Studies of women over 55 years (postmenopausal women) estimate the incidence of ovarian cysts in this age group to be about 14%.
Ovarian cyst pain
Not all ovarian cysts cause symptoms. It is common for a woman to have an ovarian cyst and not be aware of its presence. Ovarian cysts are often discovered during routine pelvic examinations or during an ultrasound scan carried out for another reason.
Ovarian cysts can cause different types and levels of pain. They may cause any severity of hurt from very mild discomfort through to severe agonising pain.
If you have a simple ovarian cyst it may only cause a mild discomfort as it enlarges in size. Then it will cause a heaviness or sensation of discomfort in the pelvis. This may be on one side or may be felt in the middle if the cysts grows large enough.
At the other extreme, if you are unlucky enough to experience torsion of an ovarian cyst, then you are likely to experience very severe acute pain. Torsion of an ovarian cyst means that the ovarian cyst has twisted and the blood supply to the cyst and that portion of the ovary has been reduced or cut off. This results in severe pain.
Severe pain can also occur if there is bleeding into an ovarian cyst. If this happens then the result is usually severe pain on one side of the lower pelvic region.
If an ovarian cyst ruptures this usually leads to sudden onset severe pelvic pain.
Women who have a torsion of an ovarian cyst, bleeding into a cyst or rupture of a cyst often get such severe symptoms that they see a doctor urgently and are usually admitted to hospital as an emergency.
For women with less severe long term pain or symptoms from an ovarian cyst, the symptoms tend to be related to the size and position of the ovarian cyst.
A very large ovarian cyst or cysts will cause discomfort due to their size. The symptoms will often be worsened by moving around or prolonged standing. There may be a sensation of fullness and the lower abdomen may appear swollen and bloated. In extreme cases a women will be able to feel a mass in her lower abdomen – often this is felt in the middle when a cyst is very large.
Some women describe being able to feel the cyst when lying flat on their stomach.
Pelvic pain is the commonest symptom. Usually this on one side of the pelvic cavity.
If the ovarian cyst presses on other organs in the pelvis it can cause other symptoms such as:
- Constipation – because of pressure on the large intestine.
- The need to pass urine frequently – due to the ovarian cyst pressing on the bladder. Sometimes it can be difficult to empty the bladder completely.
- Indigestion or heartburn – due to pressure on the stomach. A large cyst may cause a woman to feel full up after eating.
- Irritable bowel syndrome – again due to pressure on the intestine or colon.
- Low back pain – due to pressure on the lower back. Some women may experience a dull ache in their thighs.
The ovarian cyst pain may vary in frequency and intensity with the menstrual cycle. The pain is often worse during a period.
Having ovarian cysts may affect the regularity of your periods. Periods may become heavier or even lighter. They may be less frequent or more frequent. This happens because of hormonal changes that are associated with ovarian cysts.
An ovarian cyst may cause discomfort or pain during sexual intercourse. This is known as dyspareunia. It is usually deep dyspareunia and present on one side, though the pain may be also at times felt in the middle of the pelvis. >
Weight gain may be a symptom if an ovarian cyst grows very large, but this is unusual.
A large ovarian cyst may cause the vague symptom of bloating or abdominal distension. This can develop very gradually and in middle aged or elderly women should be taken seriously as it may be the only symptom of an ovarian cyst which is cancerous. Ovarian cancer is sometimes referred to as the silent killer by doctors because symptoms are often not present until the cancerous cyst grows very large and then the only symptom is often one of mild bloating or abdominal distension.
Other symptoms of ovarian cysts include dizzyness, a sensation of feeling light headed, and even tiredness which in some cases may be an extreme tiredness or exhaustion.
Breast tenderness may occur due to hormonal changes.
Symptoms that require urgent medical attention: Severe pain, pain that is associated with fever and vomiting, faintness, weakness, dizzyness and/or rapid breathing.
Types of pain from an ovarian cyst
The pain may be dull or sharp, constant or intermittent.
How to relieve the pain from an ovarian cyst
If you have severe pain then consult a doctor immediately.
If you are experiencing pain from an ovarian cyst, the quickest way to obtain relief is by taking painkillers. Start with over the counter analgesics such as acetaminophen (Tylenol - US) (paracetamol in the UK) or ibuprofen (Nurofen, Advil). These are effective for mild to moderate pain. For more severe pain stronger painkillers, requiring a doctor's prescription, are needed. These include stronger NSAIDS like diclofenac (Voltaol, Voltaren), mefenamic acid (Ponstan) and naproxen (Naprosyn) or opiates such as codeine, dihydrocodeine, pethidine or morphine. Opiates can be taken in addition to acetaminophen - examples of medications which contain an opiate and acetaminophen (paracetamol) include: cocodamol, codydramol, Vicodin and Darvocet.
There are other ways of relieving pain from ovarian cysts. These include: Gentle therapeutic massage, the careful use of thermal heat pads, or ice-packs to the site of the pain, poultices, TENS machines, acupuncture, and hypnosis.
What are ovarian cysts?
An ovarian cyst is fluid filled sac that arises in an ovary. They can vary in size from the size of a pea to the size of a very large melon. They may be single or multiple. They can occur in women of all ages. They are usually benign (harmless) but can be cancerous (malignant). If benign and simple, they often disappear without treatment. If large, troublesome or if cancer is suspected they are removed surgically. They are very common. They are most frequent between the years from menarche to the menopause (the childbearing years). They are most likely to be cancerous in older women, particularly post-menopausal women.
Types of ovarian cyst
Doctors divide ovarian cysts into functional and non-functional types. In terms of frequency, functional ovarian cysts account for about 24% of all ovarian cysts, benign cysts 70% and malignant cysts 6%
Functional ovarian cysts
Functional cysts form as a normal part of the menstrual cycle. Such cysts may include:
Follicular cyst. These are the most common type. During the menstrual cycle, a follicle containing the unfertilized egg (ovum) ruptures and releases the egg at the time of ovulation. If this does not occur, a follicular cyst of more than 2.5 cm diameter may form.
Corpus luteum cysts appear after ovulation. The corpus luteum is the remnant of the follicle after the ovum has been released and moved to the fallopian tube. This normally degrades within 5–9 days. A corpus lutem that is more than 3 cm is defined as cystic.
Thecal cysts occur within the thecal layer of cells surrounding developing oocytes. Under the influence of excessive hCG, thecal cells may proliferate and become cystic. This is usually happens to both ovaries.
Non functional ovarian cysts
Non functional cysts are usually benign, but they can be malignant (cancerous). An ovary with many cysts, which may be found in normal women, or within the setting of polycystic ovarian syndrome (PCOS).
Polycystic ovarian syndrome
PCOS is a specific situation in which multiple cystic follicles are present in the ovaries is the PCOS (also known as Stein–Leventhal syndrome). The clinical syndrome comprises oligomenorrhoea, infertility, hirsutism and obesity. From an endocrine point of view, there is disordered secretion of LH and FSH, leading to ovulation failure. The ovaries become enlarged and contain multiple cystic follicles. The capsule of the ovary is thickened, and there are usually no stigmata of ovulation, i.e. corpora lutea and corpora albicantes are absent.
Endometrial ovarian cysts
Cysts caused by endometriosis in an ovary, these are often called chocolate cysts.
Haemorrrhagic ovarian cyst
This is where bleeding has occurred inside the cyst in the ovary. When the bleeding happens this can lead to severe ovarian cyst pain.
Ovarian serous cystadenoma
This type of cyst can develops papillary growths which may be so numerous that the cyst can appear to be solid in nature on a scan. Ovarian serous cystadenomas are most common in women aged between 40-50 years. About 15-25% are present in both ovaries and about 20-25% are cancerous.
Ovarian mucinous cystadenoma
These are most common large ovarian tumours which may become extremely large. These cysts are filled with mucinous material and they may rupture may leading to a condition known as pseudomyxoma peritonei. They may be multilocular. They are most common in women aged beteween 20-40 years. About 5-10% occur on both sides and approximately 5% are malignant.
Benign neoplastic cystic tumours of germ cell origin
- Benign cystic teratoma; rarely malignant. They arise from primitive germ cells. A benign mature teratoma (dermoid cyst) may contain well-differentiated tissue, e.g. hair, teeth. 20% occur on both sides. They are most common in young women.
- Poorly differentiated, malignant teratomas are rare.
Benign neoplastic solid tumours
- Fibroma (less than 1% are malignant); small, solid benign fibrous tissue tumours. They are associated with Meigs' syndrome and ascites (fluid in the abdominal cavity).
- Thecoma (less than 1% are malignant).
- Brenner's tumour: These are rare ovarian tumours displaying benign, borderline or proliferative, and malignant variants. Over 95% are benign and more than 90% are present on one side only (unilateral). They may be associated with mucinous cystadenoma and cystic teratoma.
These are also known as paratubal cysts. They are epithelium-lined fluid-filled cysts in the adnexa adjacent to the fallopian tube and ovary. Paraovarian cysts have been found in women of all ages but seem to be most common in the third to fifth decades of life. An Italian study estimated their incidence to be about 3%. Most paratubal cysts are small and asymptomatic. Typical sizes reported in medical studies are 1 to 8 cm in diameter. Larger paraovarian lesions may reach 20 or more cm in diameter and become symptomatic exerting pressure and leading to pain symptoms in the lower abdomen. Large cysts may undergo torsion of the adnexa inflicting acute pain. Prior to surgery, paratubal cysts are usually visualised during an ultrasound scan. However, because of the close proximity of the ovary that may contain follicle cysts, it may be difficult to identify a cyst as paratubal or paraovarian. Paraovarian cystsare usually benign, but may very rarely become cancerous.
Most ovarian cysts are symptomless and are often only diagnosed by chance, during a routine pelvic examination or ultrasound scan. If you have symptoms such as pelvic pain then an ovarian cyst may be diagnosed during the tests which are performed as part of the investigation of this pain. It is then a matter of trying to decide whether this cyst is the cause of the symptoms or whether it is just an incidental finding and the pelvic pain has another cause such as endometriosis or irritable bowel syndrome.
An ultrasound scan is the best primary investigation for ovarian cysts. It is simple to perform and provides useful information such as the size, position, number and nature (characteristics) of the cyst. It is important to see whether the lesion is fluid filled, solid or a mixture of fluid filled and solid. A simple fluid filled cyst is usually a follicular cyst and is always benign. Malignant ovarian cysts appear as mixed solid and fluid filled cysts or as solid tumours.
Other tests that the doctor may carry out include:
A positive pregnancy test may mean that the cyst is a corpus luteum cyst. These form when the follicle that released the ovum closes and fills with fluid. They are harmless and nearly always disappear spontaneously in about 3 months.
CA 125 blood test. This is a protein antigen the levels of which are often raised in ovarian cancer. If you have a mixed or solid ovarian cyst the doctor may arrange for this test. If the level is high it does not definitely mean ovarian cancer, because other conditions may cause the level of CA 125 to be elevated. These conditions include: endometriosis, pelvic inflammatory disease, uterine fibroids, ascites, and pregnancy – there are many causes of a raised CA 125.
As part of the investigation of the doctor will usually request routine blood tests such as a blood count, liver function tests, tests of kidney function, an ESR and CRP.
A CT scan (CAT scan) involves taking x-ray images as slices through the body. These are then analysed by a computer and detailed images are produced the the organs within the body. A CT scan provides more detailed information about an ovarian lesion than a plain x-ray, and is often arranged in addition to an ultrasound scan to provide more information about a cyst in an ovary.
A MRI scan uses radio waves and strong magnetic fields to produce detailed images of the organs within the body. It does not involve x-rays. An MRI is used as an additional investigation to obtain more detailed pictures and information about an ovarian cyst.
A laparoscopy is a type of key-hole surgery. Small incisions are made in the adbominal wall and a thin tube is inserted into the abdominal and pelvic cavities. Air is gently pumped into the abdomen to separate the organs and improve the view. During a laparoscopic procedure the cyst in the ovary can be viewed directly and removed if necessary. Tissue samples (biopsies) can be taken from suspicious or worrying tumours.
The advantages of a laparoscopy are the fact that a definite diagnosis can be made and the ovarian cyst can be removed at the same time.
A lapaotomy involves a larger incision in the abdominal wall and an open surgical procedure. If the cyst is large, or the gynaecologist concerned that the ovarian cyst is cancerous, then a laparotomy may be a advised. The cyst can be removed during a laparotomy. The cyst is then sent for histological examination by a pathologist.
Histology involves examining the removed cyst or piece of tissue (biopsy) under a microscope by a pathologist. This enables the cells to be examined and a definite diagnosis of the type of cyst to be made. It is then possible to decide whether the ovarian cyst is benign or malignant (cancerous).
It is reassuring to know that most ovarian cysts disappear on their own in 1-3 months without treatment and that most ovarian cysts are benign (not cancerous).
Treatment depends on the type of ovarian cyst (based on the doctors assessment with scans), on the symptoms, on the size of the cyst, and whether you are pre or post-menopausal. Simple functional cysts such as follicular cysts and corpus luteum cysts, usually need no treatment other than watchful waiting. These simple ovarian cysts usually go away after 3 months.
Complex cysts need urgent assessment and if cancer is suspected, they require urgent treatment. Your doctor will be able to decide which type of cyst you have from initial investigations, such as the ultrasound scan.
Treatment of functional cysts
If a functional cyst such as a follicular cyst does not go away after a period of watchful waiting, then is treatment needed? Only if the cyst is causing symptoms or there is are complications or cause for concern. If the cyst is causing pain then it can be removed surgically via a laparoscope (unless the cyst is very large).
Treatment of non-functional ovarian cysts
If an ovarian cyst appears complex (a mixture of solid and liquid on a scan) or is solid, then further urgent assessment is needed. The next step is to perform surgery to remove the cyst and examine it to work out if it is cancerous or not. This can only be done by examining the tissue of the cyst under a microscope.
If you have ovarian cyst pain, then please be reassured that this is a treatable problem.