Ovarian Cysts: Symptoms, Treatment, and When Surgery Is Needed

An ovarian cyst is a fluid-filled or mixed-content sac that develops within or on the surface of the ovary. Most women of reproductive age experience at least one ovarian cyst during their lifetime. The great majority of cysts are benign and resolve on their own; a smaller proportion require follow-up or surgical treatment. This guide reviews the different types of cysts, their symptoms, and how treatment decisions are made.

Types of ovarian cyst

1. Functional (simple) cysts

The most common type; these form as part of the menstrual cycle. They are usually smaller than 5 cm, unilocular, and contain clear fluid. Most resolve spontaneously within 1–3 menstrual cycles.

• Follicular cyst: forms when a follicle continues to grow because ovulation has not occurred.
• Corpus luteum cyst: develops when fluid accumulates in the corpus luteum after ovulation; may also be seen in early pregnancy.

2. Endometrioma (chocolate cyst)

Forms when tissue similar to the uterine lining implants in the ovary in the setting of endometriosis. Because the cyst contains old blood, its content is dark brown. It is associated with chronic pelvic pain, painful periods, painful intercourse, and infertility.

3. Dermoid cyst (teratoma)

Arises from congenital embryonic cells and may contain hair, teeth, fat, and skin tissue. It is generally benign, but as it enlarges the risk of rupture or ovarian torsion increases; surgical removal is therefore recommended.

4. Cystadenomas (serous / mucinous)

Benign tumours that develop from the outer surface of the ovary and can occasionally reach large sizes. Surgical removal is usually indicated.

5. Polycystic ovary syndrome (PCOS)

Not truly a "cyst" in the classical sense. Ultrasound shows numerous small follicles (2–9 mm) in both ovaries. PCOS is a hormonal syndrome accompanied by irregular menses, hirsutism, acne, weight gain, and insulin resistance, and requires a distinct management approach.

6. Complex or suspicious cysts

A cyst is classified as "complex" when ultrasound reveals solid components, thick septations, irregular walls, increased blood flow, or free peritoneal fluid. These cysts require more detailed evaluation for malignancy — MRI, tumour markers, and gynaecologic oncology consultation.

Symptoms

Most cysts are asymptomatic and are discovered incidentally on routine ultrasound. When symptomatic, the most common presentations are:

• Unilateral, dull or sharp pelvic pain
• Menstrual irregularities, premenstrual spotting
• Painful periods (dysmenorrhoea) and painful intercourse (particularly with endometrioma)
• Abdominal bloating, sense of fullness
• Urinary frequency or bowel pressure (with large cysts)
• Infertility (especially endometrioma and PCOS)

How is the diagnosis made?

• Transvaginal ultrasound: the gold standard; evaluates size, structure, uni- or multilocular architecture, and vascularity.
• Tumour markers: CA-125, HE4, CEA, AFP, hCG, LDH — selected according to age and cyst type. CA-125 can be elevated in endometrioma and some benign conditions and is not diagnostic on its own.
• MRI: provides a clearer view when ultrasound is inconclusive in complex cysts.
• Hormone testing: particularly when PCOS or irregular menses is suspected.

When is observation sufficient?

Cysts with the following characteristics are typically observed:

• Simple functional cysts under 5 cm
• Cysts in premenopausal women that shrink or resolve on post-menstrual follow-up ultrasound
• Normal tumour markers, no pain, no increased vascularity

Follow-up is generally performed with ultrasound every 6–12 weeks. Most functional cysts resolve within this period.

Treatment options

1. Medical therapy

Combined oral contraceptives can prevent the formation of new functional cysts but do not "dissolve" an existing cyst. In endometriosis and PCOS, hormonal therapies are used to control pain and regulate the cycle. Simple analgesics (paracetamol; NSAIDs outside pregnancy) can help with pain.

2. Surgical treatment

The modern standard is laparoscopy (keyhole surgery). It is performed through small incisions with rapid recovery and an excellent cosmetic result. Robotic surgery may be offered as an option. Open surgery (laparotomy) is reserved for very large or malignancy-suspicious cysts.

Surgical options:

• Cystectomy: removal of the cyst while preserving ovarian tissue — preferred in reproductive-age women.
• Oophorectomy: removal of the ovary — usually after menopause or when malignancy is suspected.
• Salpingo-oophorectomy: removal of the ovary and fallopian tube together.

When is surgery necessary?

Are ovarian cysts cancer?

In women of reproductive age, more than 90% of ovarian cysts are benign. The risk of ovarian cancer rises with postmenopausal status, complex morphology, rapid growth, and elevated CA-125. Women with a family history of ovarian or breast cancer may require BRCA1/BRCA2 genetic assessment.

Do cysts recur?

Recurrence of functional cysts is normal and generally not clinically significant. Endometrioma has a 20–30% recurrence rate within five years; for this reason, postoperative hormonal therapy and regular follow-up are recommended. Dermoid cysts rarely recur in the same location, but occur in the contralateral ovary in about 10% of patients.

Frequently asked questions

Do ovarian cysts prevent pregnancy?

Most small functional cysts do not interfere with conception. However, endometrioma, large dermoid cysts, and PCOS can reduce fertility. If infertility is suspected, a detailed evaluation should be performed.

Does cystectomy reduce ovarian reserve?

Surgical technique is decisive. In experienced hands, limited use of cautery during cystectomy keeps the loss of ovarian reserve to a minimum. A slight decrease in AMH (ovarian reserve) may be seen after endometrioma surgery; individualised decision-making is therefore essential in patients wishing to conceive.

Does the contraceptive pill dissolve a cyst?

It does not dissolve an existing cyst, but it can prevent the formation of new functional cysts. Existing functional cysts usually resolve on their own.

How long does recovery take after surgery?

After laparoscopic cystectomy, most patients stay one night in hospital and return to daily activities within about one week. Heavy physical activity can usually be resumed in 2–4 weeks. Open surgery may require 4–6 weeks of recovery.

Ovarian cyst evaluation and laparoscopic surgery in Adana

When an ovarian cyst is diagnosed, the priorities are accurate classification and individualised decision-making: the same cyst may require completely different management depending on the patient's age, reproductive plans, and symptom profile. For ovarian cyst evaluation, laparoscopic gynaecologic surgery, and endometriosis treatment in Adana, you can consult Op. Dr. Sadık Kükrer.