Ovarian cysts and emergency surgery

Occasionally a patient interested in coming to me for surgery would contact us and tell us that an ovarian cyst had formed and that they required emergency surgery because of the cyst. Is an ovarian cyst ever an emergency? Rarely.

There are only two situations demanding emergency surgery for an ovarian cyst:

  1. Hemorrhagic cyst with significant blood loss resulting in anemia;
  2. Severe unrelenting pain which can't be controlled with medicine.

Let's talk about these two situations a bit. The most common cause of significant hemorrhage from an ovarian cyst is a hemorrhagic corpus luteum cyst. The corpus luteum is a normal cystic structure that forms after ovulation each month. There is a physiologic in-growth of capillaries into the corpus luteum after several days, which sometimes is a bit excessive and which can rarely result in severe bleeding.

If a woman is taking birth control pills, ovulation shouldn't occur, so a hemorrhagic corpus luteum would be unlikely in that situation. I saw only a few cases of hemorrhage like this from a corpus luteum in my 30+ years of practice, so it is a rare event. The severity of symptoms and accompanying shock due to low blood pressure make the severity of the situation obvious to everyone. This can be a true emergency.

Severe unrelenting pain, sometimes accompanied by nausea and vomiting, off on one side or the other could be a symptom of an ovarian cyst, or could be due to something else like appendicitis or tubal pregnancy. Ovarian cysts rarely cause severe pain like this, although if an ovarian cyst twists, it can do so.

Leakage of the fluid contents of a cyst can sometimes cause pain that improves over the next few days, although if a cyst is filled with only clear fluid, not much pain might occur. Ultrasound examination can sometimes tell if a cyst is present and what type of fluid it might be filled with. If a cyst has truly been present and ruptures, ultrasound might be able to tell if the free fluid is bloody, filled with clots, or if it is greasy (as can occur with rupture of a dermoid cyst), or just clear like water. Sometimes the gynecologist can insert a needle through the rear wall of the vagina and retrieve some of the free fluid to see what its nature is. Severe or worsening pain uncontrolled by simple medicines is a reason to consider surgery.

Let's talk about ovarian cysts that do not need emergency surgery. This would include most cysts, since cysts can come and go just on the basis of normal ovarian function. Birth control pills do not make cysts go away, although many times they are prescribed for that purpose. Although birth control pills are supposed to keep the ovaries from ovulating, the low dose pills on the market do not always keep the ovaries totally suppressed, so the ovaries can sometimes form cysts even on the pill.

A cyst can't always be palpated on exam, and sometimes an ultrasound will be ordered to investigate pelvic pain further. A cyst as small as 1 centimeter in diameter can be seen on ultrasound. Since ovulation cysts can sometimes get to 2.5 to 3 centimeters in diameter, the presence of small cysts on ultrasound is common and may not be related to pain. A cyst size of over 6 centimeters is the arbitrary level at which surgery is frequently recommended since cysts of such a size may not go away on their own, although even large cysts don't always cause pain or undergo rupture.

Ultrasound can frequently suggest what type of a cyst is present and this might give an idea of whether it will go away or not. Endometriosis cysts can be suggested by ultrasound, but even the presence of a sizable cyst is not an emergency if it's not associated with severe pain or bleeding as discussed above. The cyst did not grow to a large size overnight and most endometrioma cysts don't rupture cataclysmically. They occasionally will leak slightly, then the cyst wall can re-seal. When they leak, they may cause pain for a few days, which then improves. Such leakage can occur every few months in some patients, sometimes only once in others. There is no evidence whatsoever that a leaking endometrioma cyst causes endometriosis to spread.

So, if you have a cyst which appears to be an endometrioma cyst, it is not an emergency to have surgery at once. In fact, this can sometimes be a bad idea since frequently other areas of disease in the pelvis are not treated because the presence of the cyst can result in tunnel vision on the part of the surgeon (looking only at the immediate issue).

In most cases, women thought to have even large endometrioma cysts can avoid emergency surgery and wait to schedule endometriosis surgery with an excision specialist unless severe pain or bleeding might be occurring. Even if ultrasound suggests a cancerous cyst, this is not an emergency, although this should obviously be handled in a timely manner.