Ovarian Problems:

Ovarian Problems:

Most women have two ovaries, one on each side of the womb. Ovaries are small egg-producing organs, about the size of almonds. The ovaries carry out a number of functions, including production of eggs and female sex hormones. Different problems can arise in each type of cell, in the production of each hormone, or sometimes in the egg itself. This online leaflet concentrates on the more common problems: polycystic ovaries and benign ovarian cysts. It does not give detailed information about ovarian cancer.

What do the ovaries do?

At birth our ovaries contain millions of unripe eggs, each held in a tiny fluid-filled sac or follicle. In adult life, one of these follicles matures each month, usually reaching a diameter of about two centimetres and then bursting to release its ripened egg into the fallopian tube. This is called ovulation. The fallopian tubes carry eggs from the ovaries into the womb.


The ovaries also produce female sex hormones. During the development of the follicle, increasing amounts of the main female hormone, oestrogen, are produced. After ovulation, the empty follicle (called the corpus luteum) produces the hormone progesterone. Progesterone stops the release of more eggs and thickens the lining of the uterus.

Small amounts of androgens (male hormones) are also produced in the ovaries. Hormones are carried in the blood stream and influence other organs such as the uterus and breasts.

Two other hormones, follicle stimulating hormone (FSH) and luteinising hormone (LH), play an important part in ovulation, but are not produced by the ovaries. They are produced by the pituitary gland at the base of the brain. FSH stimulates follicle development. LH triggers ovulation and helps maintain the corpus luteum.




What is Polycystic Ovary Syndrome?

Polycystic simply means 'many cysts' and describes the appearance of the ovary on ultrasound scan. On the scan a polycystic ovary is larger than normal with a ring of many cysts around the edge. The cysts are follicles, some are immature but contain an egg, and others are empty. A polycystic ovary contains at least ten cysts just below the surface, and although each cyst only measures between two and eight millimetres, together they make the ovary enlarged. The covering of the ovary (the capsule) thickens, which makes release of the egg difficult.

The diagram of the normal ovary showns a growing follicle and the empty follicle (called the corpus luteum) that is left behind after the release of the egg at ovulation. The diagram of the polycystic ovary showns the many cysts around the edge of the ovary.

Polycystic ovaries are common. About one in five women have them, and generally they present no problems. But when they are accompanied by some, or all, of the symptoms described below, you may be told that you have Polycystic Ovary Syndrome (PCOS). PCOS is sometimes called Stein-Leventhal syndrome after the doctors who first described it in 1935.


Symptoms of PCOS:
Irregular or absent periods:

Most women with PCOS do not ovulate because their follicles never ripen enough to reach the ovary's surface and burst. Some women ovulate occasionally. So you may not have any periods, or they may be very irregular and scanty. Women with PCOS may start their periods late and they may also always have irregular cycles. On the other hand some women may have heavy irregular bleeding because of the poor hormone control.

Infertility:

If you have PCOS you will only be ovulating occasionally or not at all, so getting pregnant without treatment may be difficult or impossible. Many women do not go to their doctors with irregular periods until they start trying to have a baby. You may only find out then that you have polycystic ovaries.

Miscarriage:

There may be an increased risk of miscarriage for women who do become pregnant.

Unwanted body hair

Many women with PCOS experience unwanted hair on their face, chest, abdomen, arms and legs. Hair growth might be quite thick and noticeable, especially if you have dark hair. Some women also notice a slight thinning of their head hair.

Acne:

Some women with PCOS have spots on their face, chest and back. Many women who go to their doctor with adult acne find they have polycystic ovaries.

Weight gain:

You may find that you put on weight easily. If you put on a lot of weight you may be at increased risk of developing heart disease, high blood pressure or diabetes later in life.

Pelvic discomfort:

Some women with PCOS feel occasional discomfort in their abdomen.

Feelings about having PCOS:

With the possible combination of all or some of these symptoms, it is hardly surprising that many women find living with PCOS a distressing experience.

We all experience continual daily exposure to images of female perfection, idealising smooth skinned, slim models who breeze through periods then effortlessly become mothers at the desired time.

Although not all women with PCOS experience all of the symptoms, any of them can have an effect on the way you view yourself, leaving you with feelings of low self-esteem. Thoughtless comments from others, including doctors, can be very upsetting.

If you want to talk to other women with similar experiences, contact the support group Verity. See the Resources section for their details.

Diagnosis:

PCOS may be diagnosed when you go to the doctor with one of the symptoms listed above. The doctor may then ask about other symptoms and may examine you internally to see if your ovaries are enlarged.

Your doctor may also take a blood sample to check your hormone levels, and may want you to have an ultrasound scan. Modern ultrasound is very sensitive and can detect small cysts.

If the diagnosis is unclear, for example if it is suspected that you may also have endometriosis or scar tissue due to previous pelvic infection, you may be offered a laparoscopy.

A laparoscopy allows the surgeon to look at the outside of the womb and at ovaries and fallopian tubes. It can also be used to take tissue samples. It involves making two small cuts, in the lower abdomen and near the navel. Air is passed into the pelvic cavity to lift the abdominal wall away from the internal organs, and a small viewing instrument (the laparoscope) is inserted through one of the incisions (see the diagram on the right). An instrument used to manipulate the pelvic organs is inserted through the other small cut. The operation usually takes about 30 minutes and is done in hospital. You will be given a general anaesthetic before the procedure and will have a few stitches afterwards.

Two small scars are left, and you may feel some discomfort, but you should be back to normal within a week. You should be told about what was found before you go home.




PCOS — causes and treatments:

It is not known why some women develop PCOS. But if a close family member has it, you are more likely to have it too. The immediate cause of all the various symptoms is known to be hormonal, and medical treatments are generally designed to change hormone levels.

Treatment tends to be different for each symptom and a treatment for one may not help another, so it is important to decide which symptom is troubling you most.

Treatments for PCOS symptoms:

Treating irregular or absent periods:

Since follicles don't ripen with PCOS, the corpus luteum doesn't form and progesterone isn't produced. As a result the endometrium (the lining of the uterus) does not thicken. It is the thickened endometrium which is lost with a normal menstrual period. Many women feel better for having a period each month. If a woman doesn't want to get pregnant, the usual way to manage PCOS is either a low dose combined contraceptive pill, or a progestogen only pill.

Treating infertility:

Although not ovulating is likely to be the cause of infertility, it is important to check for other possible causes in yourself or your partner before starting any treatment.

Treatment with the pill for other symptoms will stop you getting pregnant. If you want to induce ovulation, you will probably be offered fertility drugs such as clomiphene. 80% of women with PCOS ovulate on clomiphene but only 30 to 50% will conceive. If you're not pregnant after three clomiphene treatments, you may be given hormones directly by injection or a small wearable pump.

If hormone treatment doesn't work you may be offered a procedure called a laparoscopic ovarian diathermy, also known as ovarian drilling. This is similar to a laparoscopy except that, as well as looking inside, the doctor burns your ovaries slightly in several places. If this is successful it induces ovulation and corrects the hormonal balance. The recovery time is similar to that for a laparoscopy.

Fertility treatment carries risks and may take up a lot of your time in visits to the hospital or clinic and waits between visits. Possible side effects from fertility drugs range from headaches to unwanted multiple births — there is a fivefold increase in the likelihood of having twins. One potentially very dangerous unwanted effect is ovarian hyperstimulation syndrome, where too many follicles are stimulated to grow. Make sure any doctor who treats you talks this through with you. This is rare but you should be aware of the symptoms. If you have abdominal pain, bloating, nausea and vomiting following ovulation induction you should contact your doctor straight away.

You will probably want to take time to decide whether you really want these treatments, and you may want more detailed information so that you can make clear choices. If so, you should contact the appropriate organisations listed on the resources page.

Treatment concerning miscarriage:

Miscarriage associated with PCOS is thought to be due to high levels of LH. Drugs such as Buserelin may be used as injections or nasal sprays to suppress LH before using other drugs to induce ovulation. For more information concerning PCOS and miscarriage you may want to visit the following website: www.ovarian-cysts-pcos.com/miscarriage (please note: links included on these pages to external websites do not constitute an endorsement of the advice or services provided through these sites).

Treatments for unwanted body hair:

Unwanted hair growth (hirsutism) is caused by excess male hormones (androgens). Polycystic ovaries produce excess amounts of an androgen (testosterone). Although all women have some testosterone, people think of it as a male hormone because it influences male characteristics such as body hair and balding.

For women who don't want to conceive, excess hair is usually treated with the combined contraceptive pill and an anti-androgen. If you decide to use these treatments they may take several months to take effect. In the meantime, or as an alternative, you may wish to control hair growth with treatments such as waxing, electrolysis or lasers, or use bleaching and foundation creams to disguise growth.

Treatment for acne:

Like hair growth, acne is caused by high levels of androgens and may be helped by similar treatments. The combined contraceptive pill can help with acne as well as regulating your cycle. The progestogen-only pill can make acne worse. Over the counter or prescribed spot treatments might be worth trying, but they dry the skin. Antibiotics, while useful in treating some forms of acne, are not going to solve the problem when it is hormonal.

Weight gain;

The metabolism of a woman with PCOS is thought to differ from that of a woman without it. Women with PCOS use energy from food more efficiently, so relatively more is stored as fat. Advice to eat healthily and get plenty of exercise can be very frustrating for women with PCOS because it is more difficult to lose weight if you have PCOS. Try five smaller meals each day to help regulate blood sugar levels and reduce cravings for sweet or high fat foods. Loss of between 5 and 10% of body weight leads to a significant loss of symptoms.

Treating pelvic discomfort:

This may be helped by regulating periods. But if you have had investigations to make sure it is nothing more serious then you may feel it is worth trying alternative therapies such as acupuncture, aromatherapy or relaxation. Some women find that regular exercise such as walking eases aches and pains throughout the body.



What are ovarian cysts?

An ovarian cyst is a growth or swelling on, or inside, the ovary. It may be solid, or filled with fluid. If yours is solid you might hear it called a tumour. This can be frightening because it immediately brings cancer to mind, but tumour is just the medical term for any swelling. The vast majority of ovarian growths are not cancerous.

Cysts may grow inside the ovary or they may be attached by a stem to the outside. (The stem is sometimes called a pedicle).

Types of ovarian cysts:

Functional cysts:

These are the most common type of cysts. They occur as a variation of the normal function of the ovaries.

During your monthly cycle one of the follicles may not release its egg, or it may not shrink after ovulation. The follicle enlarges and fills with fluid. Follicular cysts can last for four to six weeks and grow to 5 to 6 cm in diameter. They usually go away by themselves.

A less common type of functional cyst can form in the corpus luteum. Corpus luteum cysts form when the corpus luteum fills with fluid instead of breaking down as it should. Corpus luteum cysts can become larger than follicular cysts and so may cause pelvic discomfort. Usually corpus luteum cysts go away over two or three menstrual cycles, but occasionally bleeding in the cyst can cause a strong abdominal pain similar to that of an ectopic pregnancy.

Dermoid cysts:

Dermoid cysts originate in the ovarian cells that form into different tissues as the fertilised egg develops. These cysts can grow quite large — up to 15 cm in diameter — and may contain hair, bone, teeth and cartilage. In about 12% of cases dermoid cysts may be present on both ovaries. They occur most commonly in young women and can occur in pregnancy. Large cysts are more prone to torsion, where the cyst twists on its stem, cutting off the blood supply and causing intense pain. Dermoid cysts should be removed surgically.

Serous and mucinous cystadenomas:

These can grow to be very big and heavy, and may even weigh several stone. Serous cystadenomas are filled with a watery liquid, and the mucinous ones with a thicker sticky fluid. Both types often grow outside the ovary, attached by stems. They are not always benign and should be removed as quickly as possible.

Endometriomas:

Up to 60% of women with endometriosis have endometriomas. These are cysts lined with endometrial cells similar to those lining the womb. These cells bleed during menstruation. The old blood in the cyst gives them a 'chocolate' appearance. They should be removed surgically.

Solid Ovarian Tumours:

Functional tumours (Ovarian stromal tumours)
Functional tumours are completely different and much rarer than functional cysts. They are called either masculinising or feminising because they produce either male or female hormones. Masculinising tumours tend to occur to women in their 20s and 30s. Feminising tumours can occur at any age, even before puberty. They are usually benign, but need to be removed surgically because of the small risk that they are not benign.


Fibromas:
These ovarian cysts are usually solid although they sometimes have fluid parts and may contain some bone. In some women they produce oestrogen. They should be removed surgically.


Brenner tumours:
These are rare, solid ovarian cysts that are most commonly found in women over 40. They are usually quite small and always benign.



Ovarian cysts — symptoms and diagnosis:

Symptoms:

Many women experience no symptoms when they have an ovarian cyst, particularly if it's small. Certain cysts grow large and may cause the abdomen to swell. Depending on where the cyst is and its size, it may put pressure on the bladder or bowels, making you need to go to the toilet more often. You may also notice abdominal discomfort and sex may be uncomfortable or painful. Your periods may be affected; they may become irregular or the bleeding may be heavier or lighter than usual.

Tumours which produce hormones cause more noticeable symptoms if they are active. If they are inactive, they won't produce hormones, and there probably won't be any symptoms unless the tumour is large.

If you have an active feminising tumour and have passed the menopause, you may start bleeding again. Girls who haven't reached puberty may find that their periods start early, and they may develop breasts and body hair.

If you have an active masculinising tumour, your periods may stop, you may become more masculine in shape and your clitoris may grow. You may grow more facial and body hair and your voice may get deeper.

Possible complications:

Although a woman may live with a cyst for years and not even know she has it, occasionally cysts do cause problems. If a cyst is growing on a stem, the stem may become twisted. This causes intense pain, vomiting and a rapid heartbeat. This emergency condition is called torsion (see diagram on the left) and you need to go to hospital for treatment.

Some cysts can burst (rupture). If this happens, how you feel depends on what the cyst contained, whether it is infected and whether there is any bleeding. There will usually be some pain when a cyst ruptures, but it is only as severe as the pain in torsion if there is bleeding or infection. Again you need to go to hospital for treatment.

Diagnosis:

As most cysts don't cause symptoms, they are found by chance, often on internal examination. They may also be picked up on an ultrasound scan during pregnancy or for another reason.

An internal examination is the first stage in diagnosis and if something is felt, you will be sent for an ultrasound scan and referred to a gynaecologist. How long you will wait to see the gynaecologist depends on your symptoms, age and where you live.

The gynaecologist will ask about your periods, age, previous pregnancies, and whether sex is painful. All of this information will help in determining the type of cyst and how much it is troubling you. You may then need to have another internal examination because the gynaecologist will want to check what your doctor has found.

This examination will be followed by an ultrasound scan to build up a fuller picture. There are two ways of scanning, using either an external or internal probe.

The internal probe is shaped like a tube with a rounded end which is inserted into your vagina and moved around to get a clear picture on the screen.

The external probe is flat and moved around whilst pressing on your abdomen. For this type of scan you need a full bladder so that your organs can be seen more clearly. Having such a full bladder is uncomfortable, especially if you have to wait, but it's important to hold on, otherwise your appointment may have to be rescheduled.

There are pros and cons with each method. Some women find the vaginal probe embarrassing, intrusive and/or uncomfortable, but sometimes it gives a clearer picture and allows blood flow to the ovary to be visualised, which helps with the diagnosis. Maintaining a full bladder for a long time then having someone pressing down on it can also be very uncomfortable. Unfortunately, you may not be offered a choice.

The scan results will add to the picture of which cyst it's likely to be. Because the ovaries are hidden away and are so close to other organs, problems in the bowel, the uterus or other organs may be confused with ovarian cysts, and diagnosis is a complicated procedure.

You may feel frustrated if doctors can't tell you what's wrong immediately, particularly if you have to wait between each stage.



Ovarian cysts — treatment:

If the scan shows a small cyst and you haven't yet reached your menopause and aren't on the pill, you are likely to have a functional cyst. As long as it isn't causing pain or other symptoms, most doctors will suggest waiting a month or two to see if it goes away on its own. You may also be offered the pill while you are waiting, as some doctors believe it improves the chances of the cyst disappearing. Although the pill doesn't seem to help once you have a functional cyst, it may help to prevent them in the first place.

If you keep on getting functional cysts, it might be worth considering it as a preventative measure. If your doctor suggests the pill for other types of cysts, or as treatment for an existing functional cyst, it is worth asking for an explanation or a second opinion if you're not happy.

Surgery:

Only functional cysts will disappear on their own; other cysts may need surgery. Your doctor will discuss with you the pros and cons of surgery.

If your cyst is discovered in pregnancy and is causing symptoms or is large, it will need to be removed. As with non-pregnant women, this will involve a general anaesthetic, but care will be taken to protect the baby and your other reproductive organs. You may be offered a laparoscopy at first to get a better view of the cyst. Depending on what's found, a technique called laparoscopic fenestration may follow. Using the same small cuts as an ordinary laparoscopy, the cyst is removed by draining its contents. These are sent to the laboratory for analysis. Recovery is much the same as for ordinary laparoscopy.

If there are concerns that the cyst may burst and spill during removal you may be advised to have a laparotomy, a more serious operation which involves a much larger cut across the top of the pubic hairline. This gives the surgeon better access to the cyst. The entire cyst is removed and sent for analysis during the operation to check that it isn't cancerous.

Whether the surgeon removes anything else largely depends on your age, whether she or he believes in keeping women's organs and on what you have consented to before surgery. If you are under forty, s/he is likely to recommend leaving the ovary intact, particularly if you want children. Even if the ovary is badly damaged by the cyst and only a small part remains, that part can still go on working normally. If you are over forty, the risk of developing cancer increases and, as a preventative measure, your doctor may recommend removing one ovary (oophorectomy) or both (bilateral oophorectomy) along with your fallopian tubes (salpingectomy) and your womb (hysterectomy).

Some doctors believe that even if you don't have cancer, it's worth removing all your reproductive organs to prevent the possibility of cancer developing in the future. Women who have a family history of ovarian cancer should discuss with their doctor whether they are at increased risk and if ovarian removal is justified (see the page on ovarian cancer for more information). In women not at particular risk of developing ovarian cancer it has been estimated that about 200 oophorectomies would have to be carried out to avoid one case of ovarian cancer.

It is important to remember that removing both ovaries will cause a premature menopause, if you haven't reached menopause. Even after menopause, the ovaries continue to produce small amounts of hormones that influence sexual health. A hysterectomy involves a long recovery period afterwards. You need to be quite clear about your own views and needs before the operation.