All the time we have patients come to our office asking if their ovarian cysts are causing pain. Yet, many times these patients have not had any imaging to show they even have a current cyst. Or they have been seen in the emergency department recently and were told that a cyst could be causing their pain. As you can imagine, the answer is not always so clear. Why is that? Because it is natural for women of reproductive age to make cysts each month! So the emergency room provider, if they do not find anything emergent, will often tell you it could be the little cyst causing your pain.
What? Cysts are natural? Yes! Each month, for a woman not on medication that prevents cystic formation, a follicular cyst will form. This is where the microscopic egg is maturing as it gets ready for release. Then ovulation happens, and believe it or not, this is a “ruptured cyst” of that follicle. Some women never notice this and others have discomfort from ovulation, sometimes a one-off or sometimes monthly. Then, after ovulation, a cyst called a corpus luteum forms and sticks around for about two weeks if you do not get pregnant and for six to eight weeks if you do. I mention this because very often when a woman receives a CT scan or a sonogram there will be some sort of natural cysts present. These most likely are not causing acute pain, and if they are, it will resolve shortly without the need for intervention.
There are also many types of non-cyclical, or non “natural” cysts that can possibly cause discomfort, or that just may be present without causing any symptoms. These have certain characteristics on a sonogram, CT, or MRI that help us determine what they are. Different types of common cysts are dermoid, endometriomas, hemorrhagic, or cancer. Obviously suspicious masses that worry us for cancer require labwork/imaging/surgery to manage. But for the others we take into consideration the type, size, imaging characteristics, and physical exam to determine if the cyst is likely the cause of the pain. For example, an endometrioma is an ovarian cyst that is made from endometriosis that attaches to the ovary. Endometriosis can cause pain so seeing this type of cyst will let us know that you have endometriosis and allow us to review management options to help alleviate your symptoms. Alternatively, you could have a larger simple cyst (just filled with fluid) or a cyst that appears to be a dermoid, which is the most common benign cyst and is filled with hair, fat, or teeth. Alone, these cysts likely do not cause pain. But if they are big enough they can twist on themselves, called ovarian torsion, and cut off their own blood supply, leading to pain. If an ovarian torsion is suspected based on exam, imagine and pain level, then you would need surgery. Lastly, sometimes ovarian cysts, when they are trying to go away on their own, bleed into themselves or into the pelvis, and this certainly can be painful. These are called hemorrhagic cysts. We can usually determine based on exam and ultrasound if this is something that can be managed with pain meds or if it would require surgery.
So in summary, most ovarian cysts (and even ruptured cysts) are in fact just natural parts of the monthly cycle and should cause little or no pain. If there is pain, it will often be self-limited. However, some types of cysts or larger cysts warrant closer evaluation and closer follow-up, and even sometimes surgery.