|Year : 2015 | Volume
| Issue : 4 | Page : 960-964
Different modalities in the management of functional ovarian cysts
Zakria F Sanad1, Said A Saleh1, Adham Mostafa MBBCh 2
1 Department of Obstetrics and Gynecology, Faculty of Medicine, Menofiya University, Menofiya, Egypt
2 Department of Obstetrics and Gynecology, Shobra Hospital, Cairo, Egypt
|Date of Submission||18-Sep-2014|
|Date of Acceptance||18-Dec-2014|
|Date of Web Publication||12-Jan-2016|
26-St.masr w elsodan, Elmahala Elkobra, Elgharbia, 11672
Source of Support: None, Conflict of Interest: None
The aim of this work is to compare the different modalities in the management of functional ovarian cysts.
A functional ovarian cyst is a growth on an ovary that develops during a woman's ovulation cycle. Women who develop a functional ovarian cyst generally remain asymptomatic and only learn of its presence during their annual female examination. Most functional ovarian cysts are small and benign, require no treatment, and dissolve on their own. If the cyst is small to moderate in size and causes no symptoms, a watchful approach will usually be adopted.
Materials and methods
This study included 80 patients with functional ovarian cysts: 40 patients followed up by transvaginal ultrasound only (expectant group) and 40 patients who received combined oral contraceptive pills (oral contraceptive group) and followed up by transvaginal ultrasound for 3 months. Persistent functional ovarian cysts will be managed by transvaginal ultrasound-guided needle cyst aspiration and then followed up by transvaginal ultrasound for 3 months.
There was no statistically significances between different modalities of management as regards short-term expectant management (31\40) and combined oral contraceptive management (34\40) for functional ovarian cysts. Persistent functional ovarian cysts were managed by transvaginal-guided ultrasound needle aspiration, which showed a high recurrence rate in both groups, 5\9 and 3\6, respectively, after short-term follow-up.
The results of the study suggest that optimal management for functional ovarian cysts in reproductive age is expectant management.
Keywords: cilest, expectant management, functional ovarian cyst, transvaginal-guided ultrasound needle aspiration
|How to cite this article:|
Sanad ZF, Saleh SA, Mostafa A. Different modalities in the management of functional ovarian cysts. Menoufia Med J 2015;28:960-4
| Introduction|| |
A functional ovarian cyst is a unilateral, unilocular, thin-walled, and echogenic sac measuring about 2.5-6 cm. A mature graffian follicle is a sac that forms on the surface of a woman's ovary during ovulation. After ovulation, the ovum is released, and the sac may close and swell up with fluid to form a functional ovarian cyst. They are not neoplasms and are mostly harmless. They do not cause symptoms and may disappear without treatment .
The appropriate management of functional ovarian cysts is one of the most controversial problems facing gynecologists today despite the different treatment modalities that are available .
Functional ovarian cysts typically disappear within 60 days without any treatment. Oral contraceptive pills may be prescribed to help establish a normal menstrual cycle and decrease the development of functional ovarian cysts, although many cysts are detected at routine physical examination. The common ovarian masses detected are germ cell tumors (27.5%) and functional ovarian cysts (25%)  .
Many previous studies have indicated that the use of oral contraceptive pills is associated with a lower risk of occurrence of functional ovarian cysts. However, few studies have considered the treatment effect of oral contraceptive pills on functional ovarian cysts. In current clinical practice, gynecologists treat functional ovarian cysts with either oral contraceptive pills or expectant management alone. Only a few recent studies have used low-dose oral contraceptive pills compared with observation alone  .
Therapeutic transvaginal ultrasound-guided cyst aspiration is indicated in women either because of coexisting medical problems or when refusing conservative management. However, the recurrence rate is high, especially when the aspirated fluid is blood stained  . The aim of this study was to compare different modalities in the management of functional ovarian cysts.
| Participants and methods|| |
This study was carried out from October 2011 to October 2013; 80 patients with functional ovarian cysts were included in this study. They were selected from among patients attending the outpatients' clinic of the Department of Obstetrics and Gynecology in Menoufiya University Hospital. Most of the women examined represented a homogenous group of the community. None of the women in this study had received management for ovarian cysts before. All patients provided their formal consent. The protocol was approved by the Ethical Committee of the Faculty of Medicine, Menofiya University. A full assessment of history was performed for all women, with a special focus on age, occupation, address, marital status, chronic pelvic pain, backache, dyspareunia, leukorrhea, abnormal uterine bleeding, amenorrhea, infertility, midmenstrual pain, obstetric history, menstrual history, and history of contraception. Patients attended the outpatient clinic after the end of menstruation; a transvaginal ultrasound was performed for the selection of cases according to the following inclusion criteria: women of reproductive age and those with unilateral ovarian cysts, 2.5-6 cm in diameter, thin-walled, unilocular without internal echoes, and no solid parts. Exclusion criteria included premenarche, postmenopause, and neoplastic ovarian swelling (any swelling more than 8 cm or that was multilocular). The patients were divided into two equal groups. Each group included 40 women as follows: group A included women who were managed expectantly. Group B included women who were administered combined oral contraceptive pills.
Women managed by either of the two modalities were followed up by transvaginal ultrasound monthly for 3 successive months.
After 3 months, persistent functional ovarian cysts from two groups were managed by transvaginal ultrasound-guided needle cyst aspiration and then the patients were followed up by transvaginal ultrasound monthly for 3 successive months.
The t-test was used to assess the statistical significance of differences between two means. On the basis of the t-test and the degree of freedom, the P-value was calculated using special tables; thus, the significance of the results was determined from the 't' distribution tables.
P < 0.05 = insignificant difference, P > 0.05 = significant difference.
P > 0.01 = highly significant difference, P > 0.001 = very highly significant difference.
| Results|| |
The current study was carried out at Menoufiya University Maternity Hospital during the period between October 2011 and October 2013. A total of 80 women with functional ovarian cysts were included in the study.
Data were analyzed using IBM© SPSS© Statistics, version 21 (IBM© Corp., Armonk, New York, USA).
Continuous numerical data were presented as mean and SD and between-group differences were compared using the unpaired Student t-test.
Qualitative data were presented as number and percentage or as ratio. Fisher's exact test was used for analysis of 2 × 2 tables. Larger contingency tables were analyzed using the χ2 -test.
P less than 0.05 was considered statistically significant.
The age of the women in group A showed a mean ± SD of 26.3 ± 2.1 years and the age of the women in group B showed a mean ± SD of 27.1 ± 2.7. Statistical analysis of these data showed no significance difference among the two groups with respect to age (P = 0.143).
[Table 1] shows ultrasonographic findings in the two study groups. In group A, the average diameter showed a mean ± SD of 3.4 ± 0.9 cm and in group B the average diameter showed a mean ± SD of 3.1 ± 0.8 cm. Statistical analysis indicated no significance difference between the size of functional ovarian cysts in the two study groups (P = 0.119). In group A, the location of the cyst in 21 patients was on the right side and in 19 patients, the location of the cyst was on the left side; in group B, in 23 patients, the location of the cyst was on the right side and in 17 patients, the location of the cyst was on the left side.
On assessment of the outcome of therapy after 1 month, the cysts were found to be in remission in 21 of the 40 women in group A and in 26 of the 40 women in group B. A total of 13 women in group A and six women in group B still had cysts. None of the women in expectant group and two women in group B showed regression. Six women in group A and six women in group B showed progression. None of the ultrasonic findings was statistically significant.
On assessment of the outcome of therapy after 2 months in the two study groups, the cysts were found to be in remission in 27 women in group A and in 29 women in group B. A total of 13 women in group A and 11 women in group B still had cysts. None of the women in group A and none of the women in group B showed regression. None of the women in group A and none of the women in group B showed progression. None of the outcomes was statistically significant (P = 0.060).
[Table 2] shows the outcome of therapy after 3 months in the two study groups. The cysts were found to be in remission in 31 women in group A and in 34 women in group B. Nine women in group A and six women in group B still had cysts. None of the women in group A and none of the women in group B showed regression. None of the women in group A and none of the women in group B showed progression. None of the outcomes was statistically significant (P = 0.567).
[Table 3] shows the recurrence rate after transvaginal aspiration in the two study groups. After 1 month, the cyst showed recurrence in four women in group A compared with two women in group B. The difference was not statistically significant (P = 1.0). After 2 months, the cyst showed recurrence in four women in group A compared with three women in group B. The difference was not statistically significant (P = 1.0). After 3 months, the cyst showed recurrence in five women in group A and in three women in group B. The difference was not statistically significant (P = 1.0) ([Figure 1], [Figure 2], [Figure 3]).
|Figure 1 Transvaginal needle aspiration of persistent functional ovarian cysts.|
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|Figure 3 Incidence of vaginal bleeding after transvaginal needle aspiration in the two study groups.|
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|Table 3 Recurrence rate after transvaginal aspiration in the two study groups |
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| Discussion|| |
Ovarian cysts are a common gynecological problem. In women of reproductive age, the prevalence of ovarian cysts is around 7%  .
Most of these cysts (80-85%) are benign, particularly functional ovarian cysts  .
Conservative management, however, is a source of anxiety for patients and clinicians. In contrast, surgical intervention for benign disease places an unnecessary burden on resources  .
The primary aim of this prospective randomized-controlled trial study was to evaluate different modalities in the management of functional ovarian cysts by comparing the remission rates of spontaneously occurring functional ovarian cysts between treatment with combined oral contraceptives (group B) and expectant management (group A) at 1, 2, and 3 months. Furthermore, functional ovarian cyst recurrence can be observed following transvaginal drainage for those cysts with a failed remission.
The remission percentages of functional ovarian cysts were as follows:
After 1 month, 52.5 and 65% in group A and group B, respectively.
After 2 months, 67.5 and 72.5% in group A and group B, respectively.
After 3 months, 77.5 and 85% in group A and group B, respectively.
Our finding is in agreement with that of Ayline et al.  , who reported that 36 patients with functional ovarian cysts were randomized to receive expectant management (group I, n = 18) or to receive oral contraceptives (group II, n = 18). After one cycle of therapy, resolution of the cysts was observed in 44.4% (n = 8) and 55.5% (n = 10) of the 18 patients in groups I and II, respectively. Complete resolution of the cysts was observed in 66.6% (n = 12) of the women in group I and in 72.2% (n = 13) of the women in group II after two cycles.
Another prospective study similar to the study of Ayline et al.  was carried out by Naz et al.  in which 47 patients with functional ovarian cysts were included. Overall, 22 patients (46.80%) received counseling for expectant management (group A) and oral contraceptives (group B) were prescribed in 25 patients (53.19%). Cyst resolution at 2 months by ultrasound was observed in 72.72% of the women in group A and in 80.0% of the women in group B. There was no statistically significant difference in cyst resolution in the two groups. These results were in agreement with those of our study.
The studies by Mackenna and colleagues , are two earlier randomized-controlled trials on the effect of combined oral contraceptive pills on the resolution of functional ovarian cysts compared with that of expectant management; they found that a similar number of functional ovarian cysts had resolved within 1 month. Moreover, all the remaining cysts resolved after 2 months; this is not in agreement with the finding of the present study.
Turan et al.  showed that remission rates of spontaneously formed functional cysts either at 5 or 10 weeks of therapy with oral contraceptive pills were similar to those of expectant management. At 5 weeks of therapy, functional ovarian cysts disappeared in 88.9% of women using low-dose monophasic oral contraceptive pills and in 76% of women on expectant management. At 10 weeks of therapy, the disappearance rates were more similar: 100 and 94.1%, respectively. The lack of statistical significance can be attributed to an insufficient number of participants enrolled in the study.
Our findings are not in agreement with the randomized-controlled trial conducted by Taskin et al.  , who examined the effectiveness of combined oral contraceptive versus expectant management of functional ovarian cysts; this study included 25 women in the oral contraceptive group and 20 women in the expectant group. The remission rates after 3 months were 13\25 (52%) in the combined oral contraceptive group and 10\20 (50%) in the expectant group; there were no statistically significant differences.
Our findings are in agreement with those of a randomized-controlled trial conducted by Sanersak et al.  . This study included 70 women. The remission rates after 2 months were 24\33 (72.2%) in the combined oral contraceptive group and 23\34 (67.6%) in the expectant group; there were no statistically significant differences.
In our study, we determined the recurrence rate after transvaginal aspiration in the two study groups. After 1 month, the cyst showed recurrence in 4 (44.4%) women in group A compared with 2 (33.3%) women in group B. After 2 months, the cyst showed recurrence in 4 (44.4%) women in group A compared with 3 (50.0%) women in group B. After 3 months, the cyst showed recurrence in 5 (55.6%) women in group A and 3 (50.0%) women in group B.
Our findings are not in agreement with those of Balat et al.  , who treated 19 cases with transvaginal ultrasound-guided needle cyst aspiration, with recurrence in five cases (26.5%) after short-term follow-up.
Our findings are not in agreement with those of Dulbaz et al.  , who treated 35 cases with functional cysts with Ca-125 level less than 35 U/ml with transvaginal ultrasound-guided needle cyst aspiration. All patients were followed up by transvaginal ultrasound for 3 months. Three recurrences (8%) were identified.
| Conclusion|| |
For functional ovarian cysts, conservative management is adequate as most cases will resolve spontaneously. There is no proven advantage in the use of combined oral contraceptives. Surgery should be reserved for patients with large or symptomatic functional ovarian cysts.
Therapeutic ultrasound-guided cyst aspiration may have a small place in women in whom surgery is considered to be high risk. However, the recurrence rate is high.
| Acknowledgements|| |
Conflicts of interest
There are no conflicts of interest.
| References|| |
Melnikow J, Penava D, et al.
MPH - family medicine. Obstet Gynecol 2008; 46
Crawford RA, Gore ME, Shepherd JH. Ovarian cancers related to minimal access surgery. Br J Obstet Gynaecol 1995; 102
Skiadas VT, Koutoulidis V, Eleytheriades M, Gouliamos A, Moulopoulos LA, Deligeoroglou E, et al.
Ovarian masses in young adolescents: imaging findings with surgical confirmation. Eur J Gynaecol Oncol 2004; 25
De Guia BC. A randomized placebo-controlled trial of low dose monophasic pills in the treatment of functional ovarian cysts. Int Congr Ser 2004; 1271
Girdling JC, Soutter WP. Benign tumours of ovary. In Shaw RW, Soutter WP, Stanton SL, eds Gynecology
. 2nd ed. Edinburgh: Churchill Livingstone; 1997. 615-625.
Borgfeldt C, Andolf E. Transvaginalsonographic ovarian finding in a random sample of women 25-40 years old. Ultrasound Obstet Gynecol 1999; 13
Hillard PJ, Berek JS. Benign disease of the female reproductive tract: symptoms and signs. Novak′s gynecology
. 13th ed. Philadelphia: LippincottWilliams Wilkins; 2002. 351-420.
Eriksson L, Kjellgren O, von Schultz B. Functional cysts or ovarian cancer. Histopathological finding during 1 year of surgery. Gynecol Obstet Invest 1985; 19
Ayline Pelin CIL, Ozturkoglu E, Demir B, Gunes M, Haberal A. Is hormonal therapy needed in the management of functional ovarian cyst
. In Feldman-Winter L, Schanler RJ, O′Connor KG, Lawrence RA, eds. Turkey: Ankara Etlik Maternity and Women′s Health Teaching and Research Hospital; 2008. 1301-3314.
Naz T, Akhter Z, Jamal T. Oral contraceptives versus expectant treatment in management of functional ovarian cysts. Department of Gynecology, Khyber Teaching Hospital, Peshawar - Pakistan. J Med Sci (Peshawar, Print) 2011; 19
MacKenna A, Fabres C, Alam V, Morales V. Clinical management of functional ovarian cysts: a prospective and randomized study. Hum Reprod 2000; 15
Turan C, Zorlu CG, Ugur M, Ozcan T, Kaleli B, Gökmen O. Expectant management of functional ovarian cysts: an alternative to hormonal therapy. Int J Gynaecol Obstet 1994; 47
Taskin O, Young DC, Mangal R, Aruh I. Prevention and treatment of ovarian cysts with oral contraceptive: a prospective randomized study. J Gynecol Surg 1996; 12
Sanersak S, Wattanakumtornkul S, Korsakul C. Comparison of low-dose monophasic oral contraceptive pills and expectant management in treatment of functional ovarian cysts. J Med Assoc Thai 2006; 89
Balat O, Sarac K, Sonmez S. Female reproductionPrinciples of physiology
. St Louis, MO: CV Mosby Company; 1996. 599.
Dulbaz S, Alibkan E, Dulbaz B, Aykan B, Suvaslioulu A, Haberal A. Laparoscopic and transvaginal ultrasound guided aspiration cytology of ovarian cysts. Ankara, Turkey: SSK Maternity and Women′s Health Training Hospital; 2003.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]