Follicular ovarian cyst

The ovarian follicular cyst is a delimited cavity formed in the ovary in the place of the primary follicle, filled with liquid contents. The formation of the follicular cyst is closely related to the menstrual function and is a consequence of the ovulation that has not been completed, therefore it is diagnosed in menstruating women, that is, in the reproductive period( mostly in the 20-35 years).

The term "cyst" is borrowed from Greek terminology: the Greek "kystis" means a bubble - a bag of liquids. The follicular cyst of the ovary is the most common( 83%) and more often the most harmless kind of ovarian cysts.

To understand where the follicular cysts originate from, it is necessary to familiarize yourself with the features of the structure and functioning of the ovaries.

Ovaries perform the function of the hormonal gland and are responsible for the reproduction of the oocytes. In the body, they do not function in isolation, their activity is integrated into the endocrine system and is associated with the hormonal activity of the thyroid and adrenal glands, and the central nervous system( the pituitary and hypothalamus) "guides" the ovaries.

The outer( white) shell covering the ovary is very dense and reliably protects it from external negative influences. Below the shell is a cortical zone with multiple cavity inclusions - pro-medial( primary) follicles at different stages of maturation. Each such follicle has a thin, formed by the compressed epithelial cells, a wall( granulosa) and a cavity filled with liquid contents( follicular fluid).In the cavity of each follicle there is an egg.

As the dominant follicle matures, the egg that is inside grows older. In the ovary, many primary follicles with maturing eggs can simultaneously be present, but only one of them is fully mature. The mature follicle reaches a diameter of 6 - 20 mm, contains an "adult" egg and is called a graafovym bubble. Every month in the ovary, only one follicle finally ripens, and, accordingly, one egg.

For ovum fertilization, it is necessary to leave the ovary, so at the end of its maturing process, the vesicle moves to the side of the belly and is torn( ovulation), releasing the germ cell.

After ovulation in the place of the destroyed graafovoy bubble remain fragments of the granulosa, from which a yellow body is formed. It does not function for long, breaking shortly before the onset of menstruation.

Since both ovaries have a similar structure and function equally, the follicular cyst of the left ovary does not differ from that on the right.

All the structural and functional events occurring in the ovary tissues are inextricably linked with the hormonal function. Hormones are synthesized by the ovaries, more precisely - the follicle and the yellow body, in strict sequence according to the phases of the cycle with the participation of the anterior lobe of the pituitary gland.

In the first( follicular) phase, the pituitary gland produces a follicle-stimulating( FSH) hormone. He "forces" the ovary( follicle) to synthesize estrogens. In the second( lutein) phase, the situation changes: the pituitary synthesizes the luteinizing( LH) hormone, and the ovaries( the yellow body) respond with progesterone secretion. Such cyclic production of hormones is repeated monthly and ensures the maturation of the egg and the subsequent ovulation.

If for any reason the follicle does not collapse, that is, ovulation does not occur, it starts accumulating the follicular fluid and increases - thus forming the follicular ovarian cyst.

A yellow body can also transform into a cyst. The mechanism of formation of the cyst of the yellow body is similar to that of a follicular cyst, when the yellow body does not collapse before menstruation, but begins to accumulate fluid( less often blood), gradually increasing and becoming a cyst.

Cysts formed by the follicle and the yellow body of the ovary are classified as so-called retention, or functional cysts. This type of cyst has a single mechanism of formation: they are formed due to the accumulation of liquid contents in the existing cavity by expanding its wall. Another type of ovarian cyst is a retention one, a parovarial cyst that forms from the rudimentary duct of the ovarian appendage after its occlusion.

As a matter of fact, the retention formations of the ovary are not true cysts, but are named only because of external similarity. The true cyst always has a thick capsule, the cells of which are able to divide and provide growth of the cyst. The true cyst is never self-reducible.

Functional cysts grow differently: cells of its thin wall( pseudocapsules) can not grow, so increasing the cyst provokes an increasing volume of liquid contents. Retention cysts, including the follicular ovarian cyst, have the ability to involution( reverse development).

The size of the follicular cyst rarely exceeds 8 cm. A small follicular ovarian cyst does not have clinical symptoms, so it is diagnosed accidentally during ultrasound scanning. With the concomitant pronounced hyperestrogenia, the patients complain of menstrual dysfunction in the form of plentiful, sometimes prolonged, menstrual dysfunction.

Complications are caused only by large( 7 cm and more) follicular cysts of the ovaries. The thin wall of the cyst can not stretch too much, so it breaks( apoplexy).Usually the patients say - "my follicular ovarian cyst burst".

Another serious complication is the torsion of the legs in the cyst. The follicular cyst of the ovary grows( literally protrudes) toward the pelvic cavity and can form a thinner base - the leg, when it twists, trophic disorders and necrosis begin in the cyst. Apoplexy and rupture of the foot of the follicular cyst provokes the symptoms of an emergency surgical pathology - "acute abdomen".

Diagnosis of the ovarian follicular cyst is not difficult. It is well visualized with ultrasound scanning. During the gynecological examination, small cysts can not be palpated, but this is possible if the cyst is large.

Because of the ability to regress, the removal of the follicular ovarian cyst is not always required. Small asymptomatic cysts, as a rule, observe. If the size of the cyst increases, symptoms of severe hormonal dysfunction appear, and the question of surgery is resolved.

The rupture of the follicular ovarian cyst, partial or complete torsion of its peduncle serves as an absolute indication for surgical intervention.

Causes of follicular ovary cyst

The appearance of functional ovarian cysts, including follicular, is closely related to hormonal dysfunction. We can say that any event that led to the lack of ovulation, can provoke the transformation of the unvoiced follicle into the cyst.

The most popular reasons for the formation of the follicular cyst in the ovary are:

- a violation of the process of normal maturation of follicles;

- too early start of menstrual function( up to 11 years);

- repeated abortions( abortions);

- endocrine dysfunction( pathology of the thyroid gland, adrenal glands), including obesity;

- an unstable menstrual cycle with sharp hormonal fluctuations;

is a long-term hormone therapy, especially associated with ovarian stimulation in infertility therapy or before the procedure of in vitro fertilization( IVF).

A significant role in hormonal disorders is given to stress. For the ovaries to function correctly, they need to get the right "commands" from the brain. With a strong psychoemotional stress, the work of the centers regulating the work of the ovaries is disturbed, which can provoke ovarian dysfunction and, as a consequence, the formation of the follicular cyst.

Separately, it should be said about the role of hormonal contraceptives. As a rule, hormonal contraception excludes cystic degeneration of follicles, as the mechanism of their contraceptive effect is to suppress ovulation to exclude the possibility of fertilization. In addition, oral contraceptives maintain a constant ratio of hormones. This group of drugs is unequal in composition, so it is extremely important to choose the necessary remedy that maximally simulates the normal menstrual cycle in a particular woman.

If the hormonal contraceptive is chosen by the patient at random, it can provoke dyshormonal disorders, so after the drug has been discontinued, a follicular ovarian cyst may form.

The appearance of a follicular cyst in adolescents is associated with imperfect hormonal regulation. During the period of formation, the hormonal function can change in a spasmodic manner, which provokes anovulatory cycles and an excess of estrogens.

The follicular cyst of the ovary is extremely rarely diagnosed in the fetus after the 26th week of development, and it is also found in newborns. This phenomenon is explained by the influence of maternal estrogen and chorionic gonadotropin( hCG) of the placenta during pregnancy and a hormonal surge in the process of childbirth. After birth, after one and a half months, this cyst in newborns almost always spontaneously regresses.

Sometimes the cause of the appearance of the follicular cyst can not be determined. Most likely, such causeless cysts are the result of a short hormonal surge.

Symptoms and signs of the ovarian follicular cyst

The ovarian follicular cyst is not always associated with pathology. Even in a healthy woman, not all cycles are accompanied by ovulation. Anovulation can be provoked by temporary non-pathological mechanisms: stresses, colds, climate change, and the like. The frequency of anovulatory cycles depends on age. So, before the age of 17, 45% of cycles pass without ovulation, and by 35 years of such cycles there is only 5%.

Thus, in healthy women during the anovulatory cycle, a small( 4 - 6 cm) follicular ovarian cyst may appear. As a rule, it does not tend to grow and over time regress. Therefore, if a healthy patient accidentally finds an asymptomatic small follicular cyst, which regresses independently over time, this finding indicates an anovulatory menstrual cycle and is not considered a pathology.

If the follicular ovarian cyst is associated with gynecological pathology, it may be accompanied by severe clinical signs:

- Pains. Sometimes they are like a feeling of bursting or heaviness. Also, there may be non-intensive pains that increase with physical activity, walking, tilting and sharp bends of the body. The follicular cyst of the left ovary provokes such sensations on the left, and the right cyst on the right.

- Intermenstrual bleeding( often clotting).Sometimes intermenstrual spotting mimics a premature regular menstruation, which lasts unusually long.

- Delayed regular menstruation, associated with increased estrogen content. The duration of such a delay can vary significantly and depends on the degree of hormonal dysfunction.

As the egg alternately ripens in each of the ovaries, with a marked hormonal abnormality, a situation is possible where the follicular cyst of the right ovary is first diagnosed, and in the subsequent cycles a similar cyst appears on the left.

Unfortunately, follicular cysts can sometimes provoke serious complications requiring immediate surgical intervention. These include:

- Rupture of the follicular ovarian cyst( rupture of the ovary capsule).It is observed infrequently( 1 - 2.5%).It can happen at any time, but more often it happens in the middle or in the second half of the cycle. The clinic of rupture of the cyst is very similar to acute surgical pathology( "acute abdomen"), for example, the bursting follicular cyst of the right ovary mimics the clinic of acute appendicitis.

The cyst rupture clinic has a sudden acute onset and is always accompanied by two leading symptoms - pain and internal bleeding. A reliable diagnosis is rarely made during a primary examination( 5%), more often "ambulance" can not accurately determine that the patient has burst a follicular ovarian cyst, and hospitalizes the patient in the surgical department.

- Torso of the base( legs) of the cyst. Provokes a violation of blood supply in the cyst area. May be complete or partial. When the vessels stop feeding the cyst wall, the process of necrosis( tissue dying) begins in it. The clinical picture of torsion also corresponds to the urgent state.

As a rule, all small uncomplicated follicular cysts are reduced independently during the next two menstrual cycles. If the follicular cyst continues to be in the ovary longer, it is considered persistent. The presence of a persistent follicular cyst in the ovary can cause temporary difficulties with the onset of pregnancy, as this ovary "turns off" from the conception process until the cyst disappears and the entire reproductive load is shifted to the second ovary.

It is not difficult to diagnose the follicular cyst. Gynecological examination does not always allow it to be detected because of its small size. Sometimes thin women manage to palpate a rounded mobile, painless formation in front and side of the uterus, however, conventional palpation does not allow to differentiate it as a follicular ovarian cyst.

Ultrasonic scanning of the pelvic cavity helps to clarify the diagnosis. Not a scan, the follicular ovarian cyst is represented by a smooth, rounded thin-walled one-cavity formation filled with liquid transparent contents. More often the diameter of the follicular cyst does not exceed 8 cm, but it grows toward the abdominal cavity. If you do a series of ultrasound studies, you can find that the characteristic rapid growth of the follicular cyst: as a rule, it increases by 2 mm per day.

Infrequently, the ovarian follicular cyst is also diagnosed in pregnant women. This situation can happen when in one ovary in the absence of ovulation the follicle was transformed into a cyst, and during the next cycle in another ovary, ovulation and subsequent fertilization occurred. The follicular cyst does not prevent the normal development of pregnancy and does not complicate childbirth.

Treatment of follicular ovarian cyst

Small( 5-6 cm) the size of the follicular cyst and the absence of negative clinical manifestations allow one to adhere to expectant management. In the overwhelming majority of cases, as a result, the follicular ovarian cyst regresses itself, which is confirmed by ultrasound. More often when scanning it can not be seen already the day before or during menstruation, but sometimes the follicular cyst can exist in the ovary a little longer and disappear only after two menstrual cycles.

A small-sized follicular cyst on the background of severe hormonal dysfunction has little chance of independent regression. Elevated levels of estrogen provokes a further increase in the size of the cyst, which means it increases the risk of developing unwanted complications. Therefore, small symptomatic follicular cysts begin to be treated immediately after detection.

Conservative treatment is also used in those situations where the follicular ovarian cyst is not reduced during dynamic observation for the next three cycles, shows a tendency to increase in size or begins to manifest clinically. Also, the therapy is invariably subjected to recurrent and persistent follicular ovarian cysts.

Since follicular cysts are formed with the participation of temporary or chronic hormonal dysfunction, the essence of conservative therapy is reduced to the restoration of normal hormonal background, correction of metabolic disturbances. Hormonal mono- and biphasic preparations( from the group of oral contraceptives) are prescribed according to the established scheme and vitamins. A good addition to hormone therapy are physiotherapy, oxygen therapy. Particular attention should be given to patients with a pronounced unsuccessful psychoemotional background, their treatment should be carried out together with psychotherapists.

The success of the therapy is correlated with the size of the follicular cyst: if the ultrasound study for control aims to reduce the size of the cyst, the therapy is considered successful and can be prolonged until it disappears completely.

Surgical removal of the follicular ovarian cyst is required if:

- cyst size exceeds 8 cm;

- there is a tendency for rapid growth;

- the effect of hormonal treatment is absent;

- the follicular cyst shows signs of torsion or rupture( emergency states);

- on the background of hormonal imbalance, the follicular ovarian cyst after a successful treatment appears again.

Thanks to the introduction of the laparoscopy method into surgical practice, the removal of the follicular cyst has become a minor trauma and uncomplicated procedure with a minimal risk of complications.

According to the clinical situation, the follicular ovarian cyst can be eliminated in several ways. The most common is the cyst excision( cystectomy).In this case, only the capsule and the contents of the cyst are removed, and all healthy tissues surrounding the cyst are preserved.

Complicated cysts require not only the removal of the cyst, but also the damaged surrounding tissue, so the "piece" of the ovary is removed in the form of a wedge( wedge resection).

If due to complications of the follicular cyst in the ovary irreversible changes occurred, an adnexectomy is performed( removal of the entire ovary).