COMMENTARY

How Effective Are Oral Contraceptives in the Treatment of Functional Ovarian Cysts? A Best Evidence Review

Maria I. Rodriguez, MD

Disclosures

October 01, 2009

Best Evidence Reference

Grimes DA, Jones LB, Lopez LM, Schulz KF. Oral contraceptives for functional ovarian cysts. Cochrane Database Syst Rev. 2009;(2):CD006134.

Abstract

This study was selected from Medscape Best Evidence, which uses the McMaster Online Rating of Evidence System. Of a possible top score of 7, this study was ranked as 6 for newsworthiness and 7 for relevance by clinicians who used this system.

Summary

Functional ovarian cysts are a common gynecologic problem among women of reproductive age worldwide. When large, persistent, or painful, a cyst may require surgery that sometimes results in removal of the ovary. Because early oral contraceptives were associated with a reduced incidence of functional ovarian cysts, beginning in the 1970s, many clinicians adopted the practice of treating ovarian cysts with oral contraceptives. The results from a meta-analysis of all randomized controlled trials to date do not support the use of oral contraceptives to treat physiologic cysts.

Background

Functional Cysts

Functional cysts are the most common masses seen in the premenopausal ovary and are estimated to affect 8%-20% of reproductive-aged women.[1] A functional cyst is a variation of a normal, physiologic process. These cysts are not neoplastic but develop when there is arrest in the normal menstrual cycle.[2] To be considered a cyst, the minimum diameter of the mass is usually 2.5-3.0 cm. Cysts may be solitary or multiple, and their growth is dependent on gonadotropins. Functional cysts are almost always found in reproductive-aged women but may also be seen in the pediatric population.

Cysts are typically asymptomatic and usually an incidental finding of abdominopelvic imaging. On ultrasound, cysts are simple in appearance, with an anechoic lumen and a rim of normal tissue.[2] Functional cysts can cause transient pain (as a result of stretching of the ovarian cortex as the mass enlarges), irritation of the peritoneum with rupture, or torsion and subsequent ischemia of the adnexa.[3]

If cysts are asymptomatic, conservative management is preferred because most cysts will resolve spontaneously within a few menstrual cycles. When cysts are painful, persistent, or large, surgical removal may be necessary. Cysts that do not resolve may be pathologic. After surgical removal, the most common findings are teratoma, endometrioma, paraovarian cyst, hydrosalpinx, or serous cystadenoma.[4,5]

Oral Contraceptives

Early epidemiologic data showed a protective effect of oral contraceptives against the development of functional ovarian cysts.[6] It was theorized that pituitary suppression of gonadotropin production by oral contraceptives would result in decreased cyst size and more rapid regression. The clinical practice of treating functional ovarian cysts with oral contraceptives was supported by an early case series of 286 women, all of whom were treated with oral contraceptives for 6 weeks.[7] A high regression rate was noted, and of the 81 women who required surgery for a persistent mass, pathology was consistent with a nonphysiologic process. Subsequent case control studies with modern formulations of oral contraceptives did not yield similar findings, but the practice of treating functional cysts with oral contraceptives has persisted nonetheless.[8,9]

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