Ovarian Cysts: A Review

Cheryl Horlen, PharmD, BCPS


US Pharmacist. 2010;35(7):1-4. 

In This Article

Management of Functional Ovarian Cysts

Ovarian follicular cysts often resolve spontaneously within one to two menstrual cycles. Transvaginal ultrasound may be repeated to check for disappearance of the cyst or a change in its size or characteristics. Resolution may occur following reabsorption of the cyst fluid or cyst rupture.[6] The rupture of a follicular cyst may cause transient pelvic pain owing to the release of follicular fluid into the peritoneum; however, medical intervention usually is not necessary.[4] Cysts that persist or change most likely will require surgical management.

Combined Hormonal Contraception

Suppression of ovulation should result in decreased cyst development, since functional cysts occur as a result of ovulation. Follicular growth and ovulation can be suppressed by inhibiting pituitary gonadotropins with combined oral contraceptives. Studies evaluating the effect of combined oral contraceptives on cyst occurrence have mixed results. High-dose oral combined hormonal contraceptives were shown in early epidemiologic studies to protect against cyst development.[10] Advances in the understanding of hormonal contraception have led to the development of oral contraceptives with lower steroid doses; however, low-dose oral contraceptives do not suppress all follicular activity.[11] Holt and colleagues conducted a case-control study of women aged 18 to 39 years with functional ovarian cysts to assess the effect of low-dose oral contraceptives on cyst occurrence.[12] Compared with the 40% to 90% reduced risk of cyst occurrence seen in studies from the 1970s, this study found a modest 28% decrease in risk. The risk of cyst occurrence was slightly lower in women using 35 mcg ethinyl estradiol monophasic oral contraceptives versus women using monophasic or multiphasic oral contraceptives with less than 35 mcg of ethinyl estradiol.

Since combined oral contraceptives reduced the risk of cyst occurrence, it was theorized that they may also accelerate spontaneous regression of functional ovarian cysts or decrease cyst size. This hypothesis led to the use of combined oral contraceptives to treat pre-existing functional ovarian cysts. However, available evidence does not support this practice. A recent Cochrane review analyzed data from seven randomized, controlled trials of oral contraceptives (any type) used for the treatment of functional ovarian cysts in a total of 500 women.[2] The primary outcome of the systematic review was cyst resolution. Two of the seven trials reported cysts associated with ovulation induction. The conclusion of the pooled analysis was that combined oral contraceptives did not hasten the resolution of functional ovarian cysts, compared with expectant management. The result was the same regardless of whether the cyst was related to ovulation induction or occurred spontaneously. Persistent cysts tended to not be physiologic. Based on the available evidence, the American College of Obstetricians and Gynecologists recommends that combined oral contraceptives not be used to treat existing functional ovarian cysts.[11]

Although combined oral contraceptives may be used in the management of functional ovarian cysts to prevent the development of new cysts, their use is not appropriate for all patients. Combined oral contraceptives should not be used in women with a history of thromboembolic disease, hypercoagulable states or other risk factors for thromboembolism, uncontrolled hypertension, migraines with aura, active liver disease, or cardiovascular or cerebrovascular disease.[13] In addition, women who smoke--especially those over the age of 35 years--are at increased risk for myocardial infarction, so combined oral contraceptives are not recommended.[13] Common adverse effects of combined oral contraceptives include breast tenderness, nausea, headaches, and bloating.[14]


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