Ovarian cyst assessment in Vienna
An ovarian cyst is a cavity, or cystic change, in or on the ovary that is usually filled with fluid. For many women the finding sounds alarming at first, but in the great majority of cases it is benign. Before the menopause, many cysts develop as part of the normal cycle and disappear on their own. What matters, therefore, is to identify those findings that need closer observation or treatment, and to avoid unnecessary procedures for harmless changes. Ultrasound diagnosis of changes in the ovaries has been one of my areas of focus since the start of my academic career. At my private practice in Vienna's 9th district (1090 Wien), I assess your finding and explain what it means, whether a follow-up is required and which treatment, if any, makes sense.
What types of ovarian cyst are there?
Functional cysts
Before the menopause, the most common cysts are what are known as functional cysts. They develop in connection with the normal cycle. Each month a small fluid-filled sac containing an egg, called a follicle, matures in the ovary. If ovulation does not take place as usual, the follicle can persist and grow. This is then called a follicular cyst. After ovulation, the follicle becomes the corpus luteum, which among other things produces progesterone for the second half of the cycle. The corpus luteum can also enlarge or fill with fluid or blood. Functional cysts of this kind often disappear on their own within one to three cycles and usually need no treatment.
Endometriomas
Endometriomas, colloquially also known as chocolate cysts, develop in connection with endometriosis. In this condition, tissue resembling the lining of the uterus is found in the area of the ovary. The cysts can fill with old, thickened blood and often have a characteristic appearance on ultrasound. Unlike functional cysts, endometriomas do not usually disappear spontaneously, and they can play a role in pain and in difficulty conceiving, among other things. You can find out more on the endometriosis page.
Dermoid cysts and cystadenomas
Dermoid cysts, usually referred to medically as mature cystic teratomas, are benign germ cell tumours. They can contain different types of tissue such as skin, hair, fat or occasionally bony or tooth-like structures. They do not disappear on their own.
Cystadenomas are, as a rule, benign epithelial tumours of the ovary. They can have a cystic structure and sometimes grow to a considerable size.
Alongside these benign changes there are, rarely, also malignant tumours or what are known as borderline tumours, which can initially look like a cyst or a cystic mass. For this reason, with every finding I carefully assess how likely it is to be benign and whether further investigations are needed.
When should you have an ovarian cyst assessed?
Many ovarian cysts are discovered by chance during an ultrasound examination and cause no symptoms at all. If you have already been told that you have a cyst, it is important above all to clarify:
What symptoms can ovarian cysts cause?
Possible symptoms include:
These symptoms are not, however, specific to an ovarian cyst. Lower abdominal pain can also originate in the bowel, the bladder, the urinary tract or other gynaecological conditions, for example. If the finding or the symptoms cannot be clearly explained by a gynaecological cause, additional assessment, for instance by a urologist or a surgeon, may therefore be advisable.
Ovarian cysts and the wish to have children
Changes in the ovaries should also be assessed carefully if you have been trying to conceive without success. A simple functional cyst does not normally impair fertility. With endometriomas the situation can be different. In connection with endometriosis, they can affect fertility. At the same time, an operation on the ovary can itself reduce the existing egg reserve. For this reason, particularly if you wish to have children, the decision as to whether an operation really offers a benefit must be made with care.
Ovarian cysts in pregnancy
Cysts on the ovary are also occasionally discovered during ultrasound examinations in pregnancy. In early pregnancy this is often an enlarged corpus luteum. It produces progesterone and so supports the early pregnancy until the placenta increasingly takes over hormone production.
Many simple cysts disappear on their own during the course of pregnancy and need only to be monitored by ultrasound.
If a cyst persists, is large, or shows complex or suspicious features on ultrasound, further follow-ups are advisable. An operation during pregnancy is necessary only in selected situations, for example in the case of considerable symptoms, complications or a suspicious finding.
Ovarian cysts after the menopause
After the menopause, normal ovulation no longer takes place, so typical cycle-related functional cysts are no longer to be expected. Nevertheless, simple, benign ovarian cysts can still occur after the menopause.
A finding of this kind should be assessed on the basis of its size and ultrasound features and, where appropriate, taking blood values into account. Not every cyst after the menopause has to be operated on or monitored indefinitely.
Depending on the finding, very small, simple cysts with a single chamber may not even need any further follow-up. Larger, complex or suspicious changes, by contrast, require more detailed assessment.
Which signs are an emergency?
Most ovarian cysts do not cause acute problems. In rare cases, however, complications can occur.
Ovarian torsion (twisting of the ovary)
In what is known as adnexal torsion, the ovary, often together with a cyst, twists around the tissue that holds it in place. This can impair the blood supply to the ovary.
Typical signs are:
Adnexal torsion is a gynaecological emergency and must be assessed by a doctor quickly. Early treatment increases the chance of preserving the normal function of the ovary.
Rupture of an ovarian cyst
A cyst can also tear or burst. Many such ruptures are uncomplicated, but they can cause sudden, severe pain. If a cyst also bleeds, in rare cases there can be heavier bleeding into the abdominal cavity.
When should you go to hospital immediately?
If you have sudden, severe lower abdominal pain, seek medical help immediately, particularly if you also have
In such a situation, do not wait for an appointment at the practice. Go to a hospital emergency department or, in an acute emergency, call an ambulance.
How do I approach an ovarian cyst?
Everything begins with a detailed conversation about your symptoms, your cycle, earlier findings and your family planning. If you already have ultrasound images, reports or operation reports, please bring them with you. With ovarian cysts in particular, how the finding has developed over time is important information.
Ultrasound as the most important examination
This is followed by the gynaecological examination with transvaginal ultrasound. It is the most important imaging examination for assessing an ovarian cyst.
I pay particular attention to:
A simple cyst typically has a single chamber and a thin wall and is filled with clear fluid. Solid components, irregular structures, certain papillary projections or a conspicuous blood supply, by contrast, can be a reason for more detailed assessment.
The ultrasound assessment of changes in the ovaries was already one of my research interests when I began working at the University Department of Obstetrics and Gynaecology at Vienna General Hospital (AKH Wien). I have published several papers on the subject. Today, these many years of experience help me to estimate the individual risk of a finding and to avoid unnecessary procedures.
When are blood tests or an MRI scan useful?
Tumour markers are not needed for every ovarian cyst. For a clearly simple cyst before the menopause they are not usually required. With certain complex or suspicious findings, blood tests can provide additional information. Depending on the situation, this includes the tumour marker CA 125, for example. A raised value does not, however, automatically mean that a malignant disease is present: endometriosis, inflammation and other benign conditions can also raise the value. In the case of heavy or prolonged bleeding, a blood count and iron status may also be useful.
If a finding cannot be assessed adequately on ultrasound, or if additional information is needed to plan further treatment, magnetic resonance imaging (MRI) may be useful.
When is it enough to monitor an ovarian cyst?
For a simple, unremarkable cyst before the menopause, treatment is often not necessary. Small simple cysts often disappear on their own within a few cycles. For simple cysts under five centimetres that cause no symptoms, even a routine follow-up is often not required.
Whether I follow up a finding, and at what interval, therefore depends on, among other things:
If the finding is probably functional but a follow-up seems advisable, the examination can be repeated after a few weeks, for example, or after one or more cycles.
Do hormones help against functional cysts?
A functional cyst that is already present does not disappear any faster if you take the pill. Hormonal contraceptives that suppress ovulation can, however, influence the development of new functional cysts. Whether such treatment makes sense depends above all on whether hormonal contraception is wanted in any case. An uncomplicated functional cyst does not usually need drug treatment of its own.
When should an ovarian cyst be operated on?
An operation can be advisable if a cyst
Not every endometriotic cyst or dermoid cyst has to be operated on because of the diagnosis alone. Age, symptoms, size, development over time, the wish to have children and the ultrasound appearance must all be considered together.
Gentle surgery that preserves the ovary
If an operation is necessary and the finding appears benign, it is often carried out as a minimally invasive procedure by laparoscopy (keyhole surgery). Particularly in women before the menopause, my aim is to remove the cyst and preserve as much healthy ovarian tissue as possible. This is especially important if you wish to have children, as the egg reserve lies in the ovary.
Whether an operation is possible through a few small incisions or whether, in rare cases, a larger abdominal incision becomes necessary depends on the size and nature of the finding and on whether a malignant disease is suspected.
Tissue that has been removed is then examined under the microscope (histology). In certain situations it can make sense to remove not only the cyst but the affected ovary, or the ovary and fallopian tube. This can be necessary, for example, with a highly suspicious finding, with an ovary that is completely taken up by the change, or in certain situations after the menopause. Wherever possible, I discuss this approach with you in detail before the operation.
What applies to endometriomas?
With endometriomas, the decision to operate has to be weighed particularly carefully. Both the condition itself and an operation on the ovary can affect the ovarian reserve. For small endometriomas that cause few symptoms, monitoring can therefore make more sense than an operation. Before assisted reproduction (IVF), too, endometriomas are not routinely removed solely to improve the chances of pregnancy. An operation can, on the other hand, be advisable in the case of severe pain, a suspicious or unclear finding, or for other individual reasons, for example.
When an endometrioma is operated on, the cyst wall is removed wherever possible, while taking care to spare as much healthy ovarian tissue as possible. Compared with simply draining the cyst, removing it lowers the risk of recurrence, but this must be weighed against possible impairment of the ovarian reserve. You can find out more on the endometriosis page.
Do dermoid cysts always have to be operated on?
No. With a dermoid cyst, too, the decision depends on size, symptoms, growth, age and the ultrasound finding. It is true that dermoid cysts do not disappear on their own and can grow over time. Larger dermoid cysts also increase the risk of ovarian torsion.
In selected cases, however, smaller dermoid cysts that clearly appear benign and cause no symptoms can also be monitored. An operation on the basis of the diagnosis alone is not necessary as a matter of principle.
Where do the operations take place?
Since leaving the University Department of Obstetrics and Gynaecology at the end of 2023, I no longer carry out procedures as part of my work at AKH Wien. Depending on the procedure and individual arrangement, operations can take place at Privatklinik Confraternität & Goldenes Kreuz or at Privatklinik Döbling, among others. After an operation, we arrange the follow-ups according to the procedure and how your recovery is progressing. I also discuss the histology report with you at that point.
Why see Prof. Obwegeser about an ovarian cyst?
Many years of experience in ultrasound diagnosis
I have been a specialist in gynaecology and obstetrics since 1993 and worked as a consultant at the University Department of Obstetrics and Gynaecology at Vienna General Hospital (AKH Wien) from 1994. I left the university department at the end of 2023. The ultrasound assessment of changes in the ovaries was the starting point of my scientific work and has been one of my areas of focus for decades. In 2003 I founded the ZEM outpatient clinic for cysts, endometriosis and fibroids at AKH Wien and headed it until the end of 2023. The “Z” in ZEM stands for “Zysten”, the German word for cysts.
Knowing when surgery is not needed matters just as much
With ovarian cysts, two of my long-standing areas of focus come together directly: gynaecological ultrasound diagnosis and minimally invasive surgery. It is important to me not only to recognise when an operation is necessary, but equally when it can be avoided. Many cysts are benign and need no surgical treatment.
If you have already been advised to have an operation, you are also welcome to come to me for a second opinion. I assess the finding again and discuss with you the possible advantages and disadvantages of monitoring and of treatment.
At the practice, I show you your ultrasound finding on the screen and explain what matters when assessing it. You should be able to understand why I recommend a follow-up or an operation and what the plan is from there.
What does the assessment cost?
My practice is a private practice without a health-insurance contract. After the examination you receive an invoice, which you can submit to your health insurer for reimbursement. The amount reimbursed depends on the insurer concerned and the services provided.
Depending on your policy, supplementary private insurance may cover further costs in full or in part.
Before a planned operation you receive a written cost estimate, so that you can clarify the costs with your private insurer and, if necessary, obtain confirmation of cover. We will be happy to tell you the specific amount for your concern in advance by telephone. You can find further information on the practice page.
Does an ovarian cyst go away on its own?
That depends on the type of cyst. Functional cysts, which develop in connection with the normal cycle, often disappear on their own within a few weeks or a few cycles. Endometriomas, dermoid cysts and cystadenomas, by contrast, do not normally disappear spontaneously.
On ultrasound it is often already possible to judge quite well what type of change is involved. In some cases, the final diagnosis only becomes clear from how the finding develops over time or from the histological examination after an operation.
Is a cyst on the ovary dangerous?
The great majority of ovarian cysts are benign, particularly before the menopause. Certain ultrasound features can indicate that a finding should be assessed in more detail. These include, for example, solid components, irregular structures or certain patterns of blood flow.
The ultrasound image allows the risk to be estimated, but it cannot reliably rule out a malignant disease in every case.
After the menopause, new or complex changes are assessed particularly carefully. At the same time, many simple cysts are benign at this stage of life too and do not automatically have to be operated on.
Can I get pregnant with an ovarian cyst?
Yes. A simple functional cyst does not normally impair fertility. Endometriomas, on the other hand, can play a role in connection with endometriosis and difficulty conceiving. At the same time, an operation on the ovary can itself impair the egg reserve.
If you wish to have children, removal is therefore not automatically the right course. I discuss with you individually whether monitoring or operating is the better strategy for your situation.
How large does a cyst have to be before it is operated on?
There is no fixed size above which every ovarian cyst has to be operated on.
The main deciding factors are:
the type and ultrasound appearance of the cyst,
symptoms,
development over time and growth,
age and menopausal status, and
whether you wish to have children.
As size increases, the risk of torsion, among other things, can rise. Size alone, however, is not a sufficient reason to operate. With simple cysts before the menopause, for example, even findings of between five and seven centimetres can often be monitored by ultrasound at first.
Will I lose the ovary during the operation?
In most cases of a benign cyst in women before the menopause, the ovary can be preserved. Wherever possible, only the cyst is removed and healthy ovarian tissue is left in place. Whether this is possible and medically sensible depends, however, on the type and size of the finding, the remaining healthy ovarian tissue and any suspicion of a malignant disease. In certain situations, removal of the entire ovary may be necessary. As far as this can be foreseen before the operation, I discuss it with you in detail.
From 1989 to 2023 at the University Department of Obstetrics and Gynaecology at Vienna General Hospital (AKH Wien), senior consultant from 1994; founder and long-standing head of the ZEM outpatient clinic for cysts, endometriosis and fibroids.
If you have been diagnosed with an ovarian cyst or would like to have lower abdominal symptoms assessed, please arrange an appointment by telephone on +43 1 317 660 0 or write to ordination@prof-obwegeser.at. My practice is at Hörlgasse 14, Top 11, 1090 Wien. Please note that the entrance is at Liechtensteinstraße 8.