Ovarian cysts due to hormonal contraception

The progressive lowering of hormonal doses in oral contraceptives (OCs) and the disappearance of estrogen from some formulations have significantly modified the profile of ovarian secretions at time causing observable side effects. Among these are sometime painful ovarian follicular cysts which may become the object of unnecessary surgical treatment. Ovarian cysts of this type are quite frequent but have not been described adequately in the literature. In 2 cases described here a 20-year-old woman with a 6-month history of use of a low-dose pill containing .35 mg of norgestrienone was operated on for a mass diagnosed on examination and sonography as a possible ectopic pregnancy. It was a ruptured ovarian follicular cyst of 60 mm in diameter. The 2nd case concerned a 39-year-old woman with unexplained pelvic pain whose ovarian cyst of 50 mm in diameter was diagnosed with sonography. The cyst disappeared within a few days of discontinuation of her triphasic OC containing levonorgestrel and ethinyl estradiol. This type of cyst can be called reactional because it is induced by OC use. So-called functional ovarian cysts were often observed with the high-dose OCs of the past. They were often inactive and should have been called reactional as well to distinguish them from benign or malignant ovarian tumors. It has been demonstrated through laparotomy and sonography that the 4 low-dose progestins currently used in France considerably increase the incidence of ovarian cysts. Cysts have also been reported with triphasic pills but no statistical study is available which assesses the risk of developing cysts with triphasic pills. It is even possible that monophasic and biphasic pills have the same properties. The symptoms of such cysts are sometime deceptive. Most reported cases received laparoscopic treatment because of pain and ovarian hypertrophy sometimes associated with metrorrhagia. Tubal pregnancy is often suspected and the cyst may rupture. Systematic sonographic study of OC users indicates that cases of latent cysts are much more numerous than are painful cases. The diameter of cystic follicules may attain up to 100 mm. Spontaneous regression usually follows termination of OC use. Intervention is recommended if the tumor persists beyond 3 months. Sonographically guided puncture is the simplest treatment. If the tumor recurs laparotomy and complete excision are required. More widespread knowledge of cystic follicules associated with low-dose OCs would help avoid diagnostic errors and unnecessary interventions.