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Dermoids: From Soup to Nuts, the Cyst That Has It All

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What has hair, teeth, yellow gooey fluid, and likes to call your ovaries home? No, this is not a bad joke or a fictional character in a fantasy novel. It’s a dermoid cyst, and it’s pretty common in women under the age of 30. Dermoids, also affectionately known in the medical world as ovarian germ cell tumors or mature cystic teratomas, comprise about 25% of all ovarian cysts. The large majority are benign (phew!) but can be quite pesky and occasionally painful.

What makes them so notable is not whom they affect but how they affect them. Let’s take a quick trip back to Bio 101. In our body, we have three types of tissue: endoderm, mesoderm, and ectoderm. These big three make up the basis of every organ in our body, including our skin. Mature cystic teratomas (nickname deromids) are comprised of all of these three cell types. Hence, they have the ability to be whatever or whoever they want. That’s why when they are removed and opened, you can see anything from hair to teeth to nerve tissue to fat cells.

Just like their Houdini-like abilities to transform into everything and anything, they are often invisible when it comes to pain. Many women find they have dermoids totally by accident on an ultrasound for something else or during a physical exam.

Symptoms in general are a side effect of size. The larger the dermoid, the more likely you will have pain, pressure, cramping, etc. Occasionally, dermoids will present with acute pain, nausea/vomiting, and a trip to the operating room. This is called ovarian torsion. When cysts take up residence in the ovaries, the size of the ovary can increase substantially. The bigger an ovary, the more apt it is to twist.

Very rarely, a dermoid cyst will make itself known by rupturing, that is, opening up. When it does this, that yuck fluid escapes its “jail” and has now leaked all over your pelvis/abdomen. This can be pretty painful and almost certainly requires a surgery to do a major clean out. Your body can react very strongly to this unwelcome substance, and unless treated ASAP, major scar tissue and other serious issues can occur.

When dermoids say cheese to our camera (the ultrasound), they have a very characteristic smile. This is a good thing because it allows us to be pretty confident in what we are dealing with. Once it is confirmed, or as close to confirmed as we can get, a treatment plan is devised. Depending on the size (and symptoms) of the cyst, surgery may be recommended. Most of the time these cysts can be removed with the aid of a laparoscope (a.k.a. camera) and a few small incisions.

This minimally invasive approach allows women to come in and go home within a few hours. While the ovary is almost always left inside in women who still have babies and pregnancy on their brain, for women who are done with the baby thinking, it is ok to remove the entire ovary. Make sure that you discuss the surgical approach and strategy with your doctor before going in. You want to make sure that you are on the same page!

Although most are benign, there is a small subset of ovarian germ cell tumors that are bad (a.k.a. can cause cancer). The names of these are definitely going to be foreign, but we will make a quick intro in case you should run into them in a dark alley. They include dysgerminonams, yolk sac tumors, and mixed germ cell tumors. Luckily, most of us will never ever meet them ourselves or know anyone who will encounter them. However, if you do, make sure you see a GYN who specializes in ovarian cancer (a.k.a. GYN oncologists). Rare ovarian tumors are their bread and butter; they know the best surgery approaches, the best medical treatments, and the best way to tackle this problem.

You may have to travel to see them (not every town/city has one in their zip code), but it’s worth the trip. They may save your ovary, save your fertility, and most importantly, save your life.
When you hear the word cyst, you probably mutter a curse word and ask what does this mean?! And then, when it is followed up by “and it looks like it may have hair, teeth, and yellow stuff,” (and no it is NOT a baby) your psyche gets even more psyched out. But don’t despair. Although dermoids are sort of disgusting to look at, they are not divas to deal with. They are fairly easy to remove, almost always benign, and come back in only about 4% of cases. Find a good doctor who knows what they are doing, and your dermoid doesn’t stand a chance!

The Most Unwelcome House Guest: Endometriomas

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When you can’t find your keys, what do you do? Most of us go to the “hot” spots and start searching. Hot spots are those places that you usually, on most days, drop your keys: on the kitchen counter, in the hallway, hanging on a hook in the garage. By hitting those high-traffic key spots, we are pretty likely to find a match.

When looking for evidence of endometriosis, we go to those hot spots, and the ovaries are the hottest of the hot spots. Endometriosis that implants on the ovaries and forms a cyst is called an endometrioma. News flash: endometriomas and the ovaries are not friends; in fact, they are not even frenemies. They are unwelcome guests that can make the ovaries incredibly unhappy. And here’s why.

Intruders are not fun in anyone’s house. This is particularly true in the ovaries that are already dealing with a limited supply of goods (a.k.a. eggs). Endometriosis on the ovaries can range from mild (a few spots) to major (a whopping 10cm, plus a cyst). Usually, the bigger the cyst, the bigger the problem. And although this may be hard or disturbing to picture, what’s inside the cyst bears a close resemblance to chocolate. While we hope that didn’t destroy your love of everything Hershey’s, Nestle, or Godiva, that is what the brown fluid that leaks out of the cyst looks like.

And while it may look like chocolate, it’s more of an inflammatory soup; factors and mediators lurking in this fluid are not pleasant. They’re irritants. They can damage the ovary and eat away at your egg supply—as well as your quality of life. It is for this reason and others that women with endometriosis often experience infertility.

The walls of endometriomas were not built in a day. They are usually quite tough and scarred. In many cases, the ovary-plus-cyst complex is stuck like glue to surrounding abdominal organs (intestines, uterus, etc.). This can make taking them out pretty challenging. Fortunately, surgeons that specialize in endometriosis surgery have a lot of weapons in their armamentarium.

You want to make sure the good guys are fighting for you, and for this reason, make sure you vet your endo surgeon well. Unlike those keys that you couldn’t find, you can’t just get a new ovary copied. If you lose it, it is forever lost. For this reason, you want to make sure whomever you are trusting to “hold them” knows what they are doing.

The good news about endometriomas is that the hot/cold/found-it game is pretty easy. An ultrasound is pretty spot on in identifying what is likely an endometrioma and what is not. On ultrasounds, the cyst/mass will look greyish/white and solid, and it usually has a lot of blood flow. If your doctor is still on the fence about what is plaguing your ovary or needs more information before surgery, an MRI is usually their go to. With these tools in our pocket, we can decide if surgery is needed, what the best approach for surgery is, and how major the surgery will be. It is important to take good before pictures (say cheese!) prior to surgery so that you have a good idea about what the after should look like.

Unfortunately, the recurrence rate of endometriomas is pretty high, especially when the surgeon does not remove the cyst wall in its entirety. Simply draining the cyst doesn’t do all that much for you or for your chances of being cured.

Word of advice…make sure to ASK your surgeon how he or she plans to remove the endo before signing that consent form. The reason for the high recurrence rate of all things endo is that estrogen is fueling its fire. If estrogen is around, endo will grow—sort of like, if you build it they will come. It is for this reason that, for women who do not have babies on the brain (because they are not ready or they are done), we recommend shutting the reproductive system down (pills, Lupron etc.) after undergoing surgery.

Cold, hot, hotter, hottest—you found it! Endometriomas are often a pretty good giveaway for underlying endometriosis. They have no game face, and when present, you can pretty easily guess what’s causing those unpleasant symptoms. While they may not need to be treated unless causing pain or contributing to infertility, they do shed some major light on what may be hiding in the dark in your pelvis. It may be the key to what you experience in the future—make sure you know where you put it!