Uterine fibroids and ovarian cysts – the important difference (& should you stop having sex?)

What’s the difference between fibroids and cysts? A doctor answers

Based in New York at the world-renowned Weill Cornell Fertility Institute, Dr Samantha Pfeifer is a board-certified obstetrician/gynaecologist and reproductive endocrinologist with over 30 years of experience in the field, specialising in reproductive surgery, as well as fertility preservation and IVF.

Today, we sit down to get her expert insight on all things uterine fibroids and ovarian ⁠cysts.

Watch as she answers:

• What’s the difference between fibroids and cysts?
• Can birth control pills cause ovarian cysts?
• Does having an ovarian cyst mean I’m not ovulating?
• Should I stop having sex if I have fibroids or cysts?
• Can fibroids and ovarian cysts cause painful sex?
• Can uterine fibroids grow back after treatment?
• And more

Want to hear more from Dr Pfeifer? Watch this next: What are the best sex positions to conceive? Your fertility questions answered

Transcript

Eloise Edington
Hello, welcome! I am Eloise, the founder and CEO of The Ribbon Box, which is a community-led media platform to help people through well-being, fertility, pregnancy, and parenting. 

I’m delighted to be speaking to Dr. Samantha Pfeifer from Weill Cornell, who is joining us today to discuss uterine fibroids and ovarian cysts.

Dr. Sam Pfeifer
Hello, hello Eloise! It’s so good to see you again, and thank you for having me.

Eloise Edington
Always interesting to hear the latest from a reproductive surgeon about these pelvic conditions, fertility, well-being, etc. I’m going to ask you a couple of questions. 

What is the difference between uterine fibroids and ovarian cysts?

Dr. Sam Pfeifer
The major difference is where they originate. Uterine fibroids are tumors that originate in the muscle of the uterus, and ovarian cysts are fluid-filled tumors, if you will, or functional cysts that arise within the ovary. So that’s the major difference. 

The other is that ovarian cysts are fluid-filled, and uterine fibroids are solid. They often feel like a lacrosse ball or a very dense ball.

Eloise Edington
Do you see patients with them often?

Dr. Sam Pfeifer
Yes, I mean, that’s one of the very common things we see in reproductive-age women. 

The other thing is, we see them frequently because we often do ultrasounds on women who are attempting pregnancy and having difficulty, so we’re picking them up. Many of them are asymptomatic, meaning that the individual was not aware she had them. 

Fibroids typically grow over time; they do not disappear. They grow at different paces, so someone may not know they may have had a fibroid for many years. 

Ovarian cysts, on the other hand, are different because some of them are functional, meaning they come and go with the menstrual cycle, and then some are persistent and reflect a benign tumor process.

It’s funny, when I diagnose an ovarian cyst on ultrasound in a patient, I’ll say, “Oh, and you have a cyst on this ovary,” and the immediate reaction is panic: “A cyst? I’ve never had a cyst before!” I say, “No, no, this is a normal cyst that happens as part of the menstrual cycle process.” A cyst forms, ovulation occurs, and that cyst that ovulation arose from then turns into a bigger cyst, which produces progesterone.

The intention is to support a pregnancy, and then, in the absence of pregnancy, it goes away, and the whole process starts again.

Eloise Edington
Can they exist at the same time?

Dr. Sam Pfeifer
They can. I mean, if you look at functional cysts, they are happening all the time in women who are having menstrual cycles. 

But benign cysts, that are tumors, can occur, and fibroids can occur because the risk factors are a little bit different. So, they are very common things, and common things can coexist rather frequently.

Eloise Edington
Should you panic if you get diagnosed with one?

Dr. Sam Pfeifer
Never panic—it’s a waste of time! Most of these are benign; most of these do not cause a problem. 

In the case of ovarian cysts, a lot of them go away. In the case of fibroids, you often don’t need to do anything about them. So, the first thing is not to panic. 

An evaluation is needed to determine if, in the case of fibroids, they are in a problematic place. Fibroids are all about location. If the fibroid is located within the cavity of the uterus, those tend to be more symptomatic, causing heavier bleeding and spotting, and those are the ones that can really cause issues with fertility. But the vast majority of them are benign. 

In women under the age of 35 to 40, the chance of there being cancer is probably less than one in 3,000, so it’s very, very rare.

Fibroids that are growing in postmenopausal women, we worry about those potentially being cancer, but the incidence of cancer is relatively low, so we don’t worry about that very much.

With ovarian cysts, if they are tumors, they often are asymptomatic. If they are present, they can cause pain symptoms, and in certain cysts, if they are over 5 cm, they can be at higher risk of having a twisting motion or torsion, which is like wringing out a dish towel. When that happens, the blood flow to the ovary is cut off, leading to the severe onset of pain, and that can ultimately result in the ovary dying, if you will.

Usually, the pain is so severe that people tend to go to an emergency room to be evaluated for that type of pain. But ovarian cysts can cause pain just by being present, so they are usually more symptomatic the larger they are.

Eloise Edington
Could someone only find out that they have a cyst from a torsion? Would that be the only symptom they might get, or would they have pain leading up to it?

Dr. Sam Pfeifer
If there’s a torsion—the twisting of the ovary—when the ovary has twisted enough so that the blood flow is cut off, it typically results in a sudden onset of severe, severe pain accompanied by nausea and vomiting. 

The classic scenario is someone suddenly having pain, dropping to their knees on the ground, and writhing in pain—that reflects the torsion. Now, leading up to that, the ovary may have twisted partially and then untwisted, so people can have random intermittent pain that’s not that severe.

You see patients who have intermittent pain on the side where there is a cyst, and the thing you always think about is: could that be intermittent partial torsion?

In those individuals, if people have a cyst and are having some symptoms, it’s better to remove the cyst to avoid having torsion. Because torsion, if left undiagnosed, can result in the ovary being removed. If it is diagnosed early, then the ovary can be surgically untwisted, and it can revive and recover. So, it’s a problem that can be fixed, but it’s good to detect any subtle pains leading up to it.

Eloise Edington
Can it cause infertility?

Dr. Sam Pfeifer
If there is a torsion, and associated with the torsion, there could be a lot of inflammation and irritation in that area, and if it goes undiagnosed, the ovary can disappear, and there can be scar tissue even involving the fallopian tube on that side. 

So, there may be destruction of the ovary and blockage of that fallopian tube, which can impact fertility. But anytime you have any inflammatory process in the abdomen, we worry about an impact on fertility. 

In women in particular, appendicitis is key because if the appendix ruptures, there’s a chance that there can be a lot of scar tissue, which can decrease the chance of getting pregnant in the future.

Eloise Edington
Do fibroids only affect women over 30?

Dr. Sam Pfeifer
No, I think that’s a funny question, actually. Fibroids can affect anybody. I think there’s an ethnic type to this, if you will. For example, we find that African-American women are very prone to fibroids, and in that ethnic group, they often have multiple fibroids that grow very fast. 

In other situations, you can have one fibroid or two fibroids, but no more develop, so it’s kind of random. I’ve taken fibroids out of teenagers and young women. Fibroids grow in the presence of estrogen, but there are probably other factors that we are unable to pinpoint. They’re very different, and they can occur in anybody. 

I think they’re often diagnosed in older women over 30 because they’re more likely to be having ultrasounds or having situations that would warrant evaluation.

Eloise Edington
Can birth control pills cause ovarian cysts?

Dr. Sam Pfeifer
Yes, they can, which is sort of counterintuitive because we give people birth control pills to prevent ovarian cysts and to shut down the ovaries. 

One would think, “Oh, they don’t cause cysts,” but in fact, women on birth control can develop ovarian cysts. 

These are functional cysts, and they may go away, but we know that sometimes women on birth control will develop a cyst that is a functional cyst—typically not a large cyst—but they may develop a small cyst that usually resolves on its own.

Eloise Edington
Does having an ovarian cyst mean that someone is not ovulating?

Dr. Sam Pfeifer
No, not necessarily, because ovarian cysts can come and go. In women who are not ovulating, they can develop an ovarian cyst. So, again, thinking about functional cysts—cysts that are developing as a response, a functional response of hormones or something like that—versus ovarian cysts that are tumors. 

Tumors are really independent of hormonal influences. If people aren’t ovulating, they may be stimulating the follicles to grow, but there’s no release of the egg, or there’s no ovulation occurring. So, they can happen in any situation. Tumors typically don’t occur more frequently in people who ovulate or don’t, but functional cysts can occur in both of those populations.

Eloise Edington
Should someone stop having sex if they have fibroids or cysts? Can fibroids and ovarian cysts cause painful sex?

Dr. Sam Pfeifer

Fibroids and ovarian cysts can cause painful sex, yes. I think there are different situations where you may feel a fibroid pushing into the vagina, so it can be painful. 

Cysts are often painful because of the position or the size of the cyst, but it doesn’t mean that you have to stop having sex. You can wait and see what happens with your body, or, in some cases, treatment may be warranted.

Clearly, fibroids can cause pain because the uterus can be large, and it may be uncomfortable with intercourse. Ovarian cysts similarly can be sensitive and cause pain with intercourse. No, there shouldn’t be any reason to stop. 

I mean, I think, you know, clearly if fibroids are causing symptoms, they should be addressed, and there are many ways of doing that. For some, fibroids’ surgical removal is the best option.

In other situations, there are medications now people can take to treat fibroids. There are non-invasive surgical methods that can be used to address fibroids—many, many different ways of treating fibroids. 

I think the one thing that is really important to recognize is that having fibroids does not mean one has to have a hysterectomy, because, you know, in older generations, if there were fibroids, the treatment was hysterectomy, and that is not true these days. There are many, many different options to preserve the uterus for whatever reason. 

I see a lot of women who, for whatever reason, do not want to have their uterus removed, and it’s lovely that there are options that can allow someone to maintain the uterus and treat the fibroids at the same time.

Eloise Edington
Am I right in thinking that if you have your uterus removed, it sort of takes you into menopause?

Dr. Sam Pfeifer
It’s removing the ovaries. 

Eloise Edington
Oh, the ovaries, yeah.

Dr. Sam Pfeifer
So the ovaries produce all the hormones. If you just take out the uterus, then you’re not affecting the hormones, but certainly, if the uterus is removed, that does not precipitate menopause. 

If the ovaries are removed, then, of course, it’s what we call surgical menopause, which is the sudden onset of menopause, and that can be very difficult because menopause typically occurs gradually over time as the ovary produces less and less estrogen, and it’s a gradual progression. 

But if the ovaries are functioning properly and then suddenly they are removed, then there’s a very dramatic change, and that can be very difficult for an individual to go through.

Eloise Edington
I think it’s great that there’s so much people are talking about menopause now, but equally, it makes it terrifying because you just think it’s going to be such a long time to go through and the side effects sound horrific.

But great that there are ways to manage it. 

Dr. Sam Pfeifer
No, I think, you know, everyone is different. There are many people that really, really have no side effects or no symptoms at all with menopause. There are some people that have a lot of terrific symptoms with menopause, and I think there are a lot of options—hormonal options and also non-hormonal options—to help women with those symptoms. 

I think that’s fantastic because women are living longer, and to go through menopause at age 50, and you’re, you know, expecting a life expectancy maybe of another 30 or 40 years, that’s a long time. 

But the other thing is, similarly, if an ovarian cyst is present and it needs to be surgically removed for some reason, it’s really important in a young individual, and even in an older individual, to consider treatment that preserves the ovary—to take the cyst out and leave the ovary behind. 

One of the things that a lot of people do not understand is that all of the eggs are contained in the surface of the ovary. So in removing an ovarian cyst—I like analogies when I talk to patients—and I use the analogy about a banana and a banana peel. So an ovarian cyst is basically the banana, and the ovary is the banana peel. 

When you take the cyst out of the ovary, you peel the banana peel down, you peel the wall of the ovary down, you take out the cyst, and then you leave the ovary, the banana peel, behind, and that’s where all the eggs are. 

So even if the surface of the ovary is stretched over a large cyst, all of the eggs are in that capsule. You don’t want to take any of that out, and that’s how you can preserve ovarian function in the presence of taking a cyst out of the ovary. 

So, you know, an ovary does not need to be removed if there’s a cyst, and that’s really critical for a lot of people who have benign conditions and want to preserve their ovaries.

Eloise Edington
Can uterine fibroids grow back after treatment, and if so, what options are there to manage them, especially if you’re trying to conceive?

Dr. Sam Pfeifer
Yeah, if you’re trying to conceive—well, uterine fibroids, they don’t necessarily grow back; there are others that are lurking there, that are small, that will continue to grow. 

So if you have one fibroid removed, it’s very unlikely that another one will occur. If, however, there are 15 fibroids removed, there’s a 50% chance that within five years, more fibroids will be seen on ultrasound. So I think it depends on the number that are there originally, because if there are a lot in the uterus, there are often many there that are so small they cannot be addressed at that time. 

Fibroids are monoclonal tumors, and so each fibroid grows at its own pace, so there’s no guarantee that these fibroids that are popping up after a myomectomy or fibroid surgeries to remove the fibroids—there’s no way of knowing if the ones that replicate later are going to be a problem for fertility or not. It’s hard to predict. 

But I think the one thing that is very valid is that if you got a bunch of fibroids and had a bunch of them taken out, it’s very likely that you’ll have more showing up later.

Eloise Edington
But I guess people then know, and they can have it checked and make sure they’re on top of it?

Dr. Sam Pfeifer
I recommend anyone who has even an ovarian cyst or fibroids addressed—I recommend that they have intermittent ultrasounds, just so they know what’s going on. Because a lot of times, I’ll see someone shows up to see me for fibroids or a cyst, and they are totally oblivious to the fact they had it. 

They go, “I have this in my belly? I’ve got fibroids? I’ve got an ovarian cyst, and I didn’t know I had it? How long has it been there?” And they become very concerned about that. 

After the removal of either fibroids or cysts, I say, you know, I think it’s good to have an intermittent ultrasound, so you’re not blindsided by the fact that you have a massive fibroid in your uterus you didn’t know you had. 

The smaller these things are, the easier they are to remove. So the question is, at what point do you address them, and at what point do you say, “No, we have a little bit of time; we don’t need to do anything now.”

Eloise Edington
I think it’s really interesting. Well, from having been a fertility patient, you spend so many years—depending on how long you’re doing it for—but so many years monitoring what your body’s doing, having scans, monitoring cycles, you know your last period, all sorts of things. 

Then, when you’re done having your children, it’s like you’ve just sort of dropped off a cliff, and it’s kind of not really relevant what’s happening with your cycle or anything anymore. You lose track of when your period’s coming; you just get, you know, symptoms cropping up, and you think, ‘Has it already been a month?’ 

Whereas when you’re in the flow, or in the swing of treatment, and you’re waiting to start IVF, for example, you’re desperate for your period to start!

Dr. Sam Pfeifer
I mean, ignorance is bliss sometimes, you know? It’s a lot to keep up with and think about, especially for an individual who’s been attempting pregnancy and monitoring. 

Every time a cycle starts, there can often be a very big emotional down, or it could be up, like, “Okay, I get to start IVF now!” But I think that without really caring about what’s going on, a lot of that pressure is gone. 

I mean, how much time is spent tracking someone’s cycle on the apps that we have out there? That takes up a lot of time, and that time can be used to do other things. 

For people that have completed their childbearing, it could be a great relief not to have to address that.

Eloise Edington
Well, thank you so much for your expertise today. 

Please do check our link in the description, in the bio, to find out more about how Dr. Pfeifer may be able to help you, and feel free to book a consult at Weill Cornell. So, thank you very much for your time today. 

Dr. Sam Pfeifer
It was great to talk to you, as always Eloise. Thank you for having me.