Fetal ovarian cysts are found incidentally during ultrasound (Table 1).13 Ovarian cysts in children and adolescents may present as abdominal pain, asymptomatic abdominal mass, increased abdominal size, or menstrual irregularities.14-16 In patients who are pregnant, ovarian cysts may be found incidentally on ultrasound as an abdominal mass or as abdominal or back pain.17 In postmenopausal women, ovarian cysts may be found incidentally on ultrasound, such as when screening for cancer, or symptomatically with acute abdominal pain from cystic torsion or rupture.18,19

Table 1. Presentation of Ovarian Cysts

FetusIncidentally on ultrasound
Child/AdolescentAbdominal pain, asymptomatic abdominal mass, increased abdominal size, menstrual irregularities*
PregnantAbdominal or back pain*
PostmenopausalAcute abdominal pain from cystic torsion or rupture*
*May also present asymptomatically on ultrasound

Pelvic Examination

In all symptomatic patients, an abdominal and pelvic examination should be performed followed by an ultrasound. When performing the pelvic examination, the clinician may feel lumps or notice asymmetry of the ovaries.1 Transabdominal ultrasounds are generally well-tolerated by patients; however, a transvaginal ultrasound may provide clearer images. On ultrasound, simple cysts appear unilocular, anechoic, smooth-walled, have no solid components, have no internal blood flow, and show posterior acoustic enhancement.20 Simple cysts have not been found to be associated with an increased risk of ovarian cancer in premenopausal or postmenopausal women; however, complex cysts require further investigation in all ages.21-23

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The International Ovarian Tumor Analysis (IOTA) ultrasound-based rules consist of 10 points to provide quick and simple assistance in distinguishing benign from malignant tumors (Table 2).24 The tumor is identified as benign if one or more B-rules apply and no M-rules apply, and vice-versa. Should both M- and B-rules apply or neither apply, results are inconclusive.24

Table 2. IOTA 10 Simple Rules for Identifying a Benign or Malignant Tumor24

Malignant (M) RulesBenign (B) Rules
M1: Irregular solid tumorB1: Unilocular
M2: Presence of ascitesB2: Presence of solid components where the largest solid component has a largest diameter <7 mm
M3: At least 4 papillary structuresB3: Presence of acoustic shadows
M4: Irregular, multilocular, solid tumor with largest diameter 100 mmB4: Smooth, multilocular tumor with largest diameter <100 mm
M5: Very strong blood flow (color score 4)B5: No blood flow (color score 1)

Patients who experience severe pain, nausea, and vomiting should be assessed to differentiate cystic rupture from ovarian torsion.  Women of reproductive age should have a pregnancy test not only to best determine management, but also to investigate the possibility of ectopic pregnancy.25 A complete blood count will help differentiate a cyst from an abscess based on the presence of an elevated white blood cell (WBC) count. An elevated WBC count with a fever may infer a tubo-ovarian abscess. Elevated neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio in the presence of an elevated cancer antigen (CA) 125 level may indicate ovarian cancer. Elevated neutrophil-to-lymphocyte ratio with elevated WBC and neutrophil counts suggest ovarian torsion.26-30

Postmenopausal patients and those with malignant-appearing cysts should have tumor markers CA 125 and human epididymis protein 4 (HE4) levels assessed to differentiate benign from malignant cysts. CA 125 alone has a low sensitivity in early-stage ovarian cancer and can also be falsely elevated from menstruation or endometriosis.31 Conversely, HE4 is dependable in the setting of endometriosis and has been shown to increase both the sensitivity and specificity of diagnosing early stage ovarian carcinoma.31,32 This allows for aid in the diagnosis of endometriosisin the setting of an elevated CA 125 and normal HE4 as well determining which cysts are likely malignant in the setting of elevations in both biomarkers.31,33

Of note, HE4 has been found to be elevated in patients who smoke and decreased in patients who use oral contraception (when compared to other forms of contraception). The cutoff value for CA 125 is 35 U/mL for all ages and 70 pmol/L for HE4 in premenopausal patients and 140 pmol/L in postmenopausal patients.31