Management

Ovarian cysts <3 cm in diameter are considered normal and typically resolve without complication.34 However, if an ovarian cysts ruptures or bleeds, hemodynamic stability monitoring and ultrasound should be conducted. Significant bleeding on ultrasound or unstable patients should be admitted to an inpatient service for close monitoring, volume replacement, and, if warranted, referral for surgery.35

Ovarian torsion is a medical emergency that requires prompt surgical consultation for either ovarian detorsion to preserve the ovary or oophorectomy.36 Patients with endometriomas may have significant pain and pressure, and may elect to have an oophorectomy or cystectomy, especially if analgesics are unsuccessful in controlling pain.1,37 In patients who have recurrent ovarian cysts, oral contraceptives have been shown to be successful for prevention of new cysts; however, they have not been shown to decrease the size or increase the rate of healing of existing cysts.38,39

For patients at low risk for cancer whose ovarian cysts appear benign, a follow-up ultrasound 3- to 6-months after the initial ultrasound is recommended (Table 3).4,40 In women whose cyst contains malignant features, a repeat ultrasound is recommended 6 weeks after the initial ultrasound.20 Surgery may be necessary to accurately evaluate the tissue morphology if the cyst cannot be differentiated as benign or malignant, or in the case of malignant-appearing cysts.41,42 In all postmenopausal women, biomarkers CA 125 and HE4 should be assessed during the initial ultrasound.31


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Table 3. Ovarian Cyst Follow-Up Recommendations

DemographicFollow-up Recommendation
Pre-menopausal, low cancer riskRepeat ultrasound in 3-6 months
Pre-menopausal, high cancer riskRepeat ultrasound in 6 weeks
Post-menopausal, low cancer riskTumor marker CA 125 at initial ultrasound and repeat ultrasound in 3-6 months
Post-menopausal, high cancer riskTumor marker CA 125 at initial ultrasound and repeat ultrasound in 6 weeks*
Adolescent and youngerRepeat ultrasounds monthly until cyst resolution†
PregnantWatchful waiting⁺
*Exploratory surgery may be necessary to accurately evaluate the tissue morphology if the cyst cannot be differentiated as benign or malignant
† Cysts found to be growing, symptomatic, or malignant require surgical consultation
⁺ Surgery is recommended in this population when the cyst appears malignant, preferably after the first trimester.

In patients of adolescent age or younger, ultrasounds should be performed monthly until the cyst has resolved.43 Cysts found to be growing, symptomatic, or malignant require a surgical consult which may result in a range of treatments from a cystectomy to a bilateral salpingo-oophorectomy.15,16 In pregnant patients with benign-appearing ovarian cysts, watchful waiting with follow-up at the regularly scheduled fetal scans is the treatment of choice. Malignant-appearing cysts may be further evaluated with magnetic resonance imaging. If surgery is warranted in a pregnant patient, the recommendation is to wait until after the first trimester and perform the surgery laparoscopically rather than open surgery whenever feasible.44

Ovarian Cancer Risk

In a study of 15,735 postmenopausal women, serial transvaginal ultrasounds were used to assess the presence of simple cysts and the development of subsequent ovarian cancer. Women who had ≥1 cyst at baseline or developed simple cysts during the trial were not found to be at increased risk for ovarian cancer compared to their non-cyst counterparts (P =.85 and P >.99, respectively).15

In another study of 1769 postmenopausal women, 6.6% were found to have simple cysts at baseline. Of those with simple cysts, 23.3% resolved spontaneously and no malignancies were found by the end of the study.45 Finally, in a study of 15,106 women aged ≥50 years, 18% were found to have ovarian cysts (69.4% resolved spontaneously), while 27 women were diagnosed with ovarian cancer at the resolution of this study; only 10 of the women had previously been diagnosed with ovarian cysts.46

Meaghan Mize, PA-C, is a radiation oncology physician assistant at University Cancer and Blood Center, Athens, Georgia, and Alicia Elam, PharmD, is associate professor in the Department of Physician Assistant at Augusta University, Augusta, Georgia.

References

  1. The American College of Obstetricians and Gynecologists. Ovarian Cysts. https://www.acog.org/patient-resources/faqs/gynecologic-problems/ovarian-cysts. Accessed June 17, 2018.
  2. Borgfeldt C, Andolf E. Transvaginal sonographic ovarian findings in a random sample of women 25-40 years old. Ultrasound Obstet Gynecol. 1999;13(5):345-350.
  3. Breen JL, Maxson WS. Ovarian tumors in children and adolescents. Clin Obstet Gynecol. 1977;20(3):607-623.
  4. Castillo G, Alcazar JL, Jurado M. Natural history of sonographically detected simple unilocular adnexal cysts in asymptomatic postmenopausal women. Gynecol Oncol. 2004;92(3):965-969.
  5. Beckmann C, Ling F, Smith R, Barzansky B, Herbert W. Obstetrics and Gynecology. 6th ed. Lippincott Williams & Wilkins; 2009.
  6. Muzii L, Bianchi A, Bellati F, et al. Histologic analysis of endometriomas: what the surgeon needs to know. Fertil Steril. 2007;87(2):362-366.
  7. Patel MD, Feldstein VA, Lipson SD, et al. Cystic teratomas of the ovary: diagnostic value of sonography. AJR Am J Roentgenol. 1998;171(4):1061-1065.
  8. Kamel RM. A massive ovarian mucinous cystadenoma: a case reportReprod Biol Endocrinol. 2010;8:24. 
  9. Heilman J. 2-cm left sided ovarian cyst. Unchanged. Available from: https://commons.wikimedia.org/wiki/File:2cmleftovariancyst.png
  10. Haggstrom M. Dermid cyst. Unchanged. Available from: https://commons.wikimedia.org/wiki/File:Dermoid_cyst.jpg
  11. Haggstrom M. Endometrioma. Unchanged. Available from: https://commons.wikimedia.org/wiki/File:Endometrioma.jpg
  12. Heilman J. A large left ovarian cyst (5 cm) as seen on ultrasound. Unchanged. Available from: https://commons.wikimedia.org/wiki/File:LargeLeftOvCyst5cm.png
  13. Bryant AE, Laufer MR. Fetal ovarian cysts: incidence, diagnosis, and management. J Reprod Med. 2004;49(5):329-337.
  14. Schultz KA, Sencer SF, Messinger Y, et al. Pediatric ovarian tumors: a review of 67 cases. Pediatr Blood Cancer. 2005;44(2):167-173.
  15. Zhang M, Jiang W, Li G, Xu C. Ovarian masses in children and adolescents – an analysis of 521 clinical cases. J Pediatr Adolesc Gynecol. 2014;27(3):e73-77.
  16. Chu SM, Ming YC, Chao HC, et al. Ovarian tumors in the pediatric age group: 37 cases treated over an 8-year period. Chang Gung Med J. 2010;33(2):152-156.
  17. Zanetta G, Mariani E, Lissoni A, et al. A prospective study of the role of ultrasound in the management of adnexal masses in pregnancy. BJOG. 2003;110(6):578-583.
  18. Greenlee RT, Kessel B, Williams CR, et al. Prevalence, incidence, and natural history of simple ovarian cysts among women >55 years old in a large cancer screening trialAm J Obstet Gynecol. 2010;202(4):373.e1–373.e3739.
  19. Royal College of Obstetricians and Gynecologists. The Management of Ovarian Cysts in Postmenopausal Women. 2nd Ed. RCOG; July 2016.
  20. Bathala T, Bedi D, Bevers T et al. Ovarian Cyst – Incidental Finding. The University of Texas MD Anderson Cancer Center; 2019.
  21. Smith-Bindman R, Poder L, Johnson E, Miglioretti DL. Risk of malignant ovarian cancer based on ultrasonography findings in a large unselected population. JAMA Intern Med. 2019;179(1):71-77.
  22. Oyelese Y, Kueck AS, Barter JF, Zalud I. Asymptomatic postmenopausal simple ovarian cyst. Obstet Gynecol Surv. 2002;57(12):803-809.
  23. Boos J, Brook OR, Fang J, Brook A, Levine D. Ovarian Cancer: prevalence in incidental simple adnexal cysts initially identified in CT examinations of the abdomen and pelvis. Radiology. 2018;286(1):196-204.
  24. Timmerman D, Testa AC, Bourne T, et al.  Simple ultrasound‐based rules for the diagnosis of ovarian cancer. Ultrasound Obstet Gynecol. 2008;31(6):681-690.
  25. Biggs WS, Marks ST. Diagnosis and management of adnexal masses. Am Fam Physician. 2016;93(8):676-681.
  26. Kairys N, Roepke C. Tubo-ovarian abscess. In: StatPearls. Treasure Island, FL: StatPearls Publishing; Jan-Feb 2020.
  27. Yildirim M, Cendek BD, Avsar AF. Differentiation between benign and malignant ovarian masses in the preoperative period using neutrophil-to-lymphocyte and platelet-to-lymphocyte ratios. Mol Clin Oncol. 2014;3(2):317-321.
  28. Bakacak M, Serin S, Ercan O, et al. Utility of preoperative neutrophil-to-lymphocyte and platelet-to-lymphocyte ratios to distinguish malignant from benign ovarian masses. J Turk Ger Gynecol Assoc. 2016;17(1)21-25.
  29. Yilmaz M, Cimilli G, Saritemur M et al. Diagnostic accuracy of neutrophil/lymphocyte ratio, red cell distribution width and platelet distribution width in ovarian torsion. J Obstet Gynaecol. 2015;36(2)218-222.
  30. Lee JY, Shin W, Kim JS, et al. Combination of clinical and laboratory characteristics may serve as a potential diagnostic marker for torsion on mature cystic teratomas. Obstet Gynecol Sci. 2018;61(3)386-394.
  31. Dochez V, Caillon H, Vaucel E, et al. Biomarkers and algorithms for diagnosis of ovarian cancer: CA125, HE4, RMI, and ROMA, a review. J Ovarian Res. 2019;12(1):28.
  32. Moore RG, Brown AK, Miller MC et al. The use of multiple novel tumor biomarkers for the detection of ovarian carcinoma in patients with a pelvic mass. Gynecol Oncol. 2008;108(2):402-408.
  33. Partheen K, Kristjansdottir B, Sunfeldt K. Evaluation of ovarian cancer biomarkers HE4 and CA-125 in women presenting with a suspicious cystic ovarian mass. J Gynecol Oncol. 2011;22(4):244-252.
  34. Levine D, Patel MD, Suh-Burgmann EJ, et al. Simple adnexal cysts: SRU consensus conference update on follow-up and reporting.  Radiology. 2019;293(2):359-371.
  35. Raziel A, Ron-El R, Pansky M, Arieli S, Bukovsky I, Caspi E. Current management of ruptured corpus luteum. Eur J Obstet Gynecol Reprod Biol. 1993;50(1):77-81.
  36. Dasgupta R, Renaud E, Goldin AB, et al. Ovarian torsion in pediatric and adolescent patients: a systematic review. J Pediatr Surg. 2018;53(7):1387-1391.
  37. Beretta P, Franchi M, Ghezzi F, Busacca M, Zupi E, Bolis P. Randomized clinical trial of two laparoscopic treatments of endometriomas: cystectomy versus drainage and coagulation. Fertil Steril. 1998;70(6):1176-1180.
  38. Grimes D, Jones L, Schulz K. Oral contraceptives for functional ovarian cysts. Cochrane Database Syst Rev. 2009;(2):CD006134.
  39. Lanes SF, Birmann B, Walker AM, Singer S. Oral contraceptive type and functional ovarian cysts. Am J Obstet Gynecol. 1992;166(3):956-961.
  40. Alcázar JL, Olartecoechea B, Guerriero S, Jurado M. Expectant management of adnexal masses in selected premenopausal women: a prospective observational study. Ultrasound Obstet Gynecol. 2013;41(5):582-588.
  41. Curtin JP. Management of the adnexal mass. Gynecol Oncol. 1994;55(3Pt2):S42-46.
  42. Serur E, Emeney PL, Byrne DW. Laparoscopic management of adnexal masses. JSLS. 2001;5(2):143-151.
  43. Porcu E, Venturoli S, Dal Prato L, Fabbri R, Paradisi R, Flamigni C. Frequency and treatment of ovarian cysts in adolescence. Arch Gynecol Obstet. 1994;255(2):69-72.
  44. Hakoun AM, Abou-Al-Shaar I, Zaza KJ, Abou-Al-Shaar H, Salloum MNA. Adnexal masses in pregnancy: an updated review. Avicenna J Med. 2017;7(4):153-157.
  45. Conway C, Zalud I, Dilena M, et al. Simple cyst in the postmenopausal patient: detection and management. J Ultrasound Med. 1998;17(6):369-372.
  46. Modesitt SC, Pavlik EJ, Ueland FR, DePriest PD, Kryscio RJ, van Nagell JR. Risk of Malignancy in unilocular ovarian cystic tumors less than 10 centimeters in diameter. Obstet Gynecol. 2003;102(3):594-599.