From the Guidelines
Mildly enlarged ovaries do not necessarily require a workup, especially in premenopausal women, unless they are accompanied by concerning symptoms or risk factors, as the risk of malignancy is low, approximately 0.5% in premenopausal women with anechoic cysts 1. When evaluating mildly enlarged ovaries, it's essential to consider the patient's age, symptoms, and ultrasound characteristics.
- In premenopausal women, simple cysts up to 10 cm in diameter are likely to be benign and may be safely monitored using repeat imaging without surgical intervention 1.
- The American College of Obstetricians and Gynecologists recommends that simple cysts less than or equal to 5 cm in diameter in premenopausal patients require no additional management, and those less than or equal to 3 cm should be considered physiologic 1.
- For cysts greater than 5 cm but less than 10 cm in premenopausal patients, a follow-up in 8–12 weeks is recommended to confirm its functional nature or to reassess for cyst wall abnormalities 1.
- In postmenopausal women, no further management is suggested for cysts up to 3 cm, and for cysts greater than 3 cm but less than 10 cm, at least 1-year follow-up showing stability or decrease in size is recommended 1. It's crucial to note that the threshold for concern varies by age, and even mild enlargement in postmenopausal women may require more thorough investigation due to the higher risk of malignancy.
- Transvaginal ultrasound is a valuable tool for assessing ovarian volume and morphology, and hormonal testing (FSH, LH, estradiol, testosterone, DHEAS) may be considered if symptoms such as pelvic pain, irregular menstrual cycles, or infertility are present.
- CA-125 testing may be considered if there are concerns about malignancy, but its use should be judicious due to its low specificity. Overall, a tailored approach to evaluating mildly enlarged ovaries, taking into account the patient's individual characteristics and symptoms, is essential for providing optimal care.
From the Research
Mildly Enlarged Ovaries Workup
- A workup for mildly enlarged ovaries may be necessary in certain cases, as adnexal masses can have various etiologies, ranging from normal luteal cysts to ovarian cancer 2.
- The American College of Obstetricians and Gynecologists (ACOG) states that simple cysts found on ultrasound may be safely followed without intervention, even in postmenopausal women, as they are not likely cancer precursors or markers of increased risk 3.
- However, women who report abdominal or pelvic pain, increased abdominal size or bloating, difficulty eating, or rapid satiety that occurs more than 12 times per month in less than a year should be evaluated for ovarian cancer 2.
Diagnostic Considerations
- Pelvic examination has low sensitivity for detecting an adnexal mass, and negative pelvic examination findings in a symptomatic woman should not deter further workup 2.
- Transvaginal ultrasonography is the first choice for imaging of an adnexal mass, and large mass size, complexity, projections, septation, irregularity, or bilaterality may indicate cancer 2.
- A cancer antigen 125 (CA 125) test may assist in the evaluation of an adnexal mass in appropriate patients, but CA 125 levels are elevated in conditions other than ovarian cancer 2, 4.
Screening and Follow-up
- The use of CA 125 as a diagnostic biomarker has not improved patients' survival, and screening average-risk asymptomatic women with CA 125 is not recommended by any professional society 4.
- For postmenopausal women with simple ovarian cysts, ovarian cancer screening and follow-up include a CA-125 blood test and transvaginal ultrasonography (TVU) at baseline, an annual TVU for three additional years, and annual CA-125 tests for five years beyond baseline 3.
- Women with positive screening examinations, such as those with ovarian volume greater than 10 cubic cm or cyst volume greater than ten cubic cm, should be referred to a gynecologic oncology unit for follow-up investigation 3.