From the Guidelines
An ovarian cyst in a 79-year-old postmenopausal woman found on CT requires prompt gynecologic evaluation due to increased risk of malignancy, and the patient should be referred to a gynecologist or gynecologic oncologist within 1-2 weeks for transvaginal ultrasound and CA-125 blood testing. The risk of malignancy increases with age, particularly after menopause, and with cyst characteristics such as size greater than 5 cm, solid components, septations, or bilateral presentation 1. According to the American College of Radiology's O-RADS US risk stratification and management system, a simple cyst up to 10 cm in diameter on transvaginal ultrasonography performed by experienced ultrasonographers is likely to be benign and may be safely monitored using repeat imaging without surgical intervention, even in postmenopausal patients 1. However, 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 with consideration of annual follow-up for up to 5 years, if stable 1.
Key Considerations
- The patient's age and postmenopausal status increase the risk of malignancy
- Cyst characteristics, such as size, solid components, septations, or bilateral presentation, also increase the risk of malignancy
- Transvaginal ultrasound and CA-125 blood testing are essential for further evaluation
- Management depends on imaging findings and may range from surveillance to surgical intervention
Management Options
- Surveillance with repeat imaging in 3-6 months for simple cysts smaller than 5 cm
- Surgical intervention for complex or larger cysts
- Referral to a gynecologist or gynecologic oncologist for further evaluation and management
Relevant Guidelines
- American College of Radiology's O-RADS US risk stratification and management system 1
- American College of Obstetricians and Gynecologists Committee on Practice Bulletins—Gynecology recommendations for simple cysts in postmenopausal women 1
From the Research
Significance of Ovarian Cyst in Postmenopausal Female
- The risk of malignancy in an ovarian cyst increases with age, with the risk being higher in postmenopausal women 2.
- However, the majority of adnexal masses in postmenopausal women are benign 3.
- A study found that the malignancy rate of simple ovarian cysts in postmenopausal women is approximately 1 in 10,000 4.
Diagnostic Approach
- Transvaginal ultrasound is considered the imaging modality of choice for evaluating adnexal masses in postmenopausal women 3.
- CA125 levels should be checked in women who present with symptoms such as frequent bloating, feeling full quickly, loss of appetite, pelvic or abdominal pain, or needing to urinate quickly or urgently 2.
- PET/CT and PET/MRI can also be used to detect lymph node and distant metastasis in ovarian cancer, and to evaluate treatment response and detect recurrent disease 5.
Management
- Symptomatic postmenopausal women, those with a cyst ≥ 5 cm, or raised CA125 levels, should be referred to secondary care 2.
- Simple ovarian cysts in postmenopausal women are most likely to remain unchanged or disappear during follow-up, and the surgery rate is approximately 19% 4.
- The benefits of surveillance in older women with incidental ovarian cysts are limited, particularly in women with advanced age and comorbidities 6.