Do ovarian complex cysts commonly cause pain?

From the Guidelines

Complex ovarian cysts are not commonly associated with pain, and the majority of simple cysts, including those with complex features, are benign and do not require immediate intervention. According to the most recent study by Gupta et al 1, the risk of malignancy in classic “benign”-appearing lesions is < 1% in a cohort of 970 average-risk women.

Key Points to Consider

• The vast majority of simple cysts in premenopausal patients are functional cysts, which will wax and wane over time or resolve, with a small portion reflecting benign neoplasms 1.
• Unilocular cysts, as a whole, in the premenopausal population similarly have a very low risk of malignancy, with a recent meta-analysis by Parazzini et al demonstrating that in 987 unilocular cysts removed surgically in premenopausal women, the risk of malignancy was 0.6% 1.
• Classic benign lesions, including endometriomas, hemorrhagic cysts, and dermoids, have characteristic appearances on US and can be safely followed with yearly US, with the risk of missing malignant degeneration quite low 1.

Management of Complex Ovarian Cysts

• For simple cysts, including those with complex features, in premenopausal women, follow-up with US is not necessary for cysts < 5 cm, and a higher threshold for follow-up is recommended for larger cysts 1.
• For patients experiencing pain, over-the-counter pain relievers like ibuprofen or acetaminophen can help manage discomfort, and applying a heating pad to the lower abdomen may also provide relief.
• Persistent or severe pain should be evaluated by a healthcare provider, who may recommend additional treatments such as hormonal birth control or, in some cases, surgical intervention if the cyst is large, causing significant symptoms, or suspected to be potentially cancerous.

From the Research

Ovarian Complex Cysts and Pain

• Ovarian endometriomas, a type of complex cyst, can cause infertility and chronic pelvic pain 2.
• Enlarging cysts can also cause ovarian torsion, which presents with sudden onset of severe colicky unilateral pain radiating from groin to loin 3.
• Complex ovarian cysts can lead to problems even after regression in the postnatal period and require operative intervention sooner or later 4.
• Haemorrhagic ovarian cysts can cause acute pelvic pain, and ovarian vascular accidents are reported in women on oral anticoagulation presenting as an acute pelvic pain 5.

Symptoms of Ovarian Cysts

• Presenting symptoms of ovarian cysts include pelvic pain, pressure symptoms and discomfort, and menstrual disturbance 3.
• Functional cysts can be linked with irregular vaginal bleeding or menorrhagia 3.
• Symptoms which may be suggestive of a malignant ovarian cyst include weight loss, persistent abdominal distension or bloating, early satiety, pelvic or abdominal pain, and increased urinary urgency and frequency 3.

Management of Ovarian Cysts

• Simple cysts, particularly when they are < 5 cm diameter, usually resolve spontaneously without the need for intervention 3.
• In premenopausal women, simple cysts > or = 5 cm are less likely to resolve and need an annual ultrasound assessment as a minimum 3.
• The management of complex ovarian cysts, such as mature cystic teratomas, poses unique challenges given the potential impact on sexual development and fertility, and close follow-up without intervention may be considered to preserve ovarian function and future fertility 6.