Do ovarian complex cysts commonly cause pain?

From the Guidelines

Complex ovarian cysts do not commonly cause pain, and most simple cysts, regardless of size and menopausal status, are not associated with an increased risk of cancer or significant morbidity. According to a recent study by Gupta et al [@55@], the risk of malignancy in classic “benign”-appearing lesions is < 1% in a cohort of 970 average-risk women. The study also found that the risk of malignancy in benign-appearing lesions on US managed conservatively with 2-year follow-up was 0.3% to 0.4% for malignancy and 0.2% to 0.4% for acute complications such as torsion or cyst rupture [@51@].

Key Points to Consider

• A large body of evidence, including several large recent studies, has shown that simple cysts are not associated with an increased risk of cancer [@35@, @47@, @48@, @49@].
• Invasive serous cystadenocarcinoma is now thought to primarily originate from solid precursors in the fallopian tube and serous tubal intraepithelial carcinoma, further supporting the benignity of simple ovarian cysts [@50@].
• Classic benign lesions, such as endometriomas, hemorrhagic cysts, and dermoids, have characteristic appearances on US and can be safely followed with yearly US, with a low risk of malignant transformation [@52@, @53@, @54@].
• Unilocular cysts, as a whole, in the premenopausal population have a very low risk of malignancy, with a recent meta-analysis by Parazzini et al [@56@] demonstrating a risk of malignancy of 0.6% in 987 unilocular cysts removed surgically in premenopausal women.

Management and Follow-up

• Regular monitoring through ultrasounds and follow-up appointments with a gynecologist is crucial for managing complex ovarian cysts and preventing complications.
• According to the acr appropriateness criteria, US can accurately diagnose benign adnexal lesions, including simple cysts, hemorrhagic cysts, endometriomas, and dermoids, and these lesions can be followed-up with US 1.
• The rationale for follow-up of simple cysts is based on a potential risk of mischaracterization of larger cysts and potential clinical value of size monitoring growth rates of larger cysts, which may reflect benign neoplasms and warrant clinical follow-up along with a very small predisposition for torsion or rupture [@51@].

From the Research

Ovarian Complex Cysts and Pain

• Ovarian cysts can be asymptomatic, but presenting symptoms include pelvic pain, pressure symptoms, and discomfort, as well as menstrual disturbance 2.
• Complex ovarian cysts can lead to problems even after regression in the postnatal period and may require operative intervention sooner or later 3.
• The common gynaecological causes of acute pelvic pain include ruptured ectopic pregnancy, haemorrhagic corpus luteal cyst, or torsion of an ovarian cyst, which can be associated with complex ovarian cysts 4.

Characteristics of Ovarian Cysts

• Ovarian cysts occur more often in premenopausal than postmenopausal women, and most of these cysts will be benign, with the risk of malignancy increasing with age 2.
• Simple ovarian cysts appear to be stable or resolve by the next annual examination, and can be managed conservatively 5.
• Complex ovarian cysts, on the other hand, may be more likely to cause symptoms such as pain, and may require surgical intervention 3, 6.

Management of Ovarian Cysts

• The management of ovarian cysts depends on various factors, including the size and nature of the cyst, as well as the patient's age and symptoms 2, 5.
• Simple cysts found on ultrasound may be safely followed without intervention, even in postmenopausal women, while complex cysts may require surgical intervention 5.
• The American College of Obstetricians and Gynecologists (ACOG) recommends that simple cysts be managed conservatively, with follow-up ultrasound and CA-125 testing as needed 5.