What is the recommended workup for adnexal (adnexal refers to structures around the uterus, such as the ovaries, fallopian tubes, and ligaments) cysts?

From the Guidelines

The recommended workup for adnexal cysts begins with a thorough pelvic examination and transvaginal ultrasound to characterize the cyst's size, appearance, and complexity, as suggested by the most recent guidelines 1. For premenopausal women with simple cysts smaller than 5 cm, observation is typically sufficient with follow-up ultrasound in 8-12 weeks to ensure resolution, based on the low risk of malignancy in this population 1. For postmenopausal women, simple cysts smaller than 1 cm generally require no follow-up, while those 1-7 cm should be monitored with repeat ultrasound in 3-6 months, considering the slightly higher risk of malignancy in this age group 1. Complex cysts with concerning features (septations, solid components, irregular borders, or papillary projections) warrant additional evaluation with CA-125 testing and possibly other tumor markers like HE4, inhibin, AFP, or hCG depending on clinical suspicion, as recommended by recent studies 1. Color Doppler assessment may be added to evaluate blood flow patterns, and for cysts with highly suspicious features, pelvic MRI provides superior tissue characterization, as indicated by the latest research 1. Surgical intervention is indicated for symptomatic cysts causing pain or pressure, cysts larger than 10 cm, complex cysts with concerning features, or those persisting or enlarging on follow-up imaging, following the principles of minimizing morbidity and mortality while maintaining quality of life 1.

Some key points to consider in the workup of adnexal cysts include:

• The use of ultrasound as the primary imaging modality, given its safety, availability, and predictive ability for differentiating benign and malignant masses 1.
• The application of formalized ultrasound-based scoring systems, such as the O-RADS system, to stratify the risk of malignancy and guide management decisions 1.
• The importance of clinical judgment and shared decision-making in determining the optimal approach for each patient, taking into account individual risk factors, symptoms, and preferences 1.
• The role of laparoscopic surgery as a preferred approach when intervention is necessary, due to its benefits in terms of reduced postoperative pain, shorter hospital stay, and lower risks of complications 1.

By following this systematic approach, clinicians can effectively distinguish between benign physiologic cysts and potentially malignant lesions, avoiding unnecessary interventions for functional cysts that typically resolve spontaneously while ensuring timely and appropriate management for those at higher risk of complications or malignancy.

From the Research

Adnexal Cysts Workup

The workup for adnexal cysts involves a combination of clinical assessment, imaging tests, and biomarkers to determine the risk of malignancy and guide management decisions.

• Evaluation includes assessment for symptoms such as abdominal pain, abdominal bloating, and early satiety, as well as a family history of ovarian, breast, or certain heritable syndromes 2.
• Transvaginal ultrasonography is the imaging test of choice for evaluating adnexal masses for size and complexity 2, 3, 4.
• Adnexal cysts that are greater than 10 cm, contain solid components, or have high color flow on Doppler ultrasonography are high risk for malignancy 2.
• Further imaging, if warranted, should be completed with computed tomography or magnetic resonance imaging, particularly if there is concern for disease outside the ovary 2, 4.
• Multimodal assessment tools that use ultrasonography and biomarkers, such as the risk of malignancy index, are useful in the diagnosis and exclusion of malignant causes 2.
• Asymptomatic masses that are determined to be benign may be observed and managed expectantly 2, 5.
• In symptomatic or emergent cases, such as ectopic pregnancy or ovarian torsion, a gynecologist should be consulted 2.
• In any adnexal mass with high risk for malignancy, a consultation with gynecologic oncology is indicated 2, 6.

Imaging Tests

• Transvaginal ultrasonography has a closer accuracy in the diagnosis of serous cysts and serous cystadenoma, ovarian carcinoma, and endometrioma than computed tomography 4.
• Computed tomography is more accurate than transvaginal ultrasonography in the diagnosis of cystic teratoma 4.
• Ultrasound-guided aspiration is not an effective option for the treatment of low-risk adnexal cysts, with a low resolution rate and potential complications 5.

Management

• Management decisions often are influenced by the age and family history of the patient 6.
• The main goal of the diagnostic evaluation is to exclude malignancy 6.
• Criteria for the identification of adnexal masses that are likely to be malignant and may warrant referral to or consultation with a gynecologic oncologist include size, complexity, and risk of malignancy index 2, 6.