What is the management approach for ovarian cysts?

From the Guidelines

The management of ovarian cysts should prioritize a conservative approach with observation and pain control for most functional ovarian cysts, reserving surgical intervention for large, complex, or suspicious cysts. The approach to managing ovarian cysts depends on several factors including the type of cyst, its size, the presence of symptoms, and patient-specific factors such as menopausal status and desire for fertility preservation.

• For premenopausal women, simple cysts less than or equal to 5 cm in diameter typically do not require follow-up, as they are likely to be functional and resolve spontaneously 1.
• For postmenopausal women, simple cysts up to 10 cm in diameter are likely to be benign and may be safely monitored without surgical intervention, according to the American College of Obstetricians and Gynecologists Committee on Practice Bulletins—Gynecology 1.
• The O-RADS US risk stratification and management system provides a framework for categorizing adnexal lesions based on their risk of malignancy, guiding management decisions such as the need for follow-up ultrasound, specialist referral, or surgical intervention 1.
• Classic benign lesions like endometriomas, hemorrhagic cysts, and dermoids have characteristic appearances on ultrasound and can often be managed conservatively with yearly follow-up, given their low risk of malignant transformation 1.
• The risk of malignancy in unilocular cysts is low, especially in premenopausal women, where the risk is approximately 0.6% 1.
• Surgical intervention is considered for cysts that are large, complex, persistent, or suspicious for malignancy, with laparoscopic cystectomy preferred for benign cysts to preserve ovarian tissue 1.

Given the most recent and highest quality evidence, a conservative management approach is recommended for most ovarian cysts, with surgical intervention reserved for cases where there is a significant risk of malignancy or complications 1. This approach aims to balance the risk of complications against the likelihood of spontaneous resolution, prioritizing fertility preservation when appropriate while ensuring patient safety.

From the Research

Management Approach for Ovarian Cysts

The management of ovarian cysts depends on various factors, including the size, type, and symptoms of the cyst, as well as the patient's age and medical history.

• For functional ovarian cysts, treatment with combined oral contraceptives did not hasten resolution in any trial, and most cysts resolved without treatment within a few cycles 2.
• Watchful waiting for two or three cycles is often appropriate for functional ovarian cysts, and surgical management may be indicated if cysts persist 2.
• Simple ovarian cysts found on ultrasound may be safely followed without intervention, even in postmenopausal women, as they are not likely cancer precursors and can be managed conservatively 3.
• The American College of Obstetricians and Gynecologists (ACOG) recommends following unilocular simple cysts in postmenopausal women without intervention, with annual transvaginal ultrasonography (TVU) and CA-125 blood tests for five years beyond baseline 3.

Diagnostic Considerations

• Transvaginal ultrasonography (TVU) is used to screen for ovarian cancer and to monitor ovarian cysts, with a positive screening examination indicating a need for further investigation 3.
• The TVU screening examination is considered positive if findings include ovarian volume greater than 10 cubic cm, cyst volume greater than ten cubic cm, any solid area or papillary projection, or any mixed (solid/cystic) component within a cystic ovarian tumor 3.
• Ovarian cysts can be incidental findings on imaging done for other reasons, and proper triage is necessary to decrease unnecessary procedures and worry while obtaining the best survival benefit for those ultimately found to have cancer 4.

Conservative Management

• Simple ovarian cysts in postmenopausal women can be followed conservatively, as their risk for malignant transformation is low, with the majority resolving spontaneously or persisting unaltered on follow-up 5.
• A study of women using a levonorgestrel-releasing intrauterine system (LNG-IUS 13.5mg) found that ovarian cysts were present in 1.6% of participants at screening and 1.1-2.4% at each subsequent visit, with the majority being functional in nature and resolving within a few months 6.