What is the plan of care for a 21-year-old female with a 7.9 cm minimally complex left ovarian cyst and a small amount of pelvic free fluid?

From the Guidelines

The plan of care for a 21-year-old female with a 7.9 cm minimally complex left ovarian cyst and small pelvic free fluid should include monitoring with pelvic ultrasounds every 8-12 weeks to confirm its functional nature or to reassess for cyst wall abnormalities, as the risk of malignancy is low in premenopausal women with simple cysts up to 10 cm in diameter 1.

Key Considerations

• The patient's age and the size of the cyst are important factors in determining the risk of malignancy, with premenopausal women having a lower risk of malignancy compared to postmenopausal women 1.
• The presence of a small amount of pelvic free fluid may indicate minor leakage from the cyst and should be monitored as part of the overall assessment.
• The American College of Obstetricians and Gynecologists Committee on Practice Bulletins—Gynecology recommends that simple cysts up to 10 cm in diameter on transvaginal ultrasonography performed by experienced ultrasonographers are likely to be benign and may be safely monitored using repeat imaging without surgical intervention, even in postmenopausal patients 1.

Management

• Monitoring with pelvic ultrasounds every 8-12 weeks to assess for cyst growth or changes.
• Pain management with NSAIDs like ibuprofen 600mg every 6 hours or naproxen 500mg twice daily if necessary.
• The patient should be advised to seek immediate medical attention if experiencing severe abdominal pain, fever, vomiting, or dizziness, which could indicate cyst rupture or torsion.

Rationale

• The risk of malignancy in premenopausal women with simple cysts up to 10 cm in diameter is low, and surgical intervention may not be necessary unless the cyst is complex or shows signs of malignancy 1.
• The O-RADS US risk stratification and management system recommends follow-up in 8-12 weeks for cysts greater than 5 cm but less than 10 cm in premenopausal patients 1.
• A recent study by Gupta et al demonstrated 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 1.

From the Research

Plan of Care

The plan of care for a 21-year-old female with a 7.9 cm minimally complex left ovarian cyst and a small amount of pelvic free fluid involves several considerations:

• The patient's age and symptoms should be taken into account, as ovarian cysts are more common in premenopausal women 2.
• The size and complexity of the cyst, as well as the presence of pelvic free fluid, should be evaluated using ultrasound, which is the first-line investigation for ovarian cysts 3.
• The patient's symptoms, such as pelvic pain or discomfort, should be assessed and managed accordingly.
• The risk of ovarian torsion, which is more common in the presence of an ovarian cyst, should be considered, especially if the patient presents with sudden onset of severe colicky unilateral pain radiating from groin to loin 2.
• The patient's CA125 levels should be checked, especially if she presents with symptoms such as frequent bloating, feeling full quickly, loss of appetite, pelvic or abdominal pain, or needing to urinate quickly or urgently 2.

Management Options

The management options for the patient include:

• Conservative management with annual ultrasound assessment, as simple cysts > 5 cm are less likely to resolve in premenopausal women 2.
• Surgical management, such as laparoscopic surgery, may be necessary if the patient's symptoms persist or worsen, or if there is a suspicion of ovarian torsion or malignancy 3, 4.
• The patient should be referred to secondary care if she has a cyst > 5 cm, raised CA125 levels, or symptoms suggestive of a malignant ovarian cyst, particularly in the over 50 age group 2.

Surgical Considerations

If surgical management is necessary, the following considerations should be taken into account:

• The risk of hidden blood loss, which is more common in laparoendoscopic single-site surgery (LESS) than in conventional laparoscopic surgery (CLS) 4.
• The operative time, pre-hematocrit, pre-hemoglobin, and pelvic adhesions are positively correlated with hidden blood loss in CLS 4.
• Intraoperative bleeding, operative time, pre-hematocrit, CA125, and cyst volume are independent risk factors for hidden blood loss in LESS 4.