From the Guidelines
Management of a septated ovarian cyst should prioritize watchful waiting with follow-up ultrasound in 8-12 weeks for asymptomatic premenopausal women with cysts smaller than 5 cm, while symptomatic patients or those with larger cysts, concerning features, or persistence beyond 2-3 months may require surgical intervention. The approach to managing a septated ovarian cyst depends on several key factors including the patient's age, symptoms, cyst size, and risk of malignancy 1.
Key Considerations
- Patient age: Premenopausal women have a lower risk of malignancy compared to postmenopausal women.
- Symptoms: Symptomatic patients may require pain management with NSAIDs (e.g., ibuprofen 400-600 mg every 6-8 hours or naproxen 500 mg twice daily) and possibly hormonal contraceptives to prevent new cyst formation.
- Cyst size and characteristics: Larger cysts (>5 cm), those with thick septations (>3 mm), numerous septations, solid components, papillary projections, or increased blood flow are of greater concern for malignancy.
Management Strategies
- Asymptomatic premenopausal women with septated cysts < 5 cm: Watchful waiting with follow-up ultrasound in 8-12 weeks is often recommended 1.
- Symptomatic patients or those with larger cysts, concerning features, or persistence beyond 2-3 months: Surgical intervention may be necessary, typically involving laparoscopic cystectomy or oophorectomy depending on the patient's age and desire for future fertility.
- Postmenopausal women with septated cysts: Generally require surgical evaluation due to a higher malignancy risk.
Evidence-Based Recommendations
The most recent and highest quality study, published in 2024 1, supports a conservative approach for asymptomatic premenopausal women with small septated ovarian cysts, while emphasizing the need for prompt surgical evaluation in cases with high-risk features or in postmenopausal women. This approach aligns with the goal of minimizing morbidity, mortality, and optimizing quality of life for patients with septated ovarian cysts.
From the Research
Management of Septated Ovarian Cyst
- The management of a septated ovarian cyst depends on various factors, including the size of the cyst, the presence of symptoms, and the risk of malignancy 2.
- For septated cystic ovarian tumors without solid areas or papillary projections, the risk of malignancy is low, and they can be followed sonographically without surgery 2.
- Ultrasound is the first-line investigation for evaluating ovarian cysts, and it can help identify the characteristics of the cyst, such as the presence of septations, size, and vascularity 3, 4.
- In cases where the diagnosis is in doubt or there are concerns about malignancy, further evaluation with other imaging modalities, such as computed tomography (CT), may be necessary 4.
- For patients with recurrent ovarian torsion, conservative management via transabdominal ultrasound-guided ovarian cyst aspiration may be a viable option 5.
Ultrasound Characteristics
- Septated ovarian cysts can have various ultrasound characteristics, including a unilateral enlarged ovary, uniform peripheral cystic structures, and a coexistent mass within the affected ovary 4.
- The presence of flow at color Doppler imaging does not exclude the possibility of torsion, but it may indicate that the ovary is viable 4.
- Typical ultrasound features of ovarian mature cystic teratomas, which can sometimes present as septated ovarian cysts, include mixed echogenicity of cystic fluid, acoustic shadowing, and no or little vascularization on color Doppler 6.
Treatment Options
- For patients with symptomatic septated ovarian cysts or those with a high risk of malignancy, surgical removal of the cyst may be necessary 3, 2.
- In cases where surgery is not immediately necessary, suppression of ovulation with the combined oral contraceptive may be used to prevent recurrent cyst rupture or haemorrhage 3.
- Fixation of the ovary by various techniques may be considered to prevent recurrent torsion 3.