What is the management approach for ovarian cysts?

Management of Ovarian Cysts

The management of ovarian cysts should be stratified based on menopausal status, cyst size, and ultrasound characteristics, with purely fluid cysts in postmenopausal women requiring either ultrasound follow-up or surgical excision, while premenopausal women with cysts less than 3 cm generally require no intervention. 1

Risk Stratification and Initial Assessment

The O-RADS (Ovarian-Adnexal Reporting and Data System) classification provides a framework for risk assessment:

• O-RADS 1-2 (<1% risk of malignancy): Conservative management with follow-up
• O-RADS 3 (1-<10% risk of malignancy): Evaluation by ultrasound specialist or MRI
• O-RADS 4-5 (≥10% risk of malignancy): Evaluation by gynecologic oncologist 1

Premenopausal Women

• Simple cysts ≤3 cm: No further management required 1
• Simple cysts >3 cm but <10 cm: Follow-up ultrasound in 8-12 weeks (preferably during proliferative phase) 2, 1
• Simple cysts ≥10 cm: Referral to gynecologist 1
• Nonsimple unilocular smooth cysts ≤3 cm: No management required 2
• Nonsimple unilocular smooth cysts >3 cm and <10 cm: Follow-up ultrasound in 8-12 weeks; if persistent or enlarging, consider referral to ultrasound specialist or MRI 2

Postmenopausal Women

• Simple cysts ≤3 cm: Optional follow-up at 1 year 2
• Simple cysts >3 cm but <10 cm: Annual ultrasound follow-up for 5 years 1
• Purely fluid, echogenic, thin-walled cysts >5 cm without endocystic vegetations: Must be followed by ultrasonography or excised by a gynecological surgeon (transvaginal aspiration is contraindicated) 2
• Nonsimple unilocular smooth cysts: Consider ultrasound specialist evaluation or MRI regardless of size; management by gynecologist is suggested 2

Special Cyst Types

Hemorrhagic Cysts

• Usually resolve spontaneously within 8-12 weeks
• ≤5 cm: No further management required
• >5 cm but <10 cm: Follow-up ultrasound in 8-12 weeks
• ≥10 cm: Referral to gynecologist 1

Endometriotic Cysts

• May require hormonal suppression after surgical removal 3
• Surgical treatment is the primary therapeutic option for symptomatic endometriomas 3
• Small asymptomatic endometriomas should not be treated surgically, especially in patients older than 35 years 3

Extraovarian Cysts

• Simple paraovarian cysts: No further follow-up needed (optional follow-up at 1 year in postmenopausal women)
• Peritoneal inclusion cysts or hydrosalpinges: Management by gynecologist 2

Surgical Intervention Criteria

Surgical excision should be considered for:

• Cysts causing discomfort or difficulty walking
• Cysts showing growth during follow-up
• Cysts with suspicious features
• Large cysts (>4 cm) due to risk of rupture or torsion 1, 3

Surgical Approach

• Laparoscopy is preferred for benign-appearing cysts 4
• For large cysts, direct trocar insertion within the ovarian cyst followed by aspiration of fluid contents can facilitate laparoscopic management 4
• Fine-needle aspiration by transabdominal or transvaginal route for cytological examination of ovarian masses (solid or mixed) is contraindicated 2

Important Caveats

• Avoid needle aspiration: Simple needle aspiration or incision and drainage have high recurrence rates 1
• Diagnostic accuracy: The preoperative discrimination between benign and malignant ovarian cysts remains challenging despite advanced imaging 5
• Pregnancy considerations: Most unilocular and anechoic ovarian cysts in the first trimester are corpus luteum cysts and typically resolve by the end of the first trimester. For cysts >6 cm that require surgery during pregnancy, the ideal period is early second trimester 6
• Fertility considerations: In women with infertility, surgical treatment should be considered if they failed to get pregnant despite 1-1.5 years of trying 3

For patients with O-RADS 3 lesions (1-<10% risk of malignancy), consultation with a US specialist or MRI examination is recommended to minimize the risk of overlooking suspicious features, but there is no need for consultation with a gynecologic oncologist 2.