How is progesterone (a steroid hormone) used to manage ovarian cysts?

Progesterone in the Management of Ovarian Cysts

Progesterone therapy is not recommended as a primary treatment for functional ovarian cysts as it does not hasten cyst resolution compared to watchful waiting. 1, 2

Diagnosis and Classification of Ovarian Cysts

The management of ovarian cysts depends on their classification and risk assessment:

• Simple cysts (O-RADS 1-2, <1% risk of malignancy):

  • ≤3 cm: No further management required

  • 3 cm but <10 cm: Follow-up ultrasound in 8-12 weeks

  • Persistent cysts: Annual ultrasound surveillance 3

• Complex cysts (O-RADS 3-5, ≥1% risk of malignancy):

  • Require specialist evaluation regardless of size
  • Higher risk cysts (O-RADS 4-5, ≥10% risk) need gynecologic oncology referral 3

Evidence Against Progesterone for Functional Ovarian Cysts

Multiple studies have demonstrated that hormonal therapy with progesterone or combined oral contraceptives does not accelerate the resolution of functional ovarian cysts:

• A Cochrane review found that combined oral contraceptives do not hasten resolution of functional ovarian cysts compared to watchful waiting 1
• A randomized controlled trial showed that estrogen/progestin treatment did not affect the rate of disappearance of functional ovarian cysts 2
• Most functional cysts resolve spontaneously within a few menstrual cycles without treatment 1

Appropriate Management Algorithm

1. Initial Assessment:

   • Ultrasound imaging to characterize cyst morphology
   • Apply O-RADS classification system 3

2. For Simple Cysts (O-RADS 1-2):

   • ≤3 cm: No intervention needed

   • 3 cm: Follow-up ultrasound in 8-12 weeks

   • Watchful waiting for 2-3 menstrual cycles is appropriate 1

3. For Complex or Persistent Cysts:

   • Specialist referral for further evaluation
   • MRI may be indicated for cysts >5 cm 3

4. Surgical Management is indicated for:

   • Cysts causing significant symptoms (pain, discomfort)
   • Cysts showing growth during follow-up
   • Cysts with suspicious features
   • Persistent cysts after observation period 3

Special Situations Where Progesterone May Be Considered

While progesterone is not recommended for treating typical functional ovarian cysts, there are specific situations where hormonal therapy may be considered:

• Recurrent functional cysts: In cases of frequently recurring functional cysts, hormonal suppression with combined oral contraceptives may be used preventatively (not as treatment) 3

• Endometriotic cysts: Hormonal suppression with progesterone or combined hormonal contraceptives may be used after surgical removal to prevent recurrence 3

• Polycystic Ovary Syndrome: Hormonal therapy may be used to regulate menstrual cycles but not specifically to treat ovarian cysts 3

Conclusion

The current evidence does not support the use of progesterone or combined oral contraceptives for treating functional ovarian cysts. Watchful waiting is the recommended approach for most functional cysts, with surgical intervention reserved for persistent, symptomatic, or suspicious cysts. Management should be guided by ultrasound characteristics and the O-RADS classification system to identify cysts requiring more aggressive intervention.