Management of Ovarian Cysts
The management of ovarian cysts should follow the O-RADS classification system, with simple cysts ≤3 cm requiring no further management, while cysts with complex features or high O-RADS scores (4-5) warrant surgical evaluation regardless of size. 1
Diagnostic Approach
Initial Assessment: Transvaginal ultrasound combined with transabdominal ultrasound is the most useful modality for evaluation of adnexal masses 2
Color/Power Doppler: Should be included in all ultrasound examinations to evaluate vascularity of any solid components 2
Risk Stratification: The O-RADS classification provides a framework for risk assessment:
O-RADS Category Risk of Malignancy Management 1-2 <1% Conservative management with follow-up 3 1-<10% Evaluation by ultrasound specialist or MRI 4-5 ≥10% Evaluation by gynecologic oncologist
Management Based on Cyst Characteristics
Simple Cysts
- ≤3 cm: No further management required; optional follow-up at 1 year may be considered 1
- >3 cm but <10 cm: Follow-up ultrasound in 8-12 weeks, preferably during proliferative phase 1
- Persistent cysts: Annual ultrasound surveillance; refer for specialist evaluation if morphology changes 1
Nonsimple Cysts
- Unilocular smooth nonsimple cysts: Evaluation by ultrasound specialist or MRI regardless of size 1
- Complex features (septations, solid components, irregular walls): Additional evaluation regardless of size 1
- Specific types:
Surgical Management Indications
Surgical excision is indicated for:
- Cysts causing discomfort or difficulty walking
- Cysts showing growth during follow-up
- Cysts with suspicious features (O-RADS 4-5)
- Postmenopausal women with complex cysts 1
Special Considerations
Premenopausal Women
- Expectant management is appropriate for non-suspicious cysts with normal CA-125 levels 3
- Most cysts in premenopausal women are functional and will resolve spontaneously 2
Postmenopausal Women
- Unilocular, anechoic cysts <5 cm with normal CA-125 may be followed up 3
- More aggressive follow-up or intervention is recommended due to higher malignancy risk 1
Pregnant Women
- Ultrasound is the modality of choice for assessing suspected adnexal lesions in pregnant patients 2
- Expectant management is appropriate for non-suspicious cysts 3
Important Caveats
- Avoid needle aspiration: Fine-needle aspiration or simple drainage is contraindicated due to high recurrence rates and potential for spreading malignant cells if cancer is present 1
- MRI for indeterminate masses: MRI is the most useful modality for further evaluation of lesions that remain indeterminate after sonographic evaluation 2
- CT limitations: CT is not recommended for characterization of indeterminate adnexal masses; MRI is preferred 2
- PET/CT limitations: Cannot reliably differentiate between benign and malignant adnexal lesions 2
Follow-up Recommendations
- Simple cysts in premenopausal women: Follow-up ultrasound in 8-12 weeks if >3 cm
- Simple cysts in postmenopausal women: Annual ultrasound for persistent cysts
- Complex or suspicious cysts: Referral to gynecologic oncologist for further management
The management approach should be guided by ultrasound characteristics, patient age, menopausal status, and presence of symptoms, with the primary goal of identifying and appropriately treating potentially malignant lesions while avoiding unnecessary interventions for benign cysts.