From the Guidelines
Ovarian cysts should be managed based on their type, size, and symptoms, with a focus on minimizing unnecessary interventions and preserving ovarian tissue, as most simple cysts are benign and resolve spontaneously 1.
Detection Strategies
Ovarian cysts are typically detected through:
- Pelvic examinations
- Ultrasound imaging
- Sometimes blood tests
Management Strategies
Management depends on the type, size, and symptoms of the cyst.
- For asymptomatic functional cysts (follicular or corpus luteum cysts), watchful waiting is recommended with follow-up ultrasound in 1-3 months as most resolve spontaneously 1.
- For symptomatic cysts, pain management with NSAIDs like ibuprofen (400-600mg every 6 hours) or naproxen (500mg twice daily) is appropriate 1.
- Combined hormonal contraceptives may be prescribed to prevent new cyst formation but don't accelerate resolution of existing cysts.
- Surgical intervention is indicated for cysts that are large (>5-10cm), persistent (beyond 2-3 menstrual cycles), complex in appearance, causing severe symptoms, or in postmenopausal women 1.
- Laparoscopic cystectomy is preferred when possible to preserve ovarian tissue.
- Emergency medical attention is necessary for signs of cyst rupture or torsion, including severe pain, fever, vomiting, or dizziness.
- Regular gynecological check-ups are important for women with a history of ovarian cysts.
Risk Stratification
The O-RADS US risk stratification and management system can be used to categorize ovarian cysts into different risk categories, including:
- O-RADS 1: Normal ovary
- O-RADS 2: Almost certainly benign
- O-RADS 3: Low risk of malignancy
- O-RADS 4: Intermediate risk of malignancy
- O-RADS 5: High risk of malignancy The O-RADS system can help guide management decisions, with more frequent follow-up and specialist referral recommended for higher-risk categories 1.
Classic Benign Lesions
Classic benign lesions, such as endometriomas, hemorrhagic cysts, and dermoids, have characteristic appearances on ultrasound and can be safely followed with yearly ultrasound, with a low risk of malignant transformation 1.
Unilocular Cysts
Unilocular cysts, as a whole, in the premenopausal population have a very low risk of malignancy, with a recent meta-analysis demonstrating a risk of malignancy of 0.6% in 987 unilocular cysts removed surgically in premenopausal women 1.
Solid Adnexal Masses
The most common benign solid adnexal mass is the uterine fibroid, which can often be mistaken for a solid adnexal mass, and the presence of bridging vessels can help identify uterine origin along with careful search for the ovaries 1.
From the Research
Detection Strategies
- Ovarian cysts can be detected using pelvic ultrasonography, which is the primary imaging modality for evaluation of ovarian cystic lesions 2
- Endovaginal ultrasound with Doppler enhancement is the best imaging technique to establish the nature of cysts and to distinguish cysts suspicious for malignancy 3
- Transvaginal ultrasonography (TVU) can be used for ovarian cancer screening and follow up, with a CA-125 blood test 4
- The TVU screening examination is considered positive when findings include ovarian volume greater than 10 cubic cm, cyst volume greater than ten cubic cm, any solid area or papillary projection, or any mixed (solid/cystic) component within a cystic ovarian tumor 4
Management Strategies
- Expectant management is the choice in premenopausal and pregnant women with non-suspicious cysts and normal levels of CA-125 5
- Operation is recommended in women with cysts larger than 5 cm and/or elevated levels of CA-125 5
- Women with symptoms should be operated regardless of age, menopausal status, or ultrasound findings 5
- Pelvic laparoscopy is the surgical approach of choice for the treatment of non-functional benign ovarian cysts 3
- Conservative treatment to shell out the cyst and preserve functional ovarian tissue should be reserved for women desirous of future pregnancies 3
- Simple ovarian cysts can be managed conservatively, and do not require intervention even in postmenopausal women 4