What is the workup for a 30-year-old female patient presenting to the Emergency Department (ED) with abdominal pain suspected to be caused by a possible ovarian cyst?

Workup for a 30-Year-Old Female with Suspected Ovarian Cyst in the ED

The standard workup for a 30-year-old female with abdominal pain from a suspected ovarian cyst should include transvaginal and transabdominal ultrasound as the first-line imaging, followed by laboratory tests including serum CA-125, CBC, and pregnancy test. 1, 2

Initial Assessment

History Elements to Focus On:

• Pain characteristics (onset, duration, location, radiation, severity)
• Menstrual history (last menstrual period, regularity)
• Associated symptoms (nausea, vomiting, fever, urinary symptoms)
• Previous history of ovarian cysts or gynecological conditions
• Sexual activity and contraceptive use

Physical Examination:

• Vital signs (including temperature to assess for infection)
• Abdominal examination (tenderness, guarding, distension, masses)
• Pelvic examination to assess for adnexal tenderness or masses
• Assessment for peritoneal signs

Diagnostic Workup Algorithm

Step 1: Laboratory Tests

• Pregnancy test (urine or serum β-hCG) to rule out pregnancy-related conditions 1
• Complete blood count (CBC) to assess for infection or anemia
• Comprehensive metabolic panel
• Serum CA-125 (especially if there are concerning features for malignancy) 1
• Urinalysis to rule out urinary tract infection

Step 2: Imaging Studies

Primary Imaging:

• Pelvic ultrasound (transvaginal and transabdominal) 1, 2
  • Most sensitive initial imaging for ovarian pathology
  • Can characterize cyst features (size, septations, solid components)
  • Can assess for complications (rupture, hemorrhage, torsion)
  • Should evaluate:
    • Uterus (size, endometrial thickness)
    • Ovaries (size, presence of cysts, masses)
    • Cul-de-sac for free fluid 1
    • Vascular flow using Doppler (critical if torsion is suspected) 1

Secondary Imaging (if ultrasound is inconclusive):

• CT abdomen and pelvis with IV contrast 1
  • Indicated when:
    • Ultrasound is non-diagnostic
    • Broader differential diagnosis is being considered
    • Complications are suspected (rupture, torsion)
  • Provides better assessment of surrounding structures

Step 3: Risk Stratification

• Apply O-RADS US Risk Stratification system to categorize ovarian/adnexal findings 1
  • O-RADS 1: Normal ovaries
  • O-RADS 2: Almost certainly benign (<1% risk of malignancy)
  • O-RADS 3: Low risk (1-10% risk of malignancy)
  • O-RADS 4: Intermediate risk (10-50% risk of malignancy)
  • O-RADS 5: High risk (>50% risk of malignancy)

Management Based on Findings

Simple Ovarian Cysts (<5 cm):

• Often functional and resolve spontaneously
• Consider pain management and follow-up ultrasound in 6-8 weeks 3

Larger Cysts (5-10 cm) or Symptomatic Cysts:

• Gynecology consultation in the ED
• Consider admission if severe pain, signs of complications, or inability to tolerate oral intake 4

Complicated Cysts or Suspected Torsion:

• Immediate gynecology consultation
• Surgical intervention may be necessary, especially with:
  • Signs of torsion (sudden onset severe pain, nausea/vomiting, abnormal Doppler flow) 1, 5
  • Cyst rupture with significant bleeding
  • Large cysts (>10 cm) causing significant symptoms 4

Common Pitfalls to Avoid

1. Missing ovarian torsion: Maintain high suspicion with sudden onset severe pain, even with normal Doppler flow (up to 5% of torsed ovaries have normal flow) 1

2. Inadequate imaging: Both transabdominal and transvaginal approaches should be used when possible for complete assessment 1, 2

3. Overlooking other causes: Differential diagnosis should include appendicitis, diverticulitis, urinary tract infection, and other gynecological conditions

4. Delayed consultation: Early gynecology consultation is warranted for concerning findings or severe symptoms

5. Inadequate follow-up: Ensure appropriate follow-up is arranged for cysts that are managed conservatively

By following this systematic approach, clinicians can effectively evaluate and manage patients with suspected ovarian cysts while minimizing complications and ensuring appropriate treatment.