Initial Management of Ovarian Cysts
The initial approach to managing an ovarian cyst should be based on ultrasound characterization using the Ovarian-Adnexal Reporting and Data System (O-RADS) for risk stratification, with management decisions guided by cyst characteristics, size, and the patient's menopausal status. 1
Diagnostic Approach
- Combined transabdominal and transvaginal ultrasound is the most useful initial imaging modality for assessment of ovarian cysts 2
- Color or power Doppler should be included to evaluate vascularity of any solid components 2
- Serum CA-125 and other tumor markers may be useful when malignancy is suspected 2, 3
- MRI is recommended for further characterization of indeterminate masses on ultrasound 2
Management Based on Menopausal Status
Premenopausal Women
- Simple cysts ≤5 cm require no additional management 1
- Simple cysts >5 cm but <10 cm should be followed up in 8-12 weeks 1
- Hemorrhagic cysts <10 cm should be followed up in 8-12 weeks to confirm resolution 1
- Fine-needle aspiration of purely fluid cysts is controversial and generally not recommended due to:
Postmenopausal Women
- Simple cysts ≤3 cm require no further management 1, 3
- Simple cysts >3 cm but <10 cm should have at least 1-year follow-up 1
- Transvaginal aspiration of purely fluid cysts >5 cm is contraindicated 2
- These cysts must be followed by ultrasonography or excised by a gynecological surgeon 2
Risk Stratification Using O-RADS
- O-RADS 1 (0% risk of malignancy): Normal ovaries 1
- O-RADS 2 (<1% risk): Simple cysts or classic benign lesions 1
- O-RADS 3 (1-<10% risk): Requires gynecologist management 1
- O-RADS 4 (10-<50% risk): Warrants gynecologic oncology consultation 1
- O-RADS 5 (≥50% risk): Requires direct referral to gynecologic oncologist 1
Special Considerations
- Large cysts approaching 10 cm may require both transvaginal and transabdominal examination for complete evaluation 1
- Endometriomas require yearly follow-up due to small risk of malignant transformation 1
- Dermoid cysts <10 cm may have optional initial follow-up at 8-12 weeks 1
Common Pitfalls and Caveats
- Mischaracterization of larger cysts is possible due to technical limitations of transvaginal ultrasound 1
- The risk of malignancy in benign-appearing lesions managed conservatively with 2-year follow-up is very low (0.3-0.4%) 1
- CT scanning is not a useful preoperative staging tool for suspected malignant ovarian masses 2
- PET/CT cannot reliably differentiate between benign and malignant adnexal lesions 2