What size ovarian cyst requires a specialist referral?

Ovarian Cyst Size Requiring Specialist Referral

Ovarian cysts ≥10 cm in size require specialist referral regardless of type, while smaller cysts require referral based on specific characteristics and menopausal status. 1

Size-Based Referral Guidelines by Cyst Type

Simple Cysts

• In premenopausal women:

  • <5 cm: No follow-up or referral needed 1
  • 5-10 cm: Follow-up ultrasound in 8-12 weeks; if persistent, consider referral 1
  • ≥10 cm: Specialist referral required 1

• In postmenopausal women:

  • Simple cysts of any size with concerning features: Refer to specialist 1
  • ≥10 cm: Specialist referral required 1

Hemorrhagic Cysts

• In premenopausal women:

  • ≤5 cm: No further management needed 1

  • 5 cm but <10 cm: Follow-up in 8-12 weeks; if persists or enlarges, refer to ultrasound specialist, gynecologist, or for MRI 1

  • ≥10 cm: Specialist referral required 1

• In postmenopausal women:

  • Any size (should not typically occur): Refer to ultrasound specialist, gynecologist, or for MRI 1, 2

Dermoid Cysts and Endometriomas

• In premenopausal women:

  • <10 cm: Optional initial follow-up at 8-12 weeks; if not removed, annual ultrasound surveillance 1
  • ≥10 cm: Specialist referral required 1
  • Any size with changing morphology or developing vascular component: Refer to specialist 1

• In postmenopausal women:

  • Any size: Consider specialist referral due to higher risk of malignancy or malignant transformation 1, 2
  • Any size with changing morphology or developing vascular component: Direct referral for MRI 1, 2

Risk-Based Referral Criteria (Beyond Size)

O-RADS Classification System

• O-RADS 3 (1-10% risk of malignancy): Includes simple and unilocular nonsimple cysts ≥10 cm 1
• O-RADS 4 (10-50% risk of malignancy): Includes multilocular cysts ≥10 cm or with irregular inner wall/septal irregularity 1
• O-RADS 5 (≥50% risk of malignancy): Specialist referral required regardless of size 1

Additional Referral Considerations

• Cysts with solid components: Refer to specialist regardless of size 1
• Multiloculated septated cysts in postmenopausal women: Refer to specialist regardless of size 2
• Large cysts (>4 cm) in women with infertility concerns: Consider surgical evaluation due to risk of rupture or torsion 3, 4

Common Pitfalls to Avoid

• Failing to consider menopausal status when determining management 1, 2
• Not recognizing that hemorrhagic cysts should not typically occur in postmenopausal women 1
• Overlooking changes in morphology or developing vascularity, which significantly increase malignancy risk 2
• Not comparing current imaging with previous studies to detect subtle changes 2
• Unnecessary referral of small, simple cysts in premenopausal women that are likely to resolve spontaneously 1

Urgent Referral Indications (Regardless of Size)

• Symptoms of torsion or rupture (acute pain): Immediate gynecological emergency referral 4
• Presence of ascites and/or peritoneal nodules: Specialist referral required 1
• Rapid growth between imaging studies: Specialist referral required 2