What is the approach to managing a patient with ovarian cysts?

Management of Ovarian Cysts: A Risk-Stratified Approach

The management of ovarian cysts should follow a risk-stratified approach based on patient age, menopausal status, cyst characteristics, and risk of malignancy, with simple cysts up to 10 cm being safely monitored without surgical intervention in most cases. 1

Classification and Initial Assessment

Premenopausal Women

• Simple cysts ≤3 cm should be considered physiologic (follicles) and require no additional management 1
• Simple cysts >3 cm but ≤5 cm require no further management 1
• Simple cysts >5 cm but <10 cm should be followed up in 8-12 weeks (ideally in proliferative phase) to confirm functional nature or assess for cyst wall abnormalities 1
• If cyst persists or enlarges after follow-up, management by a gynecologist is suggested 1

Postmenopausal Women

• Simple cysts ≤3 cm require no further management 1
• Simple cysts >3 cm but <10 cm should have at least 1-year follow-up showing stability or decrease in size, with consideration of annual follow-up for up to 5 years if stable 1
• If cyst enlarges, management by a gynecologist is recommended 1

Management by Cyst Type

Hemorrhagic Cysts

• Premenopausal women: No further management if ≤5 cm; follow-up in 8-12 weeks if >5 cm but <10 cm 1
• Postmenopausal women: Hemorrhagic cysts should not occur; if found, further evaluation by ultrasound specialist, gynecologist referral, or MRI is suggested 1

Dermoid Cysts and Endometriomas

• Premenopausal women: Optional initial follow-up at 8-12 weeks; if not surgically removed, annual ultrasound surveillance should be considered 1
• Postmenopausal women: Consider annual ultrasound follow-up if not surgically excised, but note higher risk of malignancy and malignant transformation, especially for endometriomas 1
• If changing morphology or developing vascular component within the lesion is observed, referral for specialist evaluation is recommended 1

Nonsimple Unilocular Smooth Cysts

• Premenopausal women: No management required if ≤3 cm; follow-up ultrasound in 8-12 weeks for cysts >3 cm and <10 cm 1
• Postmenopausal women: Follow-up in 1 year is an option if ≤3 cm, but additional characterization by ultrasound specialist or MRI should be considered regardless of size 1

Special Considerations

Fine-Needle Aspiration

• Fine-needle aspiration for cytological examination of solid or mixed ovarian masses is contraindicated 1
• For purely fluid cysts in postmenopausal women >5 cm, transvaginal aspiration is contraindicated; these should be followed by ultrasonography or excised by a gynecological surgeon 1
• In premenopausal women, management of purely fluid cysts remains controversial with no clear consensus 1

Risk Assessment Tools

• The Ovarian-Adnexal Reporting and Data System (O-RADS) provides a standardized risk stratification framework for ovarian cysts 1
• O-RADS categorizes lesions based on risk of malignancy, with O-RADS 1-2 being almost certainly benign (<1% and <4% risk of malignancy, respectively) 1

Tumor Markers

• Serum CA-125 should be measured before surgery and chemotherapy 1
• Other markers (CEA, CA19.9) should only be measured if CA-125 is not elevated, particularly for mucinous or endometrioid tumors 1
• In young women, alpha-fetoprotein and beta-HCG should be measured to exclude germ cell tumors 1

Indications for Surgical Management

• Cysts >10 cm in any patient group 1, 2
• Cysts with concerning features on imaging (solid components, papillary projections, septations) 2
• Symptomatic cysts (pain, pressure symptoms) 3
• Enlarging cysts during follow-up 1, 3
• Elevated CA-125 or other concerning tumor markers 2, 4
• Postmenopausal women with complex cysts 1, 5

Complications to Monitor

• Cyst rupture and torsion are potential complications 4
• Torsion is a gynecological emergency requiring urgent surgical intervention 4
• Malignant transformation, particularly in endometriomas in postmenopausal women 1

Follow-up Recommendations

• Timing of follow-up should be based on cyst type, size, and patient characteristics 1
• For functional cysts in premenopausal women, follow-up during proliferative phase (after menstruation) is optimal 1
• For postmenopausal women with persistent simple cysts, annual follow-up for up to 5 years may be appropriate 1
• Any cyst showing concerning changes during surveillance should prompt referral to gynecology 1