Treatment Options for Ovarian Cysts
Management of ovarian cysts should be based on cyst characteristics, size, and patient's menopausal status, with conservative management recommended for most simple cysts and surgical intervention reserved for large, complex, or symptomatic cysts. 1, 2
Classification and Initial Assessment
- Transvaginal ultrasound combined with transabdominal ultrasound is the most useful modality for evaluation of adnexal masses 1
- The Ovarian-Adnexal Reporting and Data System (O-RADS) provides standardized risk stratification for ovarian cysts 2
- Simple cysts ≤3 cm should be considered physiologic and require no additional management in premenopausal women 2
- Simple cysts >3 cm but ≤5 cm require no further management in premenopausal women 2
- Simple cysts >5 cm but <10 cm should be followed up in 8-12 weeks to confirm functional nature in premenopausal women 2
Management Based on Menopausal Status
Premenopausal Women
- Simple cysts ≤5 cm require no additional management 2, 3
- Simple cysts >5 cm but <10 cm require follow-up ultrasound in 8-12 weeks, preferably during proliferative phase 1, 2
- Hemorrhagic cysts ≤5 cm require no further management 2
- Dermoid cysts and endometriomas should have optional initial follow-up at 8-12 weeks 2, 3
Postmenopausal Women
- Simple cysts ≤3 cm require no further management 2
- Simple cysts >3 cm but <10 cm should have at least 1-year follow-up showing stability or decrease in size 1, 2
- Hemorrhagic cysts should undergo further evaluation by ultrasound specialist, gynecologist referral, or MRI 2
- Dermoid cysts and endometriomas should consider annual ultrasound follow-up 2
Management Based on Risk Stratification (O-RADS)
- O-RADS 3 lesions (1% to <10% risk of malignancy): Management by general gynecologist; consultation with ultrasound specialist or MRI examination is encouraged 1
- O-RADS 4 lesions (10% to <50% risk of malignancy): Consultation with gynecologic oncology prior to removal or referral for management 1
- O-RADS 5 lesions (50%-100% risk of malignancy): Direct referral to gynecologic oncologist 1
Surgical Management Indications
- Cysts >10 cm in any patient group should undergo surgical management 2, 4
- Persistent symptomatic cysts despite conservative management 3
- Complex cysts with features concerning for malignancy 2, 3
- Postmenopausal women with complex cysts 2
Contraindications and Cautions
- Fine-needle aspiration for cytological examination of solid or mixed ovarian masses is contraindicated 1, 3
- Transvaginal aspiration is contraindicated for purely fluid cysts in postmenopausal women >5 cm 1, 2
- CT is not useful for further characterization of indeterminate adnexal masses; MRI is preferred 1
- PET/CT cannot reliably differentiate between benign and malignant adnexal lesions 1
Follow-up Recommendations
- Timing of follow-up should be based on cyst type, size, and patient characteristics 2
- For functional cysts in premenopausal women, follow-up during proliferative phase is optimal 1, 2
- For postmenopausal women with persistent simple cysts, annual follow-up for up to 5 years may be appropriate 2