What is the treatment for ovarian cysts?

Treatment of Ovarian Cysts

The treatment of ovarian cysts should be based on cyst characteristics (size, appearance, complexity), patient's menopausal status, and symptoms, with most simple cysts ≤3 cm in premenopausal women and ≤5 cm in postmenopausal women requiring no intervention beyond monitoring. 1

Classification and Initial Assessment

• Transvaginal ultrasound combined with transabdominal ultrasound is the most useful modality for evaluating adnexal masses 2
• MRI is preferred for further evaluation of indeterminate lesions after sonographic evaluation 2
• CT is not useful for further characterization of indeterminate adnexal masses 2
• PET/CT cannot reliably differentiate between benign and malignant adnexal lesions 2

Management Based on Cyst Type and Menopausal Status

Simple Cysts

• Premenopausal women:

  • Simple cysts ≤3 cm should be considered physiologic with no additional management needed 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 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 1

Hemorrhagic Cysts

• Premenopausal women with hemorrhagic cysts ≤5 cm require no further management 1
• Postmenopausal women with hemorrhagic cysts should undergo further evaluation by ultrasound specialist, gynecologist referral, or MRI 1

Dermoid Cysts and Endometriomas

• Premenopausal women should have optional initial follow-up at 8-12 weeks 1
• Postmenopausal women should consider annual ultrasound follow-up 1
• Endometriomas may be managed surgically, especially if >4 cm due to risk of rupture or torsion 3

Surgical Management

• Surgical intervention is indicated for:

  • Cysts >10 cm in any patient group 1
  • Complex cysts with features concerning for malignancy 1
  • Persistent symptomatic cysts despite conservative management 4

• Fertility-sparing surgery is recommended for most cases, especially in younger women 2

• Laparoscopic approach is preferred for benign cysts with advantages including decreased postoperative pain, shorter hospital stay, and better cosmetic results 5, 6

• The "closed technique" and use of an impermeable bag for removal should be employed to limit risk of spillage 5

Pharmacological Management

• Oral contraceptives containing ethinyl estradiol can decrease the incidence of functional ovarian cysts when used long-term 7
• Hormonal therapy has limited role and should be considered primarily in patients with diffuse endometriosis associated with pain 3
• Options include:
  • Estrogen-progestin preparations
  • Gestagens, including progesterone-releasing intrauterine systems
  • Gonadotropin-releasing hormone agonists 3

Special Considerations

• Fine-needle aspiration for cytological examination of solid or mixed ovarian masses is contraindicated 1
• Transvaginal aspiration is contraindicated for purely fluid cysts in postmenopausal women >5 cm 1
• Women with infertility and ovarian cysts should attempt pregnancy as soon as possible; those who fail to conceive and/or are older than 35 years should consider in vitro fertilization 3
• For adnexal torsion, laparoscopic detorsion is the preferred approach 8

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 is optimal 1
• For postmenopausal women with persistent simple cysts, annual follow-up for up to 5 years may be appropriate 1
• Tumor markers (CA-125, AFP, b-hCG, LDH) should be measured when malignancy is suspected 2, 9

Risk Stratification

• The Ovarian-Adnexal Reporting and Data System (O-RADS) provides a standardized risk stratification framework 1
• O-RADS 3 lesions (1% to <10% risk of malignancy) should be managed by a general gynecologist with consultation with an ultrasound specialist or MRI examination 1
• O-RADS 4 lesions (10% to <50% risk of malignancy) require consultation with gynecologic oncology 1
• O-RADS 5 lesions (50%-100% risk of malignancy) require direct referral to a gynecologic oncologist 1