Workup for Complex Ovarian Cysts
Complex ovarian cysts require thorough evaluation with transvaginal ultrasound using the O-RADS risk stratification system, with management determined by risk category, patient age, and menopausal status. 1, 2
Initial Evaluation
- Transvaginal ultrasound combined with transabdominal approach is the most useful initial modality for evaluation of adnexal masses 1
- Color or power Doppler should be included to evaluate vascularity of any solid components 1, 2
- Complex cysts are characterized by any deviation from simple cyst morphology (unilocular, anechoic structures without solid components) 3
Risk Stratification Using O-RADS
The Ovarian-Adnexal Reporting and Data System (O-RADS) should be used to classify the cyst and determine malignancy risk:
- O-RADS 0: Incomplete evaluation 1
- O-RADS 1: Physiologic category (normal premenopausal ovary) 1
- O-RADS 2: Almost certainly benign (<1% risk of malignancy) 1
- O-RADS 3: Low risk of malignancy (1% to <10%) 1
- O-RADS 4: Intermediate risk of malignancy (10% to <50%) 1
- O-RADS 5: High risk of malignancy (≥50%) 1
Management Based on Risk Category and Menopausal Status
Premenopausal Women
- Complex cysts >5 cm require follow-up ultrasound in 8-12 weeks 2
- Complex cysts >5 cm carry a significant risk of malignancy (17.58% in one study) 3
- If a cyst persists or enlarges at follow-up, referral to a gynecologist is recommended 2, 4
- Complex cysts ≥10 cm should be managed by a gynecologist (risk of malignancy 1-10%) 4
Postmenopausal Women
- Complex cysts of any size carry a significant risk of malignancy and should be referred for surgical evaluation 3
- Complex ovarian cysts with wall abnormalities or solid areas are associated with a significant risk for malignancy 5
Further Imaging for Indeterminate Masses
- For indeterminate adnexal masses on ultrasound, contrast-enhanced MRI is recommended for further characterization 1
- MRI performs superiorly to both ultrasound and noncontrast MRI due to its ability to confirm the presence of internal enhancing soft tissue components 1
- Noncontrast MRI may be used when IV contrast is contraindicated 1
- CT is usually not useful for further characterization of indeterminate adnexal masses 1
- PET/CT cannot reliably differentiate between benign and malignant adnexal lesions 1
Laboratory Testing
- CA-125 measurement should be considered, especially in postmenopausal women with complex cysts >5 cm 3
- CA-125 has limited value in perimenopausal patients but may add value to the suspicion of malignancy in postmenopausal women with complex cysts >5 cm 3
Common Pitfalls to Avoid
- Failing to perform adequate follow-up for complex cysts 2
- Not distinguishing between simple and complex cysts, which have different management protocols 4
- Overlooking the possibility of functional cysts in premenopausal women, which typically resolve within 8-12 weeks 2
- Misclassifying complex cysts in postmenopausal women as benign, as they carry a significant risk of malignancy 3, 5
Remember that complex ovarian cysts in children and infants may require different management approaches, with surgical intervention often necessary regardless of size due to risk of torsion or neoplasm 6, 7.