How to manage an adnexal cyst?

Management of Adnexal Cysts

Transvaginal ultrasound is the first-line imaging modality for characterizing adnexal cysts, with management decisions based on cyst characteristics, size, and menopausal status. 1

Initial Evaluation

• Transvaginal ultrasound combined with transabdominal ultrasound is the most useful initial approach for evaluating suspected adnexal masses 1
• Color or power Doppler should be included in the ultrasound examination to evaluate vascularity of any solid component 1
• Most adnexal masses can be categorized as cystic, solid, or mixed based on sonographic appearance 1

Management Based on Cyst Type

Simple Cysts

• Simple cysts establish a benign process in 98.7% of premenopausal women 1
• For postmenopausal women, follow-up is recommended only for simple cysts >3 cm (or >5 cm if exceptionally well visualized) 1
• For premenopausal women, simple cysts ≤3 cm require no follow-up 1

Hemorrhagic Cysts

• Premenopausal hemorrhagic cysts ≤5 cm require no further management 1
• Premenopausal hemorrhagic cysts >5 cm but <10 cm require follow-up in 8-12 weeks 1
• Hemorrhagic cysts in postmenopausal women warrant further evaluation by ultrasound specialist, gynecologist referral, or MRI 1

Dermoid Cysts and Endometriomas

• For premenopausal patients with dermoid cysts or endometriomas <10 cm, optional initial follow-up at 8-12 weeks with annual surveillance if not surgically removed 1
• In postmenopausal patients, annual ultrasound follow-up may be considered, but the risk of malignant transformation is higher for endometriomas 1
• If morphology changes or vascular components develop, referral to ultrasound specialist or MRI is recommended 1

Nonsimple Unilocular Smooth Cysts

• Premenopausal cysts ≤3 cm require no management 1
• Premenopausal cysts >3 cm and <10 cm need follow-up ultrasound in 8-12 weeks 1
• If cyst persists or enlarges, referral to ultrasound specialist or MRI should be considered 1
• For postmenopausal women, additional characterization via specialist ultrasound or MRI should be considered regardless of size 1

Risk Stratification and Referral

O-RADS Classification System

• O-RADS 3 lesions (1% to <10% risk of malignancy): Management by general gynecologist with possible ultrasound specialist consultation or MRI 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

Indeterminate Masses

• Up to 22-24% of adnexal masses remain indeterminate after initial ultrasound 1
• MRI is the most useful modality for further evaluation of indeterminate lesions 1
• CT is not recommended for characterization of indeterminate adnexal masses 1

Special Considerations

• Initial management by a gynecologic oncologist is the second most important prognostic factor (after stage) for long-term survival in patients with ovarian malignancy 1
• Surgical exploration of benign lesions has reported complication rates of 2-15%, emphasizing the importance of accurate preoperative characterization 1
• For cysts that decrease in size by at least 10-15% at any time, further follow-up is unnecessary 2

Pitfalls to Avoid

• Misinterpreting endosalpingeal folds in hydrosalpinx as solid components 1
• Mistaking pedunculated leiomyomas for solid ovarian masses - careful identification of normal ovaries and blood supply from uterine vessels helps avoid this error 1
• Relying on CT for characterization of adnexal masses when MRI is better established for this purpose 1
• Assuming all cysts in postmenopausal women are malignant - recent evidence shows simple cysts have very low malignancy risk regardless of menopausal status 1