What medications are used to treat symptomatic ovarian cysts?

Medications for Treating Symptomatic Ovarian Cysts

Combined oral contraceptives (COCs) are the primary medication used to treat symptomatic ovarian cysts, though evidence shows they may not be more effective than expectant management for functional cysts. 1, 2

Types of Ovarian Cysts and Diagnostic Approach

• Functional ovarian cysts (follicular, corpus luteum, and theca lutein cysts) represent about 50% of adnexal masses in women of reproductive age 1
• Transvaginal ultrasound is the essential first-line imaging modality to characterize ovarian cysts as cystic, solid, or mixed 3
• MRI with intravenous contrast is recommended when ultrasound findings are indeterminate 3
• Cysts may be classified as:
  • Simple cysts (benign in 98.7% of premenopausal women) 3
  • Functional cysts (hemorrhagic cysts with spiderweb appearance) 3
  • Endometriomas (low-level internal echoes, mural echogenic foci) 3
  • Teratomas (echogenic attenuating components) 3
  • Other benign cysts (hydrosalpinges, peritoneal inclusion cysts) 3

Medical Management Options

First-Line Medications:

• Combined Oral Contraceptives (COCs)

  • Contain ethinyl estradiol and progestins (e.g., norgestrel, drospirenone) 4, 1
  • Mechanism: Suppress gonadotropins, inhibit ovulation, and alter cervical mucus 4
  • Examples:
    • Low-dose COCs containing 20-30 μg ethinyl estradiol with various progestins 1
    • Yaz (20 μg ethinyl estradiol/3 mg drospirenone) has shown better efficacy for simple ovarian cysts compared to Ovocept-LD (30 μg ethinyl estradiol/3 mg norgestrol) 1

• Progestin-containing intrauterine devices (IUDs)

  • Reduce bleeding symptoms associated with ovarian cysts 3

Second-Line Medications:

• GnRH agonists and antagonists

  • Effective at reducing tumor volume in fibroid cases 3
  • Associated with hypoestrogenic side effects including headaches, hot flushes, and bone mineral density loss 3
  • Examples: leuprolide acetate (agonist), elagolix, linzagolix, relugolix (antagonists) 3

• Selective Progesterone Receptor Modulators (SPRMs)

  • Ulipristal acetate can reduce both bleeding and bulk symptoms 3
  • May be administered intermittently 3
  • Note: Reports of hepatotoxicity have limited FDA approval in the United States 3

• Non-hormonal options

  • Tranexamic acid for reducing bleeding symptoms 3
  • NSAIDs for pain management 3

Efficacy of Medical Treatment

• Important caveat: Multiple studies show that expectant management (watchful waiting) is as effective as hormonal treatment for functional ovarian cysts 5, 2, 6
• A Cochrane review found that COCs do not hasten resolution of functional ovarian cysts compared to watchful waiting 2
• Most functional cysts resolve spontaneously within 2-3 menstrual cycles without treatment 2
• In a randomized study comparing no treatment vs. COCs vs. danazol:
  • Resolution rates were similar: 58% (no treatment), 40-65% (COCs), 54% (danazol) 6
  • Persistent cysts were often pathological rather than functional 2

Management Approach Based on Cyst Type and Patient Status

Premenopausal Women:

• For simple or functional cysts: Watchful waiting for 2-3 cycles is appropriate 2
• For symptomatic cysts (pain, irregular bleeding): COCs may help manage symptoms even if they don't accelerate cyst resolution 1
• For persistent cysts after observation: Surgical evaluation may be indicated 2

Postmenopausal Women:

• Simple cysts <5 cm may be followed with ultrasound 3
• Cysts >5 cm or with concerning features should be followed or surgically evaluated 3
• Hormonal treatment is generally not indicated 3

Common Pitfalls and Caveats

• Overtreatment: Prescribing COCs for all ovarian cysts when many will resolve spontaneously 2
• Misdiagnosis: Persistent cysts despite treatment often represent pathological conditions (endometriomas, paraovarian cysts) rather than functional cysts 2, 6
• Delayed diagnosis: Watchful waiting should be limited to 2-3 cycles; persistent cysts warrant further evaluation 2
• Surgical complications: Unnecessary surgery for benign cysts carries complication rates of 2-15% 3
• Torsion risk: Symptomatic ovarian cysts may represent emergencies like ovarian torsion requiring prompt surgical intervention 7

In summary, while COCs are commonly prescribed for symptomatic ovarian cysts, evidence suggests they may not accelerate resolution of functional cysts compared to expectant management. However, they may help manage symptoms like pain and irregular bleeding. Persistent cysts after 2-3 cycles of observation warrant further evaluation as they are more likely to be pathological.