From the Guidelines
The best next step in management for this patient is expectant management with a follow-up pelvic ultrasound in 8-12 weeks. This 22-year-old woman has a 4-cm simple ovarian cyst discovered incidentally during her annual examination. The cyst is likely a functional ovarian cyst, which commonly occurs during normal ovulation cycles. These cysts are typically benign and resolve spontaneously within 1-3 menstrual cycles without intervention. The patient's presentation supports this diagnosis: she has mild, sharp left lower abdominal pain coinciding with midcycle, normal Doppler flow on ultrasound indicating good blood supply, and no concerning features such as complex components within the cyst. Her negative pregnancy test rules out ectopic pregnancy, which is important to consider in IUD users with adnexal masses. Since the cyst is relatively small (less than 5 cm), simple in appearance, and the patient has only mild symptoms, watchful waiting is appropriate, as suggested by the O-RADS US Risk Stratification and Management System 1.
Some key points to consider in the management of this patient include:
- The risk of malignancy in simple ovarian cysts is very low, especially in premenopausal women, with studies suggesting a risk of less than 1% 1.
- The American College of Radiology (ACR) recommends that simple cysts up to 10 cm in diameter can be safely monitored with repeat imaging without surgical intervention, even in postmenopausal patients 1.
- The patient should be advised to use over-the-counter pain medications like ibuprofen for discomfort and to return sooner if she develops severe pain, fever, vomiting, or other concerning symptoms.
- If the cyst persists or enlarges at follow-up, or if symptoms worsen before then, further evaluation or intervention may be necessary, as outlined in the O-RADS US Risk Stratification and Management System 1.
Overall, the management of this patient should prioritize a conservative approach with close monitoring, given the low risk of malignancy and the high likelihood of spontaneous resolution of the cyst.
From the Research
Patient Presentation and Diagnosis
- The patient is a 22-year-old woman presenting with mild, sharp pain in her left lower abdomen for 2 days, with no other symptoms such as nausea, vomiting, or changes in bowel movements.
- She has a copper-containing intrauterine device (IUD) for contraception and is sexually active.
- Pelvic ultrasonography reveals a 4-cm simple left ovarian cyst with normal Doppler flow, and the urine pregnancy test is negative.
- The patient's vital signs are normal, and her abdomen is mildly tender over the left lower quadrant.
Risk of Ovarian Torsion
- Ovarian torsion is a rare but emergency condition in women, and early diagnosis is necessary to preserve the function of the ovaries and tubes and prevent severe morbidity 2.
- The main risk factor for ovarian torsion is an ovarian mass, and the most common symptom is acute onset of pelvic pain, followed by nausea and vomiting 2.
- The patient's presentation of mild, sharp pain in the left lower abdomen could be indicative of ovarian torsion, especially given the presence of a 4-cm ovarian cyst.
Management of Ovarian Cysts
- The optimal management of a twisted ovarian cyst is the subject of much debate, but current trends favor ovary preservation 3.
- Cystectomy or fenestration can significantly reduce the chance of retorsion by 50% and 75%, respectively, compared to detorsion only 4.
- Adnexal fixation is also important in preventing recurrence of adnexal torsion 4.
Next Steps in Management
- Given the patient's presentation and the presence of a 4-cm ovarian cyst, the best next step in management would be to consider surgical intervention, such as laparoscopy, to evaluate the cyst and prevent potential torsion 2, 3, 4.
- Cystectomy or fenestration, along with adnexal fixation, may be necessary to reduce the risk of retorsion and preserve ovarian function 4.