What are the best practices for treating ovarian cysts?

Best Practices for Ovarian Cyst Treatment

Initial Diagnostic Approach

Transvaginal ultrasound combined with transabdominal ultrasound is the primary imaging modality for evaluating ovarian cysts, with MRI reserved for indeterminate lesions—CT and PET/CT have no role in characterization. 1, 2

• Use the O-RADS (Ovarian-Adnexal Reporting and Data System) classification to standardize risk stratification and guide management decisions 1, 2
• MRI without contrast can achieve 85% sensitivity and 96% specificity for detecting malignancy when IV contrast is contraindicated 3

Management by Menopausal Status and Cyst Size

Premenopausal Women with Simple Cysts

Simple cysts ≤5 cm in premenopausal women require no management or follow-up, as they represent physiologic functional cysts that resolve spontaneously. 1, 2

• Simple cysts >5 cm but <10 cm: Follow-up ultrasound at 8-12 weeks during the proliferative phase to confirm functional nature or assess for wall abnormalities 1, 2
• Simple cysts ≥10 cm: Surgical intervention recommended 1, 2
• The evidence is robust: no simple cysts were diagnosed as cancer in women under 50 years in a cohort of 12,957 cysts 3

Postmenopausal Women with Simple Cysts

Simple cysts ≤3 cm in postmenopausal women require no further management. 1, 2

• Simple cysts >3 cm but <10 cm: Require at least 1-year follow-up demonstrating stability or size decrease 1, 2
• Annual follow-up for up to 5 years may be appropriate for persistent simple cysts 1, 2
• Only one malignancy was found among 2,349 simple cysts in women over 50 years at 3-year follow-up 3
• Simple cysts ≥10 cm: Surgical management indicated 1, 2

Management of Specific Cyst Types

Hemorrhagic Cysts

• Premenopausal women with hemorrhagic cysts ≤5 cm: No further management required 2
• Postmenopausal women with hemorrhagic cysts: Require further evaluation by ultrasound specialist, gynecologist referral, or MRI 2
• Hemorrhagic functional cysts decrease or resolve on follow-up at 8-12 weeks 3

Endometriomas and Dermoid Cysts

• Premenopausal women: Optional initial follow-up at 8-12 weeks, then annual ultrasound surveillance 2
• Postmenopausal women: Annual ultrasound follow-up due to small risk of malignant transformation 2
• Endometriomas require yearly follow-up as they can change appearance with age and have a small malignant transformation risk 3
• Dermoid cysts can be safely followed with yearly ultrasound if not excised, with very low risk of malignant degeneration 3

Risk-Stratified Management Using O-RADS

The O-RADS system provides a standardized framework that directly determines management pathways based on malignancy risk. 1, 2

• O-RADS 1-2 (almost certainly benign, <1% malignancy risk): No follow-up or surveillance only 3, 1
• O-RADS 3 (1% to <10% malignancy risk): Management by general gynecologist with ultrasound specialist consultation or MRI 1, 2
• O-RADS 4 (10% to <50% malignancy risk): Mandatory consultation with gynecologic oncology prior to removal 1, 2
• O-RADS 5 (50%-100% malignancy risk): Direct referral to gynecologic oncologist 1, 2

What NOT to Do: Critical Contraindications

Fine-needle aspiration for cytological examination of solid or mixed ovarian masses is absolutely contraindicated. 1, 2

• Transvaginal aspiration is contraindicated for purely fluid cysts >5 cm in postmenopausal women 1, 2
• Cytology has proven unreliable, with correct histopathological diagnosis in only 33.9% of cases 4

Role of Oral Contraceptives

Combined oral contraceptives do not hasten resolution of functional ovarian cysts and should not be used as treatment. 5

• A Cochrane review of 686 women across eight randomized trials found no benefit for cyst resolution 5
• Watchful waiting for 2-3 cycles is the appropriate approach for functional cysts 5
• Most functional cysts resolve spontaneously without treatment within a few cycles 5

Tumor Markers and Additional Testing

• Measure serum CA-125 before surgery when malignancy is suspected 1, 2
• Other markers (CEA, CA19.9, AFP, β-hCG, LDH) should be measured only if CA-125 is not elevated or when specific tumor types are suspected 1, 2
• Color or power Doppler should be included in ultrasound examination to evaluate vascularity of solid components 3

Surgical Indications

Surgery is indicated for: cysts ≥10 cm in any patient, complex cysts with concerning features for malignancy, persistent cysts after appropriate observation, or symptomatic cysts causing pain or complications. 1, 2

• Fertility-sparing surgery is recommended for most cases, especially in younger women 1
• Laparoscopic approach is preferred when surgery is indicated 6
• The goal is ovarian preservation whenever possible, with ovariectomy only when essential 6

Common Pitfalls to Avoid

• Do not operate prematurely on simple cysts <10 cm without appropriate observation period—the risk of malignancy in unilocular cysts in premenopausal women is only 0.5-0.6% 3
• Do not rely on cyst content appearance ("chocolate-like") or cytology for diagnosis—these are unreliable 4
• Do not assume all persistent cysts are pathological—many benign neoplasms can be safely followed 3
• The risk of malignancy in classic benign-appearing lesions managed conservatively is <1%, with acute complications (torsion, rupture) occurring in only 0.2-0.4% 3