What is the management plan for a patient with a painful adnexal cyst?

Management of Painful Adnexal Cysts

For a patient with a painful adnexal cyst, begin with transvaginal ultrasound with Doppler to characterize the mass and assess for acute complications (torsion, rupture, hemorrhage), then manage based on cyst characteristics, menopausal status, and degree of suspicion for malignancy using the O-RADS classification system. 1

Immediate Assessment

Clinical Evaluation

• Pain characteristics matter: Acute severe pain suggests torsion, rupture, or hemorrhage requiring urgent surgical consultation 2
• Obtain pregnancy test (beta-hCG) in all reproductive-age women to exclude ectopic pregnancy 3, 4
• Assess for peritoneal signs, hemodynamic instability, or fever that would indicate surgical emergency 2

Initial Imaging

• Transvaginal ultrasound combined with transabdominal ultrasound is the most useful initial approach 1
• Include color or power Doppler to evaluate vascularity of solid components and confirm blood flow (helps differentiate clot from true solid tissue) 2, 1
• Doppler can identify the "bridging vessel sign" to confirm uterine versus ovarian origin 2

Management Based on Cyst Type

Simple Cysts

• Simple cysts are benign in 98.7% of premenopausal women 2, 1
• Premenopausal women: Simple cysts ≤3 cm require no follow-up; those >3 cm may be observed if asymptomatic 1
• Postmenopausal women: Simple cysts <3 cm require no follow-up (malignancy risk only 0.3-0.4%); those >3 cm warrant follow-up ultrasound in 3-6 months 1, 5
• If pain persists despite benign appearance, consider symptomatic management or surgical consultation 3

Hemorrhagic Cysts (Common Cause of Pain)

• Premenopausal hemorrhagic cysts ≤5 cm require no further management 1
• Premenopausal hemorrhagic cysts >5 cm but <10 cm require follow-up ultrasound in 8-12 weeks to confirm resolution 1
• Postmenopausal hemorrhagic cysts warrant further evaluation with ultrasound specialist consultation, gynecologist referral, or MRI 1
• Characteristic features: spiderweb-appearing or retracting clot with peripheral vascularity on Doppler 2

Endometriomas

• Appear as complex cysts with diffuse low-level internal echoes, mural echogenic foci, or nonvascular solid attenuating components 2
• Premenopausal patients with endometriomas <10 cm: Optional initial follow-up at 8-12 weeks with annual surveillance if not surgically removed 1
• Postmenopausal endometriomas have higher malignant transformation risk; annual ultrasound follow-up recommended 1
• If morphology changes or vascular components develop, refer to ultrasound specialist or obtain MRI 1

Dermoid Cysts (Teratomas)

• Characterized by echogenic attenuating component, small horizontal interfaces, or macroscopic fat with calcification 2
• Premenopausal patients with dermoids <10 cm: Optional initial follow-up at 8-12 weeks with annual surveillance if not surgically removed 1
• Consider surgical removal if symptomatic, enlarging, or patient desires definitive management 1

Risk Stratification Using O-RADS

O-RADS 3 (1% to <10% malignancy risk)

• Manage with general gynecologist, possible ultrasound specialist consultation, or MRI 1
• Examples: complex cysts with thin septations, minimal solid components without vascularity 1

O-RADS 4 (10% to <50% malignancy risk)

• Require consultation with gynecologic oncology prior to removal or referral for management 1
• Features include moderate solid components, irregular septations, or moderate vascularity 1

O-RADS 5 (50%-100% malignancy risk)

• Direct referral to gynecologic oncologist is warranted 1
• Features include large solid components, papillary projections, very strong vascularity, or ascites 1

Indeterminate Masses

• Up to 22-24% of adnexal masses remain indeterminate after initial ultrasound 1
• MRI pelvis with and without IV contrast is the most useful modality for further evaluation 2, 1, 5
• CT is not recommended for characterization of adnexal masses due to suboptimal soft tissue delineation 2, 1
• If MRI shows benign features, follow-up ultrasound in 3-6 months is appropriate 5

Special Considerations in Pregnancy

• Pain is the most common presenting symptom in pregnant patients with adnexal masses 2
• Ultrasound features in pregnancy are similar to non-pregnant patients 2
• Most adnexal masses in pregnancy are benign: dermoids (32%), endometriomas (15%), functional cysts (12%), cystadenomas (19% combined) 2
• Only 2% of adnexal masses in pregnancy are malignant 2
• Gadolinium is not recommended during pregnancy 2

Surgical Indications

Emergent Surgery Required

• Suspected ovarian torsion (acute severe pain, enlarged ovary with decreased or absent Doppler flow) 2
• Ruptured cyst with hemodynamic instability 2
• Suspected ectopic pregnancy with rupture 3, 4

Elective Surgery Considerations

• Persistent pain despite conservative management 3
• Cysts >10 cm (higher torsion risk) 3
• Suspicious features for malignancy (O-RADS 4-5) 1
• Patient preference for definitive management of symptomatic benign masses 1

Critical Pitfalls to Avoid

• Do not assume all painful cysts require surgery—most hemorrhagic cysts resolve spontaneously in premenopausal women 1
• Do not misinterpret clot or debris as solid tissue—use Doppler to confirm absence of vascularity 2, 1
• Do not rely on CT for adnexal mass characterization—MRI is superior for soft tissue delineation 2, 1
• Do not assume all postmenopausal cysts are malignant—simple cysts <3 cm have extremely low malignancy risk (0.3-0.4%) 1, 5
• Initial management by a gynecologic oncologist is the second most important prognostic factor for ovarian cancer survival (after stage), yet only 33% of women with ovarian cancer are appropriately referred 2, 1
• Surgical exploration of benign lesions carries 2-15% complication rates, emphasizing the importance of accurate preoperative characterization 2, 1