What is the recommended management for a young woman with an adnexal mass suggestive of a dermoid cyst?

Management of Dermoid Cysts in Young Women

For a young woman with an ultrasound-confirmed dermoid cyst, surgical removal should be strongly considered to prevent ovarian torsion, particularly in premenopausal women, adolescents, and girls, as torsion risk is not reliably predicted by cyst size and occurs in approximately 22% of dermoid cases. 1

Initial Diagnostic Approach

Ultrasound is the definitive imaging modality for diagnosing dermoid cysts, with characteristic findings including echogenic attenuating components, small horizontal interfaces, or macroscopic fat with calcifications representing hair and teeth. 2, 3

• Transvaginal ultrasound combined with transabdominal ultrasound provides optimal visualization 3
• Color or power Doppler should be included to assess vascularity and exclude malignancy 3
• The presence of macroscopic fat with or without calcification and Rokitansky nodule is diagnostic 2

Risk of Torsion: The Critical Consideration

The decision for surgical intervention must prioritize torsion prevention, as this complication significantly impacts morbidity and can result in ovarian loss. 1

Key Evidence on Torsion Risk:

• Dermoid cysts cause adnexal torsion in 22.1% of surgically managed cases 1
• Younger age is significantly associated with torsion risk (mean age 28.8 years in torsion cases versus 34.5 years in non-torsion cases) 1
• Cyst size does NOT reliably predict torsion: torsion occurred in 17.7% of cysts ≤55mm, 58.8% of cysts 60-90mm, and 23.5% of cysts ≥100mm 1
• Patients with torsion present with nausea/vomiting in 47.1% of cases versus only 7.8% without torsion 1

Management Algorithm

For Premenopausal Women with Dermoid Cysts <10 cm:

Option 1 (Conservative): Initial follow-up at 8-12 weeks with annual surveillance if not surgically removed 3

Option 2 (Recommended for younger women): Proceed directly to surgical removal, particularly in:

• Pre-menarchal girls, adolescents, and young women 1
• Any patient presenting with pain, nausea, or vomiting 1
• Cysts of any size, as torsion risk is not size-dependent 1

For Dermoid Cysts ≥10 cm:

Surgical removal is indicated due to increased technical difficulty and risk of complications 3

Surgical Approach

Laparoscopic cystectomy is the preferred surgical approach for dermoid cysts, offering superior outcomes compared to open surgery. 2

Laparoscopic Advantages:

• Shorter hospital length of stay 2
• Less postoperative pain 2
• Shorter operative time and lower blood loss 2
• Median operating time of 80 minutes 4

Surgical Technique Considerations:

• Cystectomy is preferred over oophorectomy to preserve ovarian function (57% cystectomy versus 36% total oophorectomy in one series) 4
• Use extraction pouch to prevent spillage and potential chemical peritonitis 5
• Minimal spillage occurs in 42.5% of cases but does not cause chemical peritonitis with proper technique 4
• Conversion to laparotomy required in only 4.3% of cases 4

Alternative Approach:

• Vaginal removal with laparoscopic assistance offers advantages including reduced operating time and less intraperitoneal spillage compared to total laparoscopic removal 6

Special Considerations During Pregnancy

If dermoid cyst is diagnosed during pregnancy, surgical management should not be delayed if torsion is suspected or the patient is symptomatic. 2

• Laparoscopic surgery is safe throughout pregnancy when performed with appropriate precautions 2
• Second trimester timing is generally preferred but necessary surgery should not be delayed based on gestational age alone 2
• Bilateral dermoid cysts with torsion can occur even in first trimester, requiring urgent intervention 7

Critical Pitfalls to Avoid

• Do not rely on cyst size alone to determine torsion risk: even small dermoid cysts (≤55mm) can undergo torsion 1
• Do not delay surgery in young women based on asymptomatic presentation: the unpredictable nature of torsion warrants prophylactic removal 1
• Do not assume all adnexal masses in young women are functional cysts: dermoid cysts have characteristic ultrasound features that distinguish them 2, 3
• Do not perform biopsy or aspiration: complete surgical excision is required for definitive management 5, 4
• Avoid inadequate peritoneal lavage if spillage occurs during surgery 5

Monitoring for Non-Surgical Candidates

If conservative management is chosen (against the weight of torsion risk evidence):

• Annual ultrasound surveillance is required 3
• Immediate evaluation if morphology changes or vascular components develop 3
• Referral to ultrasound specialist or MRI if concerning features arise 3