What are the treatment options for an ovarian cyst?

From the Guidelines

For most ovarian cysts, especially those that are simple and small, watchful waiting with regular follow-up ultrasounds is the recommended approach, as the risk of malignancy is low 1.

Key Considerations

• The type, size, symptoms, and likelihood of cancer are crucial factors in determining the treatment plan for ovarian cysts.
• Functional ovarian cysts, which form during the menstrual cycle, often resolve on their own within 1-3 menstrual cycles, and watchful waiting is typically recommended.
• Over-the-counter pain relievers like ibuprofen (400-600mg every 6 hours) or acetaminophen (650mg every 6 hours) can help manage discomfort associated with ovarian cysts.
• For recurrent functional cysts, hormonal contraceptives such as combined oral contraceptive pills may be prescribed to prevent ovulation and new cyst formation.
• Surgical intervention is usually reserved for cysts that are large (>5-10cm), persistent (lasting longer than 2-3 months), causing severe symptoms, or suspicious for cancer, as indicated by recent guidelines 1.

Specific Recommendations

• For premenopausal women, simple cysts less than 5 cm do not need to be followed, according to a recent consensus update 1.
• For postmenopausal women, simple cysts up to 10 cm in diameter on transvaginal ultrasonography performed by experienced ultrasonographers are likely to be benign and may be safely monitored using repeat imaging without surgical intervention 1.
• Endometriomas, dermoid cysts, and other non-functional cysts usually require surgical removal as they rarely resolve spontaneously.
• Regular follow-up ultrasounds are important to monitor cyst changes, especially for those under observation, to promptly identify any potential complications such as cyst rupture or torsion requiring emergency care.

Evidence-Based Approach

• Recent studies, including a meta-analysis by Parazzini et al 1, have demonstrated that the risk of malignancy in unilocular cysts in premenopausal women is very low, approximately 0.6%.
• The American College of Radiology's Appropriateness Criteria for clinically suspected adnexal mass, no acute symptoms, supports the use of ultrasound for diagnosing and managing adnexal lesions, including simple cysts 1.
• The evidence suggests that a conservative approach with watchful waiting and regular follow-up is appropriate for most ovarian cysts, reserving surgical intervention for cases with a higher risk of complications or malignancy.

From the Research

Treatment Options for Ovarian Cysts

• The treatment of ovarian cysts depends on their nature, with accurate preoperative discrimination of benign and malignant cysts being crucial 2.
• Expectant management is often the choice for premenopausal and pregnant women with non-suspicious cysts and normal levels of CA-125 2.
• In postmenopausal women, unilocular, anechoic cysts less than 5 cm in diameter with a normal CA-125 may be followed up 2.
• Operation is recommended for women with cysts larger than 5 cm and/or elevated levels of CA-125 2.
• Women with symptoms should be operated on regardless of age, menopausal status, or ultrasound findings 2.

Surgical Approaches

• Pelvic laparoscopy is the surgical approach of choice for the treatment of non-functional benign ovarian cysts 3.
• Conservative treatment to shell out the cyst and preserve functional ovarian tissue should be reserved for women desirous of future pregnancies 3.
• Laparoscopic surgery appears to be safe and effective for the treatment of ovarian pathologies in children 4.

Diagnostic Techniques

• Endovaginal ultrasound with Doppler enhancement is the best imaging technique to establish the nature of cysts and to distinguish cysts suspicious for malignancy 3.
• Ultrasound examination is indispensable in the early detection of ovarian lesions and for identifying the correct treatment 4.
• CA-125 blood test and transvaginal ultrasonography (TVU) are used for ovarian cancer screening and follow-up 5.

Management of Specific Types of Ovarian Cysts

• Functional ovarian cysts can be managed with expectant management or hormonal treatment, with similar effectiveness 6.
• In children, the management of ovarian lesions must be based on a minimally invasive approach, based on the patient's age and ultrasound findings 4.
• In adolescents, only cysts larger than 6 cm that do not resolve with estro-progestinic therapy within 6 months should be surgically approached 4.