What is the treatment for ovarian cysts in women of various ages and medical histories?

Treatment of Ovarian Cysts

The treatment of ovarian cysts is primarily determined by cyst size, ultrasound characteristics, menopausal status, and symptoms—with most simple cysts managed conservatively through observation, while complex or large cysts (>10 cm) require surgical intervention. 1

Initial Diagnostic Approach

Transvaginal ultrasound combined with transabdominal ultrasound is the essential first step for characterizing any ovarian cyst, as it determines the entire management pathway. 1 The critical distinction is whether the cyst is simple (completely anechoic, thin smooth walls, no septations or solid components, no vascularity) versus complex (thick walls, septations, solid components, or nodularity). 1, 2

Apply the O-RADS (Ovarian-Adnexal Reporting and Data System) classification to stratify malignancy risk:

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

Management in Premenopausal Women

Simple Cysts

• ≤3 cm: No management required—these are physiologic and need no follow-up 1
• >3 cm but ≤5 cm: No further management needed 1
• >5 cm but <10 cm: Follow-up ultrasound at 8-12 weeks (preferably during proliferative phase) to confirm functional nature or assess for wall abnormalities 1
• ≥10 cm: Surgical management indicated 1

Hemorrhagic Cysts

Hemorrhagic cysts ≤5 cm require no management, as they typically decrease or resolve on follow-up at 8-12 weeks. 1

Endometriomas and Dermoid Cysts

• Optional initial follow-up at 8-12 weeks, then yearly ultrasound surveillance 1
• Surgical treatment is indicated for endometriomas >4 cm due to risk of rupture or torsion 3
• Small asymptomatic endometriomas should not be treated surgically, especially in patients older than 35 years, as surgery can compromise ovarian reserve 3
• For infertile women with endometriomas who failed to conceive after 1-1.5 years, surgical removal of the cyst with its capsule and endometriotic foci is the most efficient approach 3

Critical Pitfall to Avoid

Do not operate prematurely on simple cysts <10 cm—the malignancy risk in unilocular cysts in premenopausal women is only 0.5-0.6%, and acute complications (torsion, rupture) occur in only 0.2-0.4% of cases. 1

Management in Postmenopausal Women

Simple Cysts

• ≤3 cm: No management required 1
• >3 cm but <5 cm: At least one follow-up ultrasound at 1 year to confirm stability, with consideration for annual surveillance up to 5 years if stable 1, 2
• >5 cm but <10 cm: At least 1-year follow-up showing stability or decrease in size 1
• ≥10 cm: Surgical management indicated 1

During surveillance, assess for any increase in size, development of solid components, septations, wall irregularities, or new vascularity on color Doppler. 1

Complex Cysts

Any thick-walled, complex, or hemorrhagic cyst in a postmenopausal woman requires further evaluation by ultrasound specialist, gynecologist referral, or MRI study, even with normal CA-125. 2 Hemorrhagic cysts should not occur in postmenopausal women and their presence mandates investigation. 2

Do not apply simple cyst management algorithms to thick-walled or complex cysts—the conservative "watch and wait" approach only applies to true simple cysts with thin, smooth walls. 2

Surgical Indications Across All Age Groups

Absolute indications for surgery:

• Any cyst ≥10 cm 1
• Symptomatic cysts causing persistent pain, nausea, or vomiting regardless of size 4
• Complex cysts in postmenopausal women 1
• O-RADS 4-5 lesions 1
• Cysts with solid components, thick septations, or nodularity 2

Surgical approach: Laparoscopic surgery is safe and effective, with ovarian-sparing procedures preferred when possible. 5 The most efficient surgical treatment involves adhesiolysis and removal of the cyst along with its capsule. 3

Contraindicated Procedures

Never perform fine-needle aspiration for cytological examination of solid or mixed ovarian masses. 1, 2

Transvaginal aspiration is contraindicated for purely fluid cysts >5 cm in postmenopausal women. 1, 2

Tumor Marker Testing

Measure serum CA-125 before any surgical intervention or chemotherapy. 1 Other markers (CEA, CA19.9) should only be measured if CA-125 is not elevated. 1

Role of Pharmacotherapy

Hormonal therapy has limited utility and should be considered primarily for diffuse endometriosis associated with pain. 3 Options include estrogen-progestin preparations, gestagens (including progesteron-releasing intrauterine systems), and GnRH agonists. 3 In adolescents, only cysts >6 cm that fail to resolve with estrogen-progestin therapy within 6 months should be surgically approached. 5

Special Population: Pediatric Patients

In infants, any signs of cyst complications must be addressed surgically. 5 In adolescents, most cysts can be managed conservatively, even those >5 cm in diameter, with surgery reserved for exceptional cases. 5, 6