Management of Simple Bilateral Ovarian Cysts in a 58-Year-Old Postmenopausal Woman
These 3.5 cm bilateral simple ovarian cysts require no immediate intervention but should have at least one follow-up ultrasound at 1 year to confirm stability, with consideration for annual surveillance up to 5 years if they remain stable. 1, 2
Risk Stratification
These cysts are classified as O-RADS 2 (almost certainly benign, <1% risk of malignancy) based on their simple morphology and size less than 10 cm. 1, 2 The evidence supporting conservative management is robust:
- In a large cohort of 2,349 simple cysts in women over 50 years, only one malignancy was identified at 3-year follow-up (0.04% risk). 1
- A recent study of 619 postmenopausal women with simple cysts found only one case of papillary serous carcinoma, which occurred three years after the last surveillance ultrasound. 3
- Among postmenopausal simple cysts followed conservatively, 46.3% resolved spontaneously and 43.9% persisted unchanged. 3
Endometrial Thickness Assessment
The endometrial thickness of 0.58 cm (5.8 mm) is within normal limits for a postmenopausal woman without bleeding and requires no additional evaluation. 2 This finding does not alter the management of the ovarian cysts.
Recommended Management Algorithm
Initial Management
- No surgical intervention is indicated for simple cysts between 3-10 cm in postmenopausal women when they meet strict criteria for simple cysts. 1, 2
- The cysts must be truly simple: completely anechoic fluid content, thin smooth walls without thickening, no septations, no solid components or nodularity, and no vascularity on color Doppler. 2
Follow-Up Protocol
- Schedule follow-up ultrasound at 1 year to document stability or decrease in size. 1, 2
- If stable at 1 year, consider annual surveillance for up to 5 years. 1, 2
- Use high-quality transvaginal ultrasound performed by experienced sonographers for accurate characterization. 2
What to Monitor During Follow-Up
At each surveillance ultrasound, assess for: 2
- Any increase in cyst size
- Development of solid components or nodules
- New septations or wall irregularities
- New vascularity on color Doppler imaging
Indications for Gynecologic Referral
Refer to a gynecologist if any of the following develop: 4
- Increasing cyst size
- Development of solid components or complex features
- Abnormal Doppler flow patterns
- Patient symptoms develop
- Noncompliance with surveillance protocol
Role of Tumor Markers
CA-125 measurement is optional but not required for simple cysts in this clinical scenario. 5 The evidence shows:
- CA-125 has limited added value in postmenopausal women with simple cysts (negative predictive value 0.95, positive predictive value only 0.35). 5
- CA-125 may be more useful if the cyst develops complex features during follow-up. 5
Common Pitfalls to Avoid
- Do not operate prematurely on simple cysts <10 cm without appropriate observation—the malignancy risk in postmenopausal simple cysts is extremely low (approximately 1.5% or less). 1
- Do not confuse simple with complex cysts: Any internal echoes, septations, or solid components automatically reclassify the cyst and require different management. 2, 5
- Do not assume all persistent cysts are pathological: Many benign cysts persist unchanged for years without malignant transformation. 3
- Ensure bilateral assessment: Since both ovaries have cysts, management is driven by the highest-risk lesion, though in this case both appear equally benign. 1