From the Guidelines
Medically fit patients with ovarian cysts can be managed conservatively with observation and follow-up ultrasound, as the risk of malignancy is low, especially for simple cysts smaller than 5 cm in premenopausal women 1.
Key Considerations
- The American College of Radiology (ACR) recommends that 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, even in postmenopausal patients 1.
- For asymptomatic simple cysts smaller than 5 cm, watchful waiting with follow-up ultrasound in 2-3 months is often recommended as many resolve spontaneously.
- For symptomatic cysts, pain management with NSAIDs like ibuprofen (400-600 mg every 6 hours) or naproxen (500 mg twice daily) is appropriate.
- Combined hormonal contraceptives (such as pills containing ethinyl estradiol 20-35 mcg with progestin) can be prescribed for 3-6 months to prevent new functional cyst formation, though they don't treat existing cysts.
Surgical Intervention
- Surgical intervention is considered for cysts larger than 5-10 cm, complex or suspicious cysts, persistent cysts after several menstrual cycles, or those causing severe symptoms.
- Laparoscopic cystectomy is preferred when possible to preserve ovarian tissue.
Follow-up and Monitoring
- Patients should be monitored for complications including torsion, rupture, or hemorrhage, which present with sudden severe pain requiring immediate medical attention.
- Regular follow-up is essential to ensure resolution and rule out malignancy, especially in postmenopausal women or those with concerning ultrasound features.
Risk of Malignancy
- The risk of malignancy in simple cysts is low, with a recent meta-analysis by Parazzini et al demonstrating a risk of 0.6% in 987 unilocular cysts removed surgically in premenopausal women 1.
- The risk of malignancy in benign-appearing lesions on US managed conservatively with 2-year follow-up was 0.3% to 0.4% for malignancy and 0.2% to 0.4% for acute complications such as torsion or cyst rupture 1.
From the Research
Medically Fit Management of Ovarian Cysts
- The management of ovarian cysts depends on various factors, including the type and size of the cyst, as well as the patient's symptoms and medical history 2.
- Functional ovarian cysts are common in women of reproductive age and usually resolve spontaneously within a few cycles 3, 4, 5.
- Combined oral contraceptives have been widely used to treat functional ovarian cysts, but studies have shown that they do not hasten the resolution of these cysts 3, 4, 5.
- Watchful waiting for two or three cycles is often recommended for functional ovarian cysts, and surgical management may be indicated if the cysts persist 3, 4, 5.
- For non-functional ovarian cysts, the management approach depends on the histologic origin and nature of the cyst, as well as the patient's desire for future pregnancies 2.
- Pelvic laparoscopy is the surgical approach of choice for the treatment of non-functional benign ovarian cysts, and conservative treatment to preserve functional ovarian tissue should be reserved for women desirous of future pregnancies 2.
- The risk of ovarian cancer is a major concern, and laparoscopy is contraindicated if malignancy is suspected, in which case a median laparotomy is appropriate for radical extirpative surgery 2.
- Proper triage of incidental ovarian cysts found on imaging is essential to decrease unnecessary procedures and worry while obtaining the best survival benefit for those ultimately found to have cancer 6.