From the Guidelines
Management of ovarian cysts with risk factors requires a tailored approach based on specific patient characteristics, with the most recent evidence from 2024 suggesting that simple, asymptomatic cysts smaller than 5 cm in premenopausal women can be managed with watchful waiting and follow-up ultrasound in 8-12 weeks 1. For larger cysts (>5 cm), complex cysts, or those with concerning features, closer monitoring or surgical intervention may be necessary. Key considerations in management include:
- Patient menopausal status, with postmenopausal women generally requiring more aggressive management due to higher risk of malignancy
- Family history of ovarian or breast cancer, BRCA mutations, and other genetic risk factors
- Cyst characteristics such as size, complexity, solid components, septations, and CA-125 elevation
- Patient age, fertility desires, and overall health status
- The use of hormonal contraceptives like combined oral contraceptives (30-35 mcg ethinyl estradiol with progestin) for 3-6 months to prevent new cyst formation, but not to resolve existing cysts
- Pain management with NSAIDs like ibuprofen (400-600 mg every 6 hours) or naproxen (500 mg twice daily) for symptomatic cysts
- Referral to gynecologic oncology and surgical evaluation for high-risk cases, with laparoscopic cystectomy or oophorectomy considered based on individual patient factors. The O-RADS US risk stratification and management system provides a framework for categorizing ovarian cysts based on their risk of malignancy, with categories ranging from O-RADS 0 (normal ovary) to O-RADS 5 (high risk of malignancy) 1. Regular follow-up is essential, with imaging frequency determined by risk stratification, to balance the risk of malignancy against surgical complications and preservation of ovarian function.
From the Research
Management of Ovarian Cysts with Risk Factors
- Ovarian cysts can be managed using various techniques, including conservative treatment, laparoscopic ovarian cystectomy, and unilateral salpingo-oophorectomy (USO) 2, 3, 4, 5.
- The choice of management depends on the type of cyst, the patient's age, and the presence of risk factors for malignancy 2, 6.
- For women with clinically benign cysts, laparoscopic surgery is the preferred approach, with the aim of preserving the ovary 3.
- Conservative treatment, such as shelling out the cyst, can be reserved for women who desire future pregnancies 2.
- The risk of ovarian cancer is a major concern, and where malignancy is suspected, laparoscopy is contraindicated, and a median laparotomy is appropriate for radical extirpative surgery 2.
Diagnostic Techniques
- Endovaginal ultrasound with Doppler enhancement is the best imaging technique to establish the nature of cysts and distinguish cysts suspicious for malignancy 2.
- Transvaginal ultrasonography (TVU) and CA-125 blood tests can be used for ovarian cancer screening and follow-up 6.
- TVU screening examination is considered positive when findings include ovarian volume greater than 10 cubic cm, cyst volume greater than ten cubic cm, any solid area or papillary projection, or any mixed (solid/cystic) component within a cystic ovarian tumor 6.
Surgical Management
- Pelvic laparoscopy is the surgical approach of choice for the treatment of non-functional benign ovarian cysts 2.
- USO is the standard treatment for women with early stage pure immature ovarian teratomas who want to preserve fertility 4.
- Cystectomy with adjuvant chemotherapy may be a suitable fertility-sparing therapy when a cystectomy is the only surgical option 4.
- Cystectomy appears to be an adequate treatment for women with borderline ovarian tumors who wish to preserve fertility, provided that the patient is willing to undergo careful and prolonged follow-up 5.