Progesterone Does Not Help Resolve Functional Ovarian Cysts
Progesterone and combined oral contraceptives are ineffective for treating functional ovarian cysts in reproductive-age women and should not be used for this purpose. 1, 2
Evidence Against Hormonal Treatment
The highest quality evidence demonstrates no benefit from hormonal therapy:
A Cochrane systematic review of 8 randomized controlled trials involving 686 women found that combined oral contraceptives did not hasten resolution of functional ovarian cysts in any trial, whether cysts occurred spontaneously or after ovulation induction 1
A prospective randomized trial comparing norethindrone/mestranol to no treatment found the rate of cyst disappearance was identical between groups, with hormonal therapy providing no benefit 2
Most functional cysts resolve spontaneously within 2-3 menstrual cycles without any intervention 1
Recommended Management Algorithm
For premenopausal women with ovarian cysts:
Cysts ≤5 cm: No management required, as these are physiological and benign in 98.7% of cases 3, 4
Cysts >5 cm but <10 cm: Follow-up transvaginal ultrasound in 8-12 weeks for watchful waiting 3
Cysts >10 cm: Surgical management is indicated regardless of characteristics 3
Pain management during observation: NSAIDs (naproxen 500-550 mg or ketorolac 20 mg orally with food) are first-line for symptomatic relief 3
When Progesterone IS Indicated
Progesterone has a completely different role—it is used for endometrial protection in PCOS patients with chronic anovulation, NOT for treating existing cysts:
Medroxyprogesterone acetate 10 mg daily for 12-14 days per month induces withdrawal bleeding and prevents endometrial hyperplasia in anovulatory PCOS patients 5
This regimen protects against endometrial cancer risk from unopposed estrogen, but does not resolve ovarian cysts 5
Critical Pitfalls to Avoid
Do not prescribe hormonal therapy expecting cyst resolution—this is an outdated practice from the 1970s that lacks evidence 1
Do not attempt fine-needle aspiration of complex or solid ovarian masses, which has a 25% non-informative rate and 20% recurrence risk 3
Cysts persisting beyond 2-3 cycles are likely pathological (endometriomas, para-ovarian cysts) rather than functional, requiring surgical evaluation rather than continued observation 1
Use the O-RADS ultrasound classification system to risk-stratify cysts and determine if gynecologic oncology consultation is needed (O-RADS 4-5 require oncology involvement before any surgical intervention) 3