Can a 5.2‑cm ovarian cyst cause pain?

Can a 5.2 cm Ovarian Cyst Cause Pain?

Yes, a 5.2 cm ovarian cyst can absolutely cause pain through several mechanisms including rupture, hemorrhage, torsion, or simply from mass effect and stretching of the ovarian capsule. 1, 2

Mechanisms of Pain from Ovarian Cysts

Ovarian cysts commonly present with pelvic pain, pressure symptoms, and discomfort, particularly when they reach sizes above 5 cm. 3 The pain can manifest in several distinct patterns:

Acute Pain Presentations

• Ovarian torsion is most common when an ovarian cyst is present, presenting with sudden onset of severe colicky unilateral pain radiating from groin to loin, often accompanied by nausea and vomiting. 3, 2
• Cyst rupture typically causes acute onset pain and is generally self-limiting, though it may require laparoscopy if the diagnosis is uncertain or hemodynamic compromise occurs. 2
• Hemorrhage into the cyst produces acute pain and is usually associated with functional cysts; ultrasound findings are diagnostic for hemorrhagic cysts. 2

Chronic or Intermittent Pain

• Mass effect and capsular stretching from a 5.2 cm cyst can cause persistent pelvic pain, pressure symptoms, and discomfort even without acute complications. 3
• Functional cysts in particular can be linked with irregular vaginal bleeding or menorrhagia in addition to pain. 3

Clinical Context and Risk Stratification

The significance of a 5.2 cm cyst depends critically on menopausal status:

In Premenopausal Women

• A hemorrhagic cyst of 5.2 cm in a premenopausal woman is classified as ONCO-RADS category 3 (benign finding likely) and typically requires follow-up imaging. 1
• Simple cysts >5 cm but <10 cm should be followed up in 8-12 weeks to confirm functional nature or assess for cyst wall abnormalities. 4, 5
• The malignancy risk for simple cysts <10 cm is extremely low (0.5-0.6%), with zero malignancies reported among simple cysts in women under 50 years in a cohort of 12,957 cysts. 4

In Postmenopausal Women

• Symptomatic postmenopausal women with cysts ≥5 cm should be referred to secondary care for further evaluation. 3
• A 5.2 cm hemorrhagic cyst in a postmenopausal woman warrants further evaluation by an ultrasound specialist, gynecologist referral, or MRI. 4
• The risk of malignancy remains low but is higher than in premenopausal women, with only one malignancy found among 2,349 simple cysts at 3-year follow-up. 4

Diagnostic Approach

Transvaginal ultrasound combined with transabdominal ultrasound is the most useful imaging modality for evaluating a painful ovarian cyst and determining the cause of pain. 1, 5

Key ultrasound features to assess include:

• For torsion: Enlarged edematous ovary with peripheral displacement of follicles (though Doppler findings are variable and not diagnostic). 2
• For hemorrhage: Characteristic appearance of blood products with retracting clot and peripheral vascularity. 2
• For rupture: Free fluid in the pelvis with or without internal debris. 2

Management Algorithm

Immediate Management (Acute Pain)

• Suspected adnexal torsion should always be managed with early laparoscopy and de-torsion of the twisted tube or ovary. 2
• Cyst rupture or hemorrhage is generally self-limiting but may require laparoscopy if diagnosis is uncertain or hemodynamic instability develops. 2

Follow-Up Management (Non-Acute Pain)

For premenopausal women with a 5.2 cm cyst:

• Follow-up ultrasound in 8-12 weeks, ideally during the proliferative phase after menstruation to allow functional cysts to resolve. 4, 5
• If the cyst is hemorrhagic and functional, it typically decreases or resolves on follow-up imaging. 4, 5

For postmenopausal women with a 5.2 cm cyst:

• Referral to gynecology is indicated, particularly if symptomatic. 3
• At minimum, follow-up at 1 year with consideration of annual surveillance for up to 5 years if stable. 4, 5

Common Pitfalls to Avoid

• Do not dismiss pain in the presence of a 5.2 cm cyst as purely functional without appropriate imaging follow-up, as complications like torsion can lead to ovarian loss. 2
• Do not confuse ovarian torsion with ureteric colic—torsion pain radiates groin to loin while ureteric colic radiates loin to groin. 3
• Recurrent cyst rupture or hemorrhage should be prevented by suppression of ovulation, usually with combined oral contraceptives. 2
• The risk of acute complications (torsion, rupture) in benign-appearing lesions is 0.2-0.4%, so conservative management is appropriate in most cases. 4, 5