What is the first‑line management of an ovarian dermoid (mature cystic teratoma) in a reproductive‑age woman, including criteria for surgical removal versus observation?

Management of Ovarian Dermoid Cysts in Reproductive-Age Women

First-Line Management: Size-Based Algorithm

For typical dermoid cysts <10 cm in reproductive-age women, observation with optional initial follow-up at 8–12 weeks is appropriate, followed by annual ultrasound surveillance if not surgically removed. 1

Size-Specific Management Thresholds

• ≤5 cm: No management required in premenopausal women 1
• >5 cm but <10 cm: Follow-up ultrasound in 8–12 weeks recommended 1
  • If the cyst persists or enlarges, referral to ultrasound specialist, gynecologist, or MRI should be considered 1
• ≥10 cm: Surgical management indicated regardless of other characteristics 1

Surgical Indications Beyond Size

Laparoscopic ovarian cystectomy is the gold standard surgical approach for reproductive-age women requiring intervention, with ovarian preservation as the priority. 2

Surgery is indicated when:

• Cyst persists or enlarges on follow-up imaging 1
• Changing morphology or developing vascular component within the lesion 1
• Symptoms develop (pain, torsion, pressure effects) 3, 4
• Concern for malignant transformation (rare at 1–2% risk) 1, 5

Diagnostic Workup

Imaging Strategy

• MRI is the preferred imaging modality for definitive diagnosis, demonstrating pathognomonic features including fatty and calciferous content, hair, teeth, and cartilage 1, 2
• Ultrasound typically shows hyperechoic components with acoustic shadowing, hyperechoic lines and dots, fluid-fluid levels, or floating echogenic spherical structures 1

Laboratory Testing

• Measure AFP, β-hCG, and LDH in all patients to screen for malignant germ cell tumors, particularly important in younger women with pelvic masses 1, 2

Surgical Approach When Indicated

Technique Selection

• Laparoscopic ovarian cystectomy is recommended as the gold standard, preserving the ovary whenever possible 2
• Fertility-sparing surgery is the cornerstone of management in reproductive-age women 1, 2
• Radical surgery and full staging should be avoided as they are usually unnecessary and inappropriate 1

Critical Surgical Considerations

The risk of intraoperative spillage causing chemical peritonitis is extremely rare (0.3–2%) and can be overcome with thorough peritoneal lavage using warmed fluid. 4, 6, 7

• Patients should be counseled preoperatively about spillage risk, adhesion formation risk, and recurrence risk 3
• If spillage occurs, immediate thorough peritoneal lavage is required 4
• Chemical peritonitis from spontaneous or surgical rupture can cause severe complications including acute respiratory distress syndrome 7

Surveillance Strategy for Conservative Management

• Annual ultrasound surveillance is recommended for dermoid cysts managed conservatively 1
• Patients under gynecologist care typically receive this monitoring 1
• Optimal duration of surveillance has not been definitively established 1

Common Pitfalls to Avoid

• Do not perform fine-needle aspiration of dermoid cysts—this provides no diagnostic benefit and risks complications 8
• Do not assume all pelvic masses are ovarian—rare cases of cecal or other extraovarian dermoid cysts can masquerade as ovarian lesions 5
• Do not delay surgical intervention when changing morphology or vascular components develop, as these may indicate malignant transformation 1
• Do not perform oophorectomy routinely—cystectomy with ovarian preservation is preferred in younger women with single small cysts 6

Red Flags Requiring Urgent Evaluation

• Acute abdominal pain with peritoneal signs (suggests rupture or torsion) 4, 7
• Solid components or papillary projections on imaging (suggests possible malignancy) 1
• Elevated tumor markers (AFP, β-hCG, LDH) suggesting malignant germ cell tumor 1
• Rapid growth or changing characteristics on serial imaging 1

Special Population: Postmenopausal Women

• Higher threshold for surgical intervention due to increased malignancy risk 1
• Annual ultrasound follow-up may be considered for confident diagnosis when not surgically excised 1
• Risk of malignant transformation is higher in this population 1
• Standard surgical approach with consideration for bilateral salpingo-oophorectomy is appropriate 2