When is referral for transvaginal ultrasound indicated for a perimenopausal patient with recurrent ovarian cysts?

From the Guidelines

Referral for transvaginal ultrasound is needed for perimenopausal patients with recurrent ovarian cysts when there are concerning features such as complex cysts, cysts larger than 5 cm, or persistent cysts that don't resolve after 2-3 menstrual cycles, as these may indicate a higher risk of malignancy 1.

Key Indications for Referral

• Complex cysts (with solid components, septations, or papillary projections)
• Cysts larger than 5 cm
• Persistent cysts that don't resolve after 2-3 menstrual cycles
• Rapidly growing cysts
• Severe or worsening pelvic pain, abnormal vaginal bleeding, or symptoms suggesting possible torsion or rupture

Considerations for Simple Cysts

• Simple, thin-walled cysts smaller than 5 cm can often be monitored with repeat ultrasound in 3-6 months, as the risk of malignancy is low 1
• The transvaginal approach provides better resolution than transabdominal ultrasound for detailed assessment of ovarian morphology

Importance of Vigilance

• Perimenopausal women have a higher risk of ovarian malignancy compared to younger women, so vigilance is important
• CA-125 testing may be considered alongside imaging, though it has limited specificity in premenopausal women

Goal of Evaluation

• The goal is to distinguish between physiologic follicular cysts, which are common during perimenopause due to irregular ovulation, and potentially concerning pathologic cysts requiring intervention 1

From the Research

Referral for Transvaginal Ultrasound in Perimenopausal Patients with Recurrent Ovarian Cysts

• Referral for transvaginal ultrasound is needed for perimenopausal patients with recurrent ovarian cysts in certain situations, as outlined in the following points:

Indications for Referral

• Symptomatic postmenopausal women, those with a cyst ≥ 5 cm, or raised CA125 levels, should be referred to secondary care 2
• Simple cysts > 5 cm are less likely to resolve and need an annual ultrasound assessment as a minimum in premenopausal women 2
• Ovarian cysts may be asymptomatic but presenting symptoms include pelvic pain, pressure symptoms and discomfort and menstrual disturbance, which may require further investigation 2

Diagnostic Considerations

• Transvaginal ultrasonography (TVU) is considered positive (abnormal and suspicious for ovarian cancer) when findings include:
  • Ovarian volume greater than 10 cubic cm
  • Cyst volume greater than ten cubic cm
  • Any solid area or papillary projection extending into the cavity of a cystic ovarian tumor of any size
  • Any mixed (solid/cystic) component within a cystic ovarian tumor 3
• TVU screening examination is used at baseline, with annual TVU for three additional years, and annual CA-125 tests for five years beyond baseline for ovarian cancer screening and follow up 3

Management of Ovarian Cysts

• Expectant management of cysts with benign ultrasound morphology is a management option in selected asymptomatic premenopausal women 4
• Transvaginal ultrasonography has a closer accuracy in the diagnosis of serous cysts and serous cystadenoma, ovarian carcinoma and endometrioma than CT, even if the latter is associated with clinical and biochemical parameters such as patient's age and CA-125 plasma levels 5
• A novel index combining resistance index (RI) obtained from newly formed vessels within the ovarian lesion and serum CA 125 level can be used for the detection of ovarian malignancy, with values below the cut-off value of 1.5 associated with a high risk of ovarian malignancy 6