From the Guidelines
Ovarian cyst surgery is typically needed when cysts are large (greater than 10 cm), have concerning features on imaging that suggest potential malignancy, such as multilocular cysts with a solid component or color score up to 4, or have features highly predictive of malignancy, such as irregular solid lesions and multilocular cysts with a solid component and high color score, as indicated by the O-RADS US risk stratification and management system 1.
Indications for Surgery
The following are indications for ovarian cyst surgery:
- Cysts that are large (greater than 10 cm)
- Cysts with concerning features on imaging, such as:
- Multilocular cysts with a solid component or color score up to 4
- Irregular solid lesions and multilocular cysts with a solid component and high color score
- Presence of ascites and/or peritoneal nodules
- Cysts that have ruptured and caused significant bleeding
- Cysts that have caused ovarian torsion (twisting of the ovary)
- Suspicion of endometriomas or other complex cysts that don't resolve on their own
Type of Surgery
The type of surgery depends on the cyst characteristics and may include:
- Laparoscopic cystectomy (removing just the cyst while preserving the ovary)
- Oophorectomy (removing the entire affected ovary)
- More extensive surgery if cancer is suspected
Non-Surgical Management
Most functional cysts (those that form during normal ovulation) resolve spontaneously within 1-3 menstrual cycles and don't require surgical intervention 1. Hormonal contraceptives may be used to prevent new functional cysts but don't typically shrink existing ones that are already causing problems. For example, typical hemorrhagic cysts less than 5 cm can be managed by a US specialist, gynecologist, or MRI, while those greater than 5 cm but less than 10 cm can be followed up in 8-12 weeks 1. Similarly, typical dermoid cysts less than 10 cm with a confident diagnosis can be considered for annual US follow-up if not removed surgically 1.
Decision for Surgery
The decision for surgery should be made after careful evaluation of symptoms, cyst characteristics, age, fertility desires, and risk factors for ovarian cancer, as indicated by the O-RADS US risk stratification and management system 1.
From the Research
Indications for Ovarian Cyst Surgery
Surgery is typically considered for ovarian cysts in the following situations:
- Large cysts, especially those with a diameter of 10 cm or more 2
- Cysts that are suspected to be malignant or have a high risk of malignancy 3
- Cysts that are causing symptoms such as pain or discomfort
- Cysts that are twisting or have a high risk of twisting (adnexal torsion) 3
- Cysts that are not responding to conservative management
Surgical Approaches
Different surgical approaches can be used to manage ovarian cysts, including:
- Laparoscopic surgery, which is a minimally invasive approach that uses small incisions and a camera to visualize the cyst 3, 2, 4
- Laparoscopic ovarian cystectomy, which involves removing the cyst while preserving the ovary 5
- Unilateral salpingo-oophorectomy, which involves removing the ovary and fallopian tube on one side 2
- Ovarian preservation surgery, which aims to preserve as much ovarian tissue as possible, especially in young women 4, 5
Special Considerations
In certain situations, special considerations need to be taken into account, such as:
- Pregnancy: elective laparoscopic surgery may be considered for benign ovarian cysts during pregnancy, especially if the cyst is large or causing symptoms 6
- Fertility preservation: surgical approaches that preserve ovarian tissue and function may be preferred in women who wish to preserve their fertility 4, 5