Ovarian cysts <3 cm in diameter are considered normal and typically resolve without complication.34 However, if an ovarian cysts ruptures or bleeds, hemodynamic stability monitoring and ultrasound should be conducted. Significant bleeding on ultrasound or unstable patients should be admitted to an inpatient service for close monitoring, volume replacement, and, if warranted, referral for surgery.35
Ovarian torsion is a medical emergency that requires prompt surgical consultation for either ovarian detorsion to preserve the ovary or oophorectomy.36 Patients with endometriomas may have significant pain and pressure, and may elect to have an oophorectomy or cystectomy, especially if analgesics are unsuccessful in controlling pain.1,37 In patients who have recurrent ovarian cysts, oral contraceptives have been shown to be successful for prevention of new cysts; however, they have not been shown to decrease the size or increase the rate of healing of existing cysts.38,39
For patients at low risk for cancer whose ovarian cysts appear benign, a follow-up ultrasound 3- to 6-months after the initial ultrasound is recommended (Table 3).4,40 In women whose cyst contains malignant features, a repeat ultrasound is recommended 6 weeks after the initial ultrasound.20 Surgery may be necessary to accurately evaluate the tissue morphology if the cyst cannot be differentiated as benign or malignant, or in the case of malignant-appearing cysts.41,42 In all postmenopausal women, biomarkers CA 125 and HE4 should be assessed during the initial ultrasound.31
Table 3. Ovarian Cyst Follow-Up Recommendations
|Pre-menopausal, low cancer risk||Repeat ultrasound in 3-6 months|
|Pre-menopausal, high cancer risk||Repeat ultrasound in 6 weeks|
|Post-menopausal, low cancer risk||Tumor marker CA 125 at initial ultrasound and repeat ultrasound in 3-6 months|
|Post-menopausal, high cancer risk||Tumor marker CA 125 at initial ultrasound and repeat ultrasound in 6 weeks*|
|Adolescent and younger||Repeat ultrasounds monthly until cyst resolution†|
† Cysts found to be growing, symptomatic, or malignant require surgical consultation
⁺ Surgery is recommended in this population when the cyst appears malignant, preferably after the first trimester.
In patients of adolescent age or younger, ultrasounds should be performed monthly until the cyst has resolved.43 Cysts found to be growing, symptomatic, or malignant require a surgical consult which may result in a range of treatments from a cystectomy to a bilateral salpingo-oophorectomy.15,16 In pregnant patients with benign-appearing ovarian cysts, watchful waiting with follow-up at the regularly scheduled fetal scans is the treatment of choice. Malignant-appearing cysts may be further evaluated with magnetic resonance imaging. If surgery is warranted in a pregnant patient, the recommendation is to wait until after the first trimester and perform the surgery laparoscopically rather than open surgery whenever feasible.44
Ovarian Cancer Risk
In a study of 15,735 postmenopausal women, serial transvaginal ultrasounds were used to assess the presence of simple cysts and the development of subsequent ovarian cancer. Women who had ≥1 cyst at baseline or developed simple cysts during the trial were not found to be at increased risk for ovarian cancer compared to their non-cyst counterparts (P =.85 and P >.99, respectively).15
In another study of 1769 postmenopausal women, 6.6% were found to have simple cysts at baseline. Of those with simple cysts, 23.3% resolved spontaneously and no malignancies were found by the end of the study.45 Finally, in a study of 15,106 women aged ≥50 years, 18% were found to have ovarian cysts (69.4% resolved spontaneously), while 27 women were diagnosed with ovarian cancer at the resolution of this study; only 10 of the women had previously been diagnosed with ovarian cysts.46
Meaghan Mize, PA-C, is a radiation oncology physician assistant at University Cancer and Blood Center, Athens, Georgia, and Alicia Elam, PharmD, is associate professor in the Department of Physician Assistant at Augusta University, Augusta, Georgia.
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