Approach

In pre-menopausal women, ovarian cysts often resolve without treatment. In post-menopausal women, ovarian cysts are more likely to persist. If the patient is symptomatic or a malignant tumour is discovered, treatment usually involves surgery.

Acutely unwell: with complications of ovarian cyst

Benign ovarian cysts are commonly asymptomatic, but patients may present acutely with symptoms arising from complications such as infection, haemorrhage, torsion, cyst rupture, or necrosis.

  • Surgical exploration is a necessary first-line management tool among patients with haemodynamic instability or evidence of an acute abdomen that suggests possible ovarian torsion or cyst rupture/haemorrhage, with intravenous fluid resuscitation.[27][58]

  • When examination or imaging demonstrates massive haemorrhage, the surgical approach is laparotomy.[59] Otherwise, laparoscopy can provide diagnostic and therapeutic utility. Provided that the surgeon has adequate experience with laparoscopy, this method yields safe and reliable conservation of the affected ovary in 50% of cases.[60][61]

  • In the acutely unwell patient with cyst rupture, tubo-ovarian abscess, or pelvic inflammatory disease, parental broad-spectrum antibiotics should be given. Patients can usually be switched to a suitable oral regimen within 24 to 48 hours of improvement to complete a 14-day treatment course. At least 24 hours of inpatient observation is recommended in these patients.[62]

Pre-menopausal: with simple ovarian cyst

First-line treatment is expectant or conservative management if the patient agrees to thorough follow-up with serial ultrasounds.[32] The US Society of Radiologists in Ultrasound recommends that asymptomatic simple cysts >3 cm should be described but do not require follow up, unless they are greater than 5-7 cm, with the higher threshold for exceptionally well-visualised cysts.[63] The timing of follow-up imaging depends on the case circumstances: if any concern, or if there is less confidence in diagnosis, follow up in 2-6 months for characterisation; or follow up in 6-12 months for growth assessment.[63] In general, expectant management is the preferred choice in pre-menopausal women with non-suspicious cysts.

  • If the cyst does persist, surgical exploration and removal should proceed via laparoscopy. Histopathology can confirm the nature of the cyst. Mini-laparotomy offers a valid alternative with shorter operative time, specifically for patients in whom pneumoperitoneum poses increased risk (i.e., obesity, active pulmonary disease).[64] A large proportion of such cysts will resolve on their own.[33][65][66] Simple cysts measuring up to 10 cm in diameter are most often benign.

  • The prevalence of ovarian cancer in this circumstance is quite low, and the removal of benign cysts does not reduce the mortality from ovarian cancer.[67] Fine needle aspiration and cytology of ovarian cysts is not recommended due to the low sensitivity (25%) and high false-positive rate (73%).[38]

  • Eight randomised controlled trials from four countries revealed no hastened resolution of such cysts with the use of oral contraception pills.[66]

Pre-menopausal: with complex or solid ovarian cyst

Physiological forms of complex ovarian cysts often resolve spontaneously, but many are persistent. One study demonstrated an 8.3% spontaneous resolution rate over 34 months.[33]

  • If the diagnostic impression is benign, conservative management is first-line, with serial ultrasounds every 2 to 3 months. If persistent, treatment by laparoscopy is the next step, which will include histopathological assessment of the cyst. In patients for whom laparoscopy is contraindicated and where there is a suspicion of malignancy, laparotomy is advised with histopathological assessment of the cyst.

  • Solid cysts may be associated with necrotic tissue, and in the absence of infection, ovarian torsion, or endometrioma, these should be regarded with suspicion for malignancy. All pre-menopausal women with solid cyst require laparotomy and gynaecological oncology referral. Referral to a gynaecological oncologist should follow for women with increased germ cell tumour markers or imaging findings concerning for malignancy. A more extensive laparotomy, including staging and exploration of lymph node status, is warranted among these women.[41]

  • In a randomised trial of laparoscopy versus laparotomy in pre-menopausal women with benign-appearing masses, laparoscopy yielded a low complication rate (0%), decreased operative morbidity, decreased hospital stay, decreased post-operative pain, and no increased risk of cyst spillage.[1] Conversion to laparotomy was low among these patients (6.4%). Another study reported spillage of the cyst contents in 18% of cases in a laparoscopy-managed group and 1% in a laparotomy-managed group of women with dermoids. However, no increase in morbidity was noted.[68] Laparotomy is an option for patients in whom laparoscopy is contraindicated or where suspicion of malignancy is high.

Post-menopausal: with simple ovarian cyst

In post-menopausal women with simple (unilocular, anechoic) cysts <10 cm in diameter together with a normal cancer antigen (CA)-125, first-line treatment is conservative observation with serial ultrasounds and CA-125 levels every 2 to 3 months.[12][47][69] Guidelines vary on size and interval of ultrasounds for conservative management of simple ovarian cysts. According to the UK Royal College of Obstetricians and Gynaecologists, simple cysts <5 cm can be followed with serial ultrasounds every 4 to 6 months.[30] The US Society of Radiologists in Ultrasound recommends that no follow-up imaging is needed for asymptomatic simple cysts ≤3 cm, although those >1 cm should be documented in the medical record. Follow up is only recommended for simple cysts greater than 3-5 cm, with the higher threshold of 5 cm for simple cysts that are exceptionally well-characterised and documented.[63] The timing of follow-up imaging depends on the case circumstances: if any concern, or if there is less confidence in diagnosis, follow up in 3-6 months for characterisation; or follow up in 6-12 months for growth assessment.[63]

  • In one study of unilocular ovarian cysts <10 cm in diameter, 69.4% resolved and 6.8% persisted as a unilocular cyst.[12] Thus, the risk of malignancy is extremely low (<0.1%). Another study of unilocular ovarian cysts reported a resolution rate of approximately 44% and a low (0.6%) malignancy potential.[59]

  • If the cyst increases in size or morphology index, the physician should proceed to surgical evaluation and cyst removal that will include histopathological diagnosis. Laparoscopy should be reserved for cysts with a low suspicion for malignancy, and cyst removal should proceed in a fashion that provides histopathological diagnosis yet is complete and without intra-abdominal spillage. Size alone should not dictate surgical approach, as several studies have verified the safety and success of laparoscopy for cysts >10 cm.[70][71]

Post-menopausal: with complex or solid ovarian cyst

Patients with a complex or solid cyst who are post-menopausal should be referred to a gynaecological oncologist for surgical evaluation. If a malignant ovarian tumour is discovered incidentally, ideally a gynaecological oncologist should be consulted intraoperatively.[31]

  • Solid cysts may be associated with necrotic tissue, and in the absence of infection, ovarian torsion, or endometrioma, should be regarded with suspicion for malignancy.

  • Owing to the increased survival and prognosis for women with ovarian cancer managed by gynaecological oncologists, the American College of Obstetricians and Gynecologists developed guidelines for referral. The guidelines perform well for advanced-stage disease, with a sensitivity for malignancy of 93.2%.[31][35][39]

  • Women with a nodular or fixed pelvic mass, CA-125 value >35 U/mL, evidence of metastasis, or presence of ascites should be offered laparotomy by an experienced gynaecological oncologist.

Pregnant: with simple or complex ovarian cyst

Many ovarian cysts will be detected by routine sonography in the first or second trimester.[72] The risk of ovarian malignancy is 1 in 12,000 to 47,000, and the risk of complications such as torsion or rupture range from 1% to 6%.​[14][72][73]

The majority of the simple and complex masses will resolve spontaneously and present no risk to the pregnancy. Ideally, the surgery can be postponed to the postnatal period or time of caesarean delivery, when cystectomy can be performed with ease. Thus, first-line treatment remains conservative, with observation and serial ultrasounds. However, ovarian masses that are suspicious for malignancy, >8 cm in diameter, produce symptomatic complaints, or pose an increased risk of ovarian torsion require surgical intervention. For persistent benign-appearing cysts that are >8 cm in diameter or produce symptoms of pain or mass-effect compression on other organs, laparoscopic exploration and cyst removal should be considered. If the cyst demonstrates characteristics of malignancy, surgical removal during pregnancy should be undertaken by laparotomy in the second trimester.[14] If there is a risk of disruption of the corpus luteum at less than 12 weeks' gestation, then progesterone support is indicated.[74]

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