Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

acutely ill

1st line – laparoscopy or laparotomy

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ACUTE
|
acutely ill
1st line – 

laparoscopy or laparotomy

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]

Plus – resuscitation and haemodynamic support

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ACUTE
|
acutely ill
Plus – 

resuscitation and haemodynamic support

Treatment recommended for ALL patients in selected patient group

Adequate intravenous access with two large-bore intravenous cannulas and intravenous fluid resuscitation must be started. Central venous line placement should be considered for continuous monitoring of vital signs and haemodynamic parameters. Blood transfusion and/or vasopressor agents may be indicated if patient remains hypotensive after intravenous fluid resuscitation.

Consider – broad-spectrum antibiotics

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ACUTE
|
acutely ill
Consider – 

broad-spectrum antibiotics

Additional treatment recommended for SOME patients in selected patient group

In the acutely ill 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]

If cyst rupture is suspected without concern for tubo-ovarian abscess or pelvic inflammatory disease, then the triple antibiotic therapy regimen is used to treat sepsis caused by fluid leakage.

Primary options

cefoxitin: 2 g intravenously every 6 hours

or

cefotetan: 2 g intravenously every 12 hours

-- AND --

doxycycline: 100 mg intravenously/orally every 12 hours

OR

clindamycin: 900 mg intravenously every 8 hours

and

gentamicin: 2 mg/kg intravenously/intramuscularly as a loading dose, followed by 1.5 mg/kg every 8 hours; or 3-5 mg/kg intravenously once daily

Secondary options

ampicillin/sulbactam: 3 g intravenously every 6 hours

More

and

doxycycline: 100 mg intravenously/orally every 12 hours

ONGOING

non-pregnant: pre-menopausal with simple ovarian cyst

1st line – conservative management

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ONGOING
|
non-pregnant: pre-menopausal with simple ovarian cyst
|
not suspicious for malignancy
1st line – 

conservative management

Physiological forms of simple and complex ovarian cysts often resolve spontaneously, but many are persistent. 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.

Consider – laparoscopy

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ONGOING
|
non-pregnant: pre-menopausal with simple ovarian cyst
|
not suspicious for malignancy
Consider – 

laparoscopy

Additional treatment recommended for SOME patients in selected patient group

If the cyst persists or enlarges, surgical exploration and removal should proceed via laparoscopy. Histopathology can confirm the nature of the cyst.

1st line – laparotomy

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ONGOING
|
non-pregnant: pre-menopausal with simple ovarian cyst
|
suspicious for malignancy
1st line – 

laparotomy

If there is concern for malignancy, or laparoscopy has failed or is contraindicated, then mini-laparotomy is indicated. 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] Histopathology can confirm the nature of the cyst.

Consider – gynaecological oncology referral

Back
ONGOING
|
non-pregnant: pre-menopausal with simple ovarian cyst
|
suspicious for malignancy
Consider – 

gynaecological oncology referral

Additional treatment recommended for SOME patients in selected patient group

If the laparotomy or laparoscopy findings confirm malignancy, then gynaecological oncology referral is required.

non-pregnant: pre-menopausal with complex ovarian cyst

1st line – conservative management

Back
ONGOING
|
non-pregnant: pre-menopausal with complex ovarian cyst
|
not suspicious for malignancy
1st line – 

conservative management

Physiological forms of complex cysts often resolve spontaneously, but many are persistent. One study demonstrated an 8.3% spontaneous resolution rate over 34 months.[33] In the authors’ experience, patients with cysts with no obvious characteristics of malignancy, and cysts that measure <10 cm in diameter, can be observed with a repeat ultrasound in 2 to 3 months. Larger cysts are less likely to resolve, or may take longer to resolve.

Consider – laparoscopy

Back
ONGOING
|
non-pregnant: pre-menopausal with complex ovarian cyst
|
not suspicious for malignancy
Consider – 

laparoscopy

Additional treatment recommended for SOME patients in selected patient group

If the cyst persists, or for cysts >10 cm, surgical exploration and removal should proceed via laparoscopy, which will include histopathological assessment of the cyst.

1st line – laparotomy

Back
ONGOING
|
non-pregnant: pre-menopausal with complex ovarian cyst
|
suspicious for malignancy
1st line – 

laparotomy

Indicated for patients in whom there is suspicion of malignancy, or where laparoscopy has failed or is contraindicated. Histopathology can confirm the nature of the cyst.

Consider – gynaecological oncology referral

Back
ONGOING
|
non-pregnant: pre-menopausal with complex ovarian cyst
|
suspicious for malignancy
Consider – 

gynaecological oncology referral

Additional treatment recommended for SOME patients in selected patient group

Referral to a gynaecological oncologist should ensue for women with increased germ cell tumour markers or imaging findings concerning for malignancy.[31][41] If the laparotomy or laparoscopy findings confirm malignancy, then gynaecological oncology referral is required.

non-pregnant: pre-menopausal with solid ovarian cyst

1st line – laparotomy and gynaecological oncology referral

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ONGOING
|
non-pregnant: pre-menopausal with solid ovarian cyst
1st line – 

laparotomy and gynaecological oncology referral

Solid cysts may be associated with necrotic tissue. 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]

Histopathology can confirm the nature of the cyst.

post-menopausal with simple ovarian cyst

1st line – conservative management

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ONGOING
|
post-menopausal with simple ovarian cyst
|
not suspicious for malignancy
1st line – 

conservative management

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] 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]

1st line – laparoscopy or laparotomy

Back
ONGOING
|
post-menopausal with simple ovarian cyst
|
increasing in size and/or suspicious for malignancy
1st line – 

laparoscopy or laparotomy

If the cyst increases in size or morphology index, the physician should proceed to surgical evaluation and cyst removal. 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] Histopathology can confirm the nature of the cyst.

Consider – gynaecological oncology referral

Back
ONGOING
|
post-menopausal with simple ovarian cyst
|
increasing in size and/or suspicious for malignancy
Consider – 

gynaecological oncology referral

Additional treatment recommended for SOME patients in selected patient group

If the laparotomy or laparoscopy findings confirm malignancy, then gynaecological oncology referral is required.

post-menopausal with complex ovarian cyst

1st line – laparotomy and gynaecological oncology referral

Back
ONGOING
|
post-menopausal with complex ovarian cyst
1st line – 

laparotomy and gynaecological oncology referral

All post-menopausal women with a complex or solid cyst should be referred to a gynaecological oncologist for surgical evaluation. Women with a nodular or fixed pelvic mass, cancer antigen (CA)-125 value >35 U/mL, evidence of metastasis, or presence of ascites should be offered laparotomy by an experienced gynaecological oncologist. If a malignant ovarian tumour is discovered incidentally, ideally a gynaecological oncologist should be consulted intraoperatively.[31] Histopathology can confirm the nature of the cyst.

post-menopausal with solid ovarian cyst

1st line – laparotomy and gynaecological oncology referral

Back
ONGOING
|
post-menopausal with solid ovarian cyst
1st line – 

laparotomy and gynaecological oncology referral

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

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]

pregnant

1st line – conservative management

Back
ONGOING
|
pregnant
|
with asymptomatic, non-suspicious ovarian cyst; <8 cm in diameter
1st line – 

conservative management

Patients with asymptomatic cysts with no obvious characteristics of malignancy and <8 cm in diameter can be observed with serial ultrasounds. In general, expectant management is the treatment of choice in pregnant women with non-suspicious cysts.[31]

1st line – laparoscopy

Back
ONGOING
|
pregnant
|
with symptomatic, non-suspicious ovarian cyst or >8 cm in diameter
1st line – 

laparoscopy

Laparoscopic exploration and cyst removal should be considered in the second trimester for persistent benign-appearing cysts that satisfy one or more of the following criteria: large size (>8 cm in diameter), symptomatic complaints, or increased risk of torsion/rupture/obstruction of labour.[74]

1st line – laparotomy

Back
ONGOING
|
pregnant
|
suspicious for malignancy or solid ovarian cyst
1st line – 

laparotomy

Ideally, the surgery can be postponed to the postnatal period or time of caesarean delivery, when cystectomy can be performed with ease. If the cyst demonstrates characteristics of malignancy, surgical removal during pregnancy should be undertaken by laparotomy in the second trimester.[14] Histopathology can confirm the nature of the cyst.

Consider – gynaecological oncology referral

Back
ONGOING
|
pregnant
|
suspicious for malignancy or solid ovarian cyst
Consider – 

gynaecological oncology referral

Additional treatment recommended for SOME patients in selected patient group

If the laparotomy or laparoscopy findings confirm malignancy, then gynaecological oncology referral is required.

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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