- Author: C William Helm, MBBCh, MA, FRCS(Edin), FRCS; Chief Editor: Michel E Rivlin, MD more...
An ovarian cyst is a sac filled with liquid or semiliquid material that arises in an ovary (see the image below). Although the discovery of an ovarian cyst causes considerable anxiety in women owing to fears of malignancy, the vast majority of these lesions are benign.
Signs and symptoms
Most patients with ovarian cysts are asymptomatic, with the cysts being discovered incidentally during ultrasonography or routine pelvic examination. Some cysts, however, may be associated with a range of symptoms, sometimes severe, including the following :
Pain or discomfort in the lower abdomen
Severe pain from torsion (twisting) or rupture - Cyst rupture is characterized by sudden, sharp, unilateral pelvic pain; this can be associated with trauma, exercise, or coitus [1, 2] ; cyst rupture can lead to peritoneal signs, abdominal distention, and bleeding (which is usually self-limited)
Discomfort with intercourse, particularly deep penetration
Difficulty having bowel movements
Desire to defecate - This can occur if pressure develops
Micturition - This can occur frequently, due to pressure on the bladder
Irregularity of the menstrual cycle and abnormal vaginal bleeding - The intermenstrual interval may be prolonged, followed by menorrhagia 
Precocious puberty and early onset of menarche in young children
Abdominal fullness and bloating
Indigestion, heartburn, or early satiety
Endometriomas - These are associated with endometriosis, which causes a classic triad of painful and heavy periods and dyspareunia
Polycystic ovarian syndrome - This includes hirsutism, infertility, oligomenorrhea, obesity, and acne
Dull, bilateral pelvic pain - This may result from theca-lutein cysts 
Tachycardia and hypotension - These may result from hemorrhage caused by cyst rupture
Hyperpyrexia - This may result from some complications of ovarian cysts, such as ovarian torsion 
Adnexal or cervical motion tenderness
Diffusely tender abdomen with rebound tenderness and guarding - This may occur if hemorrhage or peritonitis ensues; a distended abdomen may be found on abdominal examination
Cachexia and weight loss, lymphadenopathy in the neck, shortness of breath, and signs of pleural effusion - These may be associated with advanced malignant disease
A large cyst may be palpable on abdominal examination, but gross ascites may interfere with palpation of an intra-abdominal mass. The cyst may be tender to palpation.
Other masses may be palpable, including fibroids and nodules in the uterosacral ligament consistent with malignancy or endometriosis
See Clinical Presentation for more detail.
An ultrasonographic examination of the pelvis should always be obtained if, on clinical examination, a patient is thought to have a pelvic mass.
The definitive diagnosis of all ovarian cysts is made based on histologic analysis. Each cyst type has characteristic findings.
Laboratory tests, although not diagnostic for ovarian cysts, can aid in the differential diagnosis of cysts and in the diagnosis of cyst-related complications. Studies include the following:
Urinary pregnancy test
Complete blood count (CBC)
Cancer antigen 125 (CA125) - The finding of an elevated CA125 level is most useful when combined with an ultrasonographic investigation while assessing a postmenopausal woman with an ovarian cyst [1, 5]
See Workup for more detail.
Many patients with simple ovarian cysts found through ultrasonographic examination do not require treatment. In a postmenopausal patient, a persistent simple cyst smaller than 5 cm in dimension in the presence of a normal CA125 value may be monitored with serial ultrasonographic examinations.[3, 6]
Oral contraceptive pills (OCPs) protect against the development of functional ovarian cysts. Existing functional cysts, however, do not regress more quickly when treated with combined oral contraceptives than they do with expectant management.
Laparotomy and laparoscopy
Persistent simple ovarian cysts larger than 5-10 cm (especially if symptomatic) and complex ovarian cysts should be considered for surgical removal. The surgical approaches include an open incisional technique (laparotomy) and a minimally invasive technique (laparoscopy) with very small incisions. Removing the cyst intact for pathologic analysis may mean removing the entire ovary.
Bilateral oophorectomy and, often, hysterectomy are performed in many postmenopausal women with ovarian cysts, because of the increased incidence of neoplasms in this population.
An ovarian cyst is a sac filled with liquid or semiliquid material that arises in an ovary. The number of diagnoses of ovarian cysts has increased with the widespread implementation of regular physical examinations and ultrasonographic technology. The discovery of an ovarian cyst causes considerable anxiety in women owing to fears of malignancy, but the vast majority of ovarian cysts are benign. (See Prognosis, Presentation, and Workup.)
These cysts can develop in females at any stage of life, from the neonatal period to postmenopause. Most ovarian cysts, however, occur during infancy and adolescence, which are hormonally active periods of development. Most are functional in nature and resolve with minimal treatment. (See Epidemiology, Prognosis, Treatment, and Medication.)
However, ovarian cysts can herald an underlying malignant process or, possibly, distract the clinician from a more dangerous condition, such as ectopic pregnancy, ovarian torsion, or appendicitis. (On the other hand, there may be an inverse relationship between ovarian cysts and breast cancer.[8, 9] ) (See Presentation and Workup.)
When ovarian cysts are large, persistent, or painful, surgery may be required, sometimes resulting in removal of the ovary. A large ovarian cyst is shown in the images below. (See Treatment.)
Abdominal pain in the female can be one of the most difficult cases to diagnose correctly in the emergency department (ED). The spectrum of gynecologic disease is broad, spanning all age ranges and representing various degrees of severity, from benign cysts that eventually resolve on their own to ruptured ectopic pregnancy that causes life-threatening hemorrhage. (See Prognosis.)
When presented with this scenario, the goal of the emergency physician is to rule out acute causes of abdominal pain associated with high morbidity and mortality, such as appendicitis or ectopic pregnancy, to assess for the possibility of neoplasm or malignancy, and either to refer the patient to the appropriate consultant or to discharge them with a clear plan for follow-up with an obstetrician/gynecologist. (See Presentation, DDx, and Workup.)
Provide patients with adequate discharge and follow-up instructions and information, including documentation of the potential risks of infertility, disability, and malignancy caused by delays or noncompliance.
Ovarian hyperstimulation syndrome
Patients with polycystic ovarian syndrome and anovulatory patients are at an increased risk of developing hyperstimulated ovary, as these conditions cause increased estradiol levels at baseline.
Ovarian hyperstimulation syndrome is seen with hyperstimulated ovaries and fluid shifts. It is graded on a spectrum from mild to severe based on weight gain and size of ovarian enlargement with accompanying nausea and vomiting. These patients are treated with bed rest, serial ultrasonography, and repeat electrolyte and hematocrit studies. Complications include rupture, ascites, pleural and pericardial effusions with subsequent hypovolemia, hemoconcentration, and electrolyte abnormalities.
Hyperreactio luteinalis is an abnormal, hypersensitive response of the ovaries to circulating levels of hCG in the absence of ovulation induction therapy, with either normal or elevated hCG levels. Hyperreactio luteinalis is typically asymptomatic or minimally symptomatic, but as many as 25% of cases can result in maternal virilization. The incidence can be increased in polycystic ovarian syndrome and other states that cause hyperandrogenism. Hyperreactio luteinalis is usually seen in the third-trimester in patients with bilateral, enlarged, multicystic ovaries.
The median menstrual cycle lasts 28 days, beginning with the first day of menstrual bleeding and ending just before the subsequent menstrual period. The variable first half of this cycle is termed the follicular phase and is characterized by increasing follicle-stimulating hormone (FSH) production, leading to the selection of a dominant follicle that is primed for release from the ovary.
In a normally functioning ovary, simultaneous estrogen production from the dominant follicle leads to a surge of luteinizing hormone (LH), resulting in ovulation and the release of the dominant follicle from the ovary and commencing the luteinizing phase of ovulation.
After ovulation, the follicular remnants form a corpus luteum, which produces progesterone. This, in turn, supports the released ovum and inhibits FSH and LH production. As luteal degeneration occurs in the absence of pregnancy, the progesterone levels decline, while the FSH and LH levels begin to rise before the onset of the next menstrual period.
Different kinds of functional ovarian cysts can form during this cycle. In the follicular phase, follicular cysts may result from a lack of physiologic release of the ovum due to excessive FSH stimulation or lack of the normal LH surge at midcycle just before ovulation. Hormonal stimulation causes these cysts to continue to grow. Follicular cysts are typically larger than 2.5 cm in diameter and manifest as a discomfort and heaviness. Granulosa cells that line the follicle may also persist, leading to excess estradiol production, which, in turn, leads to decreased frequency of menstruation and menorrhagia.
Corpus luteal cysts
In the absence of pregnancy, the lifespan of the corpus luteum is 14 days. If the ovum is fertilized, the corpus luteum continues to secrete progesterone for 5-9 weeks, until its eventual dissolution in 14 weeks’ time, when the cyst undergoes central hemorrhage. Failure of dissolution to occur may result in a corpus luteal cyst, which is arbitrarily defined as a corpus luteum that grows to 3 cm in diameter. The cyst can cause dull, unilateral pelvic pain and may be complicated by rupture, which causes acute pain and possibly massive blood loss.
Theca-lutein cysts are caused by luteinization and hypertrophy of the theca interna cell layer in response to excessive stimulation from human chorionic gonadotropin (hCG) These cysts are predisposed to torsion, hemorrhage, and rupture.
Theca-lutein cysts can occur in the setting of gestational trophoblastic disease (hydatiform mole and choriocarcinoma), multiple gestation, or exogenous ovarian hyperstimulation.
These cysts are associated with maternal androgen excess in up to 30% of cases but usually resolve spontaneously as the hCG level falls. Theca-lutein cysts are usually bilateral and result in massive ovarian enlargement, a characteristic of the condition termed hyperreactio luteinalis. (See the image below.)
Luteoma of pregnancy
A luteoma of pregnancy results when ovarian parenchyma is replaced by proliferation of luteinized stromal cells that may become hormonally active with production of androgens. Maternal virilization can occur in up to 30% of cases, with a 50% risk of virilization of the female fetus; male fetuses are unaffected. Luteoma of pregnancy appears as complex, heterogenous, hypoechoic mass on ultrasonography. After completion of pregnancy, the mass typically resolves and testosterone levels typically normalize.
Neoplastic cysts arise via the inappropriate overgrowth of cells within the ovary and may be malignant or benign. Malignant neoplasms may arise from all ovarian cell types and tissues. The most frequent by far, however, are those arising from the surface epithelium (mesothelium); most of these are partially cystic lesions. The benign counterparts of these cancers are serous and mucinous cystadenomas. Other malignant ovarian tumors may also contain cystic areas, including granulosa cell tumors from sex cord stromal cells and germ cell tumors from primordial germ cells. Cystic spaces within a tumor are seen in the image below.
Teratomas are a form of germ cell tumor containing elements from all 3 embryonic germ layers, ie, ectoderm, endoderm, and mesoderm. A mature cystic teratoma is shown in the image below.
Endometriomas are blood-filled cysts arising from the ectopic endometrium. Endometriomas are associated with endometriosis, which causes a classic triad of painful and heavy periods and dyspareunia.
Polycystic ovarian syndrome
In polycystic ovarian syndrome, the ovary often contains multiple cystic follicles 2-5 mm in diameter as viewed on sonograms. The cysts themselves are never the main problem, and discussion of this disease is beyond the scope of this article.
Risk factors for ovarian cyst formation include the following:
Infertility treatment - Patients being treated for infertility by ovulation induction with gonadotropins or other agents, such as clomiphene citrate or letrozole, may develop cysts as part of ovarian hyperstimulation syndrome
Tamoxifen - Tamoxifen can cause benign functional ovarian cysts that usually resolve following discontinuation of treatment
Pregnancy - In pregnant women, ovarian cysts may form in the second trimester, when hCG levels peak 
Hypothyroidism - Because of similarities between the alpha subunit of thyroid-stimulating hormone (TSH) and hCG, hypothyroidism may stimulate ovarian and cyst growth 
Maternal gonadotropins - The transplacental effects of maternal gonadotropins may lead to the development of neonatal and fetal ovarian cysts 
Cigarette smoking - The risk of functional ovarian cysts is increased with cigarette smoking; risk from smoking is possibly increased further with a decreased body mass index (BMI) [15, 16]
Tubal ligation - Functional cysts have been associated with tubal ligation sterilizations 
Risk factors for ovarian cystadenocarcinoma include the following:
Strong family history
History of breast cancer
BRCA gene mutations
Occurrence in the United States
Ovarian cysts are found on transvaginal sonograms in nearly all premenopausal women and in up to 18% of postmenopausal women (women develop one or more Graafian follicles each menstrual cycle, which appear as cysts on imaging).[1, 5, 18] Most of these cysts are functional in nature and benign. Mature cystic teratomas, or dermoids, represent more than 10% of all ovarian neoplasms. Ovarian cysts are the most common fetal and infant tumor, with a prevalence exceeding 30%.
The incidence of ovarian carcinoma is approximately 15 cases per 100,000 women per year. In the United States, ovarian carcinomas are diagnosed in more than 21,000 women annually, causing an estimated 14,600 deaths. Most malignant ovarian tumors are epithelial ovarian cystadenocarcinomas.
Tumors of low malignant potential make up approximately 20% of malignant ovarian tumors, whereas less than 5% are malignant germ cell tumors, and approximately 2% are granulosa cell tumors.
Malignant epithelial ovarian cystadenocarcinomas are the only ovarian cysts associated with a race predilection. Women from northern and western Europe and North America are affected most frequently, whereas women from Asia, Africa, and Latin America are affected least frequently.
Within the United States, age-adjusted incidence rates in surveillance areas are highest among American Indian women, followed by white, Vietnamese, Hispanic, and Hawaiian women. Incidence is lowest among Korean and Chinese women.
Among women for whom sufficient numbers of cases are available to calculate rates based on age, incidence in those aged 30-54 years is highest in white women, followed by Japanese, Hispanic, and Filipino women. For women aged 55-69 years, the highest rates occur in white women, followed by Hispanic and Japanese women. Among women aged 70 years or older, the highest rate occurs among white women, followed by those of African descent and Hispanic women.
Functional ovarian cysts can occur at any age (including in utero) but are much more common in women of reproductive age. They are rare after menopause. Luteal cysts occur after ovulation in reproductive-age women. Most benign neoplastic cysts occur during the reproductive years, but the age range is wide and they may occur in persons of any age.
The incidence of epithelial ovarian cystadenocarcinomas, sex cord stromal tumors, and mesenchymal tumors rises exponentially with age until the sixth decade of life, at which point the incidence plateaus.
Tumors of low malignant potential occur at a mean age of 44 years, with a span from adolescence to senescence. The average age is more than a decade less than that for invasive cystadenocarcinoma. Germ cell tumors are most common in adolescence and rarely occur in women older than 30 years.
In a child found to have a symptomatic abdominopelvic mass, the ovary is the most common site of origin. Although such masses are infrequent occurrences, the percentage due to malignant tumors is thought to be higher than for older age groups. The most common are germ cell tumors, followed by epithelial and granulosa cell tumors. Such tumors may be partially cystic.
The prognosis for benign cysts is excellent. All such cysts may occur in residual ovarian tissue or in the contralateral ovary. Overall, 70%-80% of follicular cysts resolve spontaneously.
Malignancy is a common concern among patients with ovarian cysts. Pregnant patients with simple cysts smaller than 6cm in diameter have a malignancy risk of less than 1%. Most of these cysts resolve by 16-20 weeks' gestation, with 96% of these masses resolving spontaneously. In postmenopausal patients with unilocular cysts, malignancy develops in 0.3% of cases.
In complex, multiloculated cysts, the risk of malignancy climbs to 36%. If cancer is diagnosed, regional or distant spread may be present in up to 70% of cases, and only 25% of new cases will be limited to stage I disease.
Mortality associated with malignant ovarian carcinoma is related to the stage at the time of diagnosis, and patients with this carcinoma tend to present late in the course of the disease. The 5-year survival rate overall is 41.6%, varying between 86.9% for International Federation of Gynecology and Obstetrics (FIGO) stage Ia and 11.1% for stage IV.
A distinct group of less aggressive tumors of low malignant potential runs a more benign course but still is associated with definite mortality. The overall survival rate is 86.2% at 5 years.
The potential of benign ovarian cystadenomas to become malignant has been postulated but, to date, remains unproven. Malignant change can occur in a small percentage of dermoid cysts and endometriomas.
Granulosa cell tumors are associated with an 82% survival rate, whereas squamous cell carcinomas arising in a dermoid cyst are associated with a very poor outcome.
The potential of benign ovarian cystadenomas to become malignant has been postulated but, to date, remains unproven. Malignant change can occur in a small percentage of dermoid cysts and endometriomas.
Ovarian cysts have a broad range of potential outcomes. In most cases, the cyst is benign and asymptomatic, requires no further management, and will resolve on its own. In other cases, ovarian cyst–related accidents, such as rupture and hemorrhage or torsion, occur.
Ovarian cysts larger than 4 cm in diameter have been shown to have a torsion rate of approximately 15%. Ovarian torsion involves the rotation of the ovarian vascular pedicle, causing obstruction to venous and, eventually, arterial flow that can lead to infarction. (See the image below.)
Most torsion cases occur in premenopausal females of childbearing age, but up to 17% of cases affect prepubertal and postmenopausal women. It is also strongly associated with ovarian stimulation and polycystic ovarian syndrome. Ovarian torsion is more common on the right side owing to the sigmoid colon restricting the mobility of the left ovary.
Malignancy may be seen in up to 2% of cases of ovarian torsion. The most common ovarian mass associated with torsion is a dermoid cyst.
CT scanning and ultrasonography can assist with diagnosis. The absence of blood flow within an ovary can support the diagnosis of torsion. Treatment options include laparoscopic “detorsion” and adnexal preservation in premenopausal women and salpingo-oophorectomy in postmenopausal women. Ovarian function may be preserved with laparoscopic detorsion in 90% of cases.
The outcome of ovarian cyst rupture is evaluated based on associated symptoms and will dictate whether the patient is discharged or admitted for laparoscopy.
Ovarian cyst rupture commonly occurs with corpus luteal cysts. They involve the right ovary in two thirds of cases and usually occur on days 20-26 of the woman’s menstrual cycle. Mittelschmerz is a form of physiologic cyst rupture. In pregnant women, hemorrhagic corpus luteal cysts are usually seen in the first trimester, with most resolving by 12 weeks' gestation. Hemorrhage and shock may occur and may present late in the symptomatology.
In ovarian cyst rupture, ultrasonography may demonstrate free fluid in the pouch of Douglas in 40% of cases. Cyst rupture and hemorrhage may be treated conservatively with observation if the patient is stable, with follow-up scanning in 6 weeks to confirm hemorrhage resolution. Laparoscopy is indicated in hemodynamic compromise, possibility of torsion, no relief of symptoms within 48 hours, or increasing hemoperitoneum or falling hemoglobin concentration.
Benign cysts can cause pain and discomfort related to pressure on adjacent structures, torsion, rupture, and hemorrhage (within and outside of the cyst). Morbidity also includes menorrhagia, an increased intermenstrual interval, dysmenorrhea, pelvic discomfort, and abdominal distention. Benign cysts rarely cause death.
Mucinous cystadenomas may cause a relentless collection of mucinous fluid within the abdomen, known as pseudomyxoma peritonei, which may be fatal without extensive treatment.
Approximately 3% of theca lutein cysts are complicated by torsion or hemorrhage, and approximately 30% of these cysts can cause maternal androgen excess. Follicular cysts can cause excess estradiol production, leading to metrorrhagia and menorrhagia.
Ovarian cysts, and more specifically corpus luteal cysts, can rupture, causing hemoperitoneum, hypotension, and peritonitis. This can be exacerbated in women with bleeding dyscrasias, such as those with von Willebrand disease and those receiving anticoagulation therapy.
Malignant ovarian cystic tumors can cause severe morbidity, including the following:
Abnormal uterine bleeding
Deep venous thrombosis
Cystic granulosa cell tumors may secrete estrogen, leading to postmenopausal bleeding and precocious puberty in elderly patients and young patients, respectively.
In addition to the normal complications of cysts, the presence of cysts in pregnancy may cause obstructed labor.
Bottomley C, Bourne T. Diagnosis and management of ovarian cyst accidents. Best Pract Res Clin Obstet Gynaecol. 2009 Oct. 23(5):711-24. [Medline].
Lambert MJ, Villa M. Gynecologic ultrasound in emergency medicine. Emerg Med Clin North Am. 2004 Aug. 22(3):683-96. [Medline].
Bailey CL, Ueland FR, Land GL, DePriest PD, Gallion HH, Kryscio RJ, et al. The malignant potential of small cystic ovarian tumors in women over 50 years of age. Gynecol Oncol. 1998 Apr. 69(1):3-7. [Medline].
Stany MP, Hamilton CA. Benign disorders of the ovary. Obstet Gynecol Clin North Am. 2008 Jun. 35(2):271-84, ix. [Medline].
Schmeler KM, Mayo-Smith WW, Peipert JF, Weitzen S, Manuel MD, Gordinier ME. Adnexal masses in pregnancy: surgery compared with observation. Obstet Gynecol. 2005 May. 105(5 Pt 1):1098-103. [Medline].
Roman LD. Small cystic pelvic masses in older women: is surgical removal necessary?. Gynecol Oncol. 1998 Apr. 69(1):1-2. [Medline].
ACOG Practice Bulletin No. 110: noncontraceptive uses of hormonal contraceptives. Obstet Gynecol. 2010 Jan. 115(1):206-18. [Medline].
Knight JA, Lesosky M, Blackmore KM, Voigt LF, Holt VL, Bernstein L, et al. Ovarian cysts and breast cancer: results from the Women's Contraceptive and Reproductive Experiences Study. Breast Cancer Res Treat. 2008 May. 109(1):157-64. [Medline].
Bosetti C, Scotti L, Negri E, Talamini R, Levi F, Franceschi S, et al. Benign ovarian cysts and breast cancer risk. Int J Cancer. 2006 Oct 1. 119(7):1679-82. [Medline].
Clement PB. Anatomy and histology of the ovary. Kurman RJ, ed. Blaustein's Pathology of the Female Genital Tract. 5th ed. New York, NY: Springer-Verlag; 2002. 649-673.
Katz VL. Comprehensive Gynecology. 5th ed. Philadelphia: Mosby Elsevier.; 2007. 1098-103.
Glanc P, Salem S, Farine D. Adnexal masses in the pregnant patient: a diagnostic and management challenge. Ultrasound Q. 2008 Dec. 24(4):225-40. [Medline].
Caruso PA, Marsh MR, Minkowitz S, Karten G. An intense clinicopathologic study of 305 teratomas of the ovary. Cancer. 1971 Feb. 27(2):343-8. [Medline].
Heling KS, Chaoui R, Kirchmair F, Stadie S, Bollmann R. Fetal ovarian cysts: prenatal diagnosis, management and postnatal outcome. Ultrasound Obstet Gynecol. 2002 Jul. 20(1):47-50. [Medline].
Wyshak G, Frisch RE, Albright TE, Albright NL, Schiff I. Smoking and cysts of the ovary. Int J Fertil. 1988 Nov-Dec. 33(6):398-404. [Medline].
Holt VL, Cushing-Haugen KL, Daling JR. Risk of functional ovarian cyst: effects of smoking and marijuana use according to body mass index. Am J Epidemiol. 2005 Mar 15. 161(6):520-5. [Medline].
Holt VL, Cushing-Haugen KL, Daling JR. Oral contraceptives, tubal sterilization, and functional ovarian cyst risk. Obstet Gynecol. 2003 Aug. 102(2):252-8. [Medline].
McDonald JM, Modesitt SC. The incidental postmenopausal adnexal mass. Clin Obstet Gynecol. 2006 Sep. 49(3):506-16. [Medline].
American Cancer Society. Cancer Facts and Figures 2009. Estimated New Cancer Cases and Deaths by Sex, US, 2009. American Cancer Society. Available at http://www.cancer.org/docroot/stt/stt_0.asp?from=fast. Accessed: December 24, 2009.
Sykes PH, Quinn MA, Rome RM. Ovarian tumors of low malignant potential: a retrospective study of 234 patients. Int J Gynecol Cancer. 1997. 7:218-26.
Miller BA, Kolonel LN, Bernstein L, et al. Racial/Ethnic Patterns of Cancer in the United States 1988-1992. National Cancer Institute. 1996.
Giuntoli RL 2nd, Vang RS, Bristow RE. Evaluation and management of adnexal masses during pregnancy. Clin Obstet Gynecol. 2006 Sep. 49(3):492-505. [Medline].
Castillo G, Alcazar JL, Jurado M. Natural history of sonographically detected simple unilocular adnexal cysts in asymptomatic postmenopausal women. Gynecol Oncol. 2004 Mar. 92(3):965-9. [Medline].
Committee opinion no. 477: the role of the obstetrician-gynecologist in the early detection of epithelial ovarian cancer. Obstet Gynecol. 2011 Mar. 117(3):742-6. [Medline].
Jacobs I, Bast RC Jr. The CA 125 tumour-associated antigen: a review of the literature. Hum Reprod. 1989 Jan. 4(1):1-12. [Medline].
Visintin I, Feng Z, Longton G, Ward DC, Alvero AB, Lai Y. Diagnostic markers for early detection of ovarian cancer. Clin Cancer Res. 2008 Feb 15. 14(4):1065-72. [Medline].
McIntosh M, Anderson G, Drescher C, Hanash S, Urban N, Brown P. Ovarian cancer early detection claims are biased. Clin Cancer Res. 2008 Nov 15. 14(22):7574; author reply 7577-9. [Medline].
Greene MH, Feng Z, Gail MH. The importance of test positive predictive value in ovarian cancer screening. Clin Cancer Res. 2008 Nov 15. 14(22):7574; author reply 7577-9. [Medline].
Bast RC Jr, Badgwell D, Lu Z, Marquez R, Rosen D, Liu J, et al. New tumor markers: CA125 and beyond. Int J Gynecol Cancer. 2005 Nov-Dec. 15 Suppl 3:274-81. [Medline].
Osmers R. Sonographic evaluation of ovarian masses and its therapeutical implications [editorial]. Ultrasound Obstet Gynecol. 1996 Oct. 8(4):217-22. [Medline].
Loyer EM, Whitman GJ, Fenstermacher MJ. Imaging of ovarian carcinoma. Int J Gynecol Cancer. 1999 Sep. 9(5):351-361. [Medline].
Vandermeer FQ, Wong-You-Cheong JJ. Imaging of acute pelvic pain. Clin Obstet Gynecol. 2009 Mar. 52(1):2-20. [Medline].
Chan L, Lin WM, Uerpairojkit B, Hartman D, Reece EA, Helm W. Evaluation of adnexal masses using three-dimensional ultrasonographic technology: preliminary report. J Ultrasound Med. 1997 May. 16(5):349-54. [Medline].
Kupesic S, Plavsic BM. Early ovarian cancer: 3-D power Doppler. Abdom Imaging. 2006 Sep-Oct. 31(5):613-9. [Medline].
Menon U, Gentry-Maharaj A, Hallett R, Ryan A, Burnell M, Sharma A, et al. Sensitivity and specificity of multimodal and ultrasound screening for ovarian cancer, and stage distribution of detected cancers: results of the prevalence screen of the UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS). Lancet Oncol. 2009 Apr. 10(4):327-40. [Medline].
Partridge E, Kreimer AR, Greenlee RT, Williams C, Xu JL, Church TR, et al. Results from four rounds of ovarian cancer screening in a randomized trial. Obstet Gynecol. 2009 Apr. 113(4):775-82. [Medline]. [Full Text].
Higgins RV, Matkins JF, Marroum MC. Comparison of fine-needle aspiration cytologic findings of ovarian cysts with ovarian histologic findings. Am J Obstet Gynecol. 1999 Mar. 180(3 Pt 1):550-3. [Medline].
Moran O, Menczer J, Ben-Baruch G, et al. Cytologic examination of ovarian cyst fluid for the distinction between benign and malignant tumors. Obstet Gynecol. 1993 Sep. 82(3):444-6. [Medline].
Lu D, Davila RM, Pinto KR, Lu DW. ThinPrep evaluation of fluid samples aspirated from cystic ovarian masses. Diagn Cytopathol. 2004 May. 30(5):320-4. [Medline].
Grimes DA, Jones LB, Lopez LM, Schulz KF. Oral contraceptives for functional ovarian cysts. Cochrane Database Syst Rev. 2009 Apr 15. CD006134. [Medline].
Medeiros LR, Rosa DD, Bozzetti MC, Fachel JM, Furness S, Garry R, et al. Laparoscopy versus laparotomy for benign ovarian tumour. Cochrane Database Syst Rev. 2009 Apr 15. CD004751. [Medline].
Maiman M. Laparoscopic removal of the adnexal mass: the case for caution. Clin Obstet Gynecol. 1995 Jun. 38(2):370-9. [Medline].
Vergote I, De Brabanter J, Fyles A, Bertelsen K, Einhorn N, Sevelda P. Prognostic importance of degree of differentiation and cyst rupture in stage I invasive epithelial ovarian carcinoma. Lancet. 2001 Jan 20. 357(9251):176-82. [Medline].
Bakkum-Gamez JN, Richardson DL, Seamon LG, Aletti GD, Powless CA, Keeney GL, et al. Influence of intraoperative capsule rupture on outcomes in stage I epithelial ovarian cancer. Obstet Gynecol. 2009 Jan. 113(1):11-7. [Medline].
Eltabbakh GH, Charboneau AM, Eltabbakh NG. Laparoscopic surgery for large benign ovarian cysts. Gynecol Oncol. 2008 Jan. 108(1):72-6. [Medline].
[Guideline] Qaseem A, Humphrey LL, Harris R, Starkey M, Denberg TD. Screening pelvic examination in adult women: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2014 Jul 1. 161(1):67-72. [Medline].
American College of Obstetricians and Gynecologists Committee on Gynecologic Practice. Committee opinion no. 534: well-woman visit. Obstet Gynecol. 2012 Aug. 120(2 Pt 1):421-4. [Medline]. [Full Text].
Leiserowitz GS. Managing ovarian masses during pregnancy. Obstet Gynecol Surv. 2006 Jul. 61(7):463-70. [Medline].
International Federation of Gynecology and Obstetrics. Annual Report on the Results of Treatment in Gynaecological Cancer. J Epidemiol Biostat. 1998. 3:1-68.
Pavlik EJ, Ueland FR, Miller RW. Frequency and disposition of ovarian abnormalities followed with serial transvaginal ultrasonography. Obstet Gynecol. Aug 2013;122(2):210-7. Available at http://journals.lww.com/greenjournal/pages/articleviewer.aspx?year=2013&issue=08000&article=00005&type=abstract. Accessed: Aug 13 2013.