Ovarian Cysts Treatment & Management

  • Author: C William Helm, MB, BCh, MA, FRCS(Edin), FRCS; Chief Editor: Michel E Rivlin, MD   more...
 
Updated: Apr 22, 2011
 

Medical Care

  • Many patients with simple ovarian cysts based on ultrasonographic findings 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 ultrasonography examinations.[24, 25] Some evidence suggests that cysts up to 10 cm can be safely followed in this way.
  • Premenopausal women with asymptomatic simple cysts smaller than 8 cm on sonograms in whom the CA125 value is within the reference range may be monitored with a repeat ultrasonographic examination in 8-12 weeks. Hormone therapy, including the use of the oral contraceptive pill, is not helpful in causing resolution.[26]
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Surgical Care

  • 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. Whichever route is used, the goals remain the same and include the following:
    • To confirm the diagnosis of an ovarian cyst
    • To assess whether the cyst appears to be malignant
    • To obtain fluid from peritoneal washings for cytologic assessment
    • To remove the entire cyst intact for pathologic analysis (This may mean removing the entire ovary.)
    • To assess the opposite ovary and other abdominal organs
    • To perform additional surgery as indicated
  • The use of laparoscopic techniques is becoming widespread and the indications are extending. Laparoscopy is preferred to laparotomy when indicated because it has less adverse effects for the patient and leads to faster recovery.[27] However, it is essential that the disease outcome for the patient is not inferior to that achieved with laparotomy.[28]
  • Some patients, including those with chronic lung disease who are unable to tolerate a high intra-abdominal pressure or a steep head-down position, are unsuitable for laparoscopy. Others are unsuitable because of previous surgeries causing severe adhesions. For many situations the most important factor is the skill and experience of the surgeon.
  • With benign cysts there is no absolute contraindication to the use of laparoscopy. Such patients include those considered to have a dermoid cyst or endometrioma, those with functional or simple cysts that are causing symptoms and have not resolved with conservative management, and those presenting with acute symptoms. Although the aim should be to remove all cysts intact[29, 30] , if this is not possible the cyst and/or affected ovary may be placed in a protective bag that allows the cyst to be ruptured and drained without contamination prior to removal.
  • Malignant ovarian cysts associated with widespread disease are usually managed by laparotomy.
  • Some controversy surrounds the surgical approach for very large benign-appearing ovarian cysts. The traditional approach for both was a long, midline incision. Some now promote the laparoscopic drainage of the former allowing the ovary to be removed through a small incision.[31] The down side to this is the potential for the cyst to spill cancer cells into the abdominal cavity. Laparoscopy is now used to remove small to medium-sized cancerous ovarian cysts (up to about 12 cm) and to stage ovarian cancer.
  • Excision of a benign cyst alone, with conservation of the ovary, may be performed in patients who desire retention of their ovaries for future fertility or other reasons. Included are endometrioma, dermoid, and functional cysts.
  • If the ovarian cyst is benign, removal of the opposite ovary should be considered in postmenopausal, perimenopausal, and premenopausal women older than 35 years who have completed their family and are considered at increased genetic risk for subsequent development of ovarian carcinoma. These indications are all relative and the issues should be discussed with the patient prior to any surgery.
  • A gynecologic cancer specialist should be available to help with any patient who undergoes surgery for a potentially malignant ovarian cyst. This allows the appropriate surgery to be performed on patients found to have cancer. Whenever possible, the patient should have consulted with the specialist prior to the surgery to allow all issues to be addressed.
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Consultations

  • Infertility and reproductive endocrinologist for endometrioma and polycystic ovary syndrome
  • Gynecologic oncologist for any complex ovarian cyst or adnexal mass, especially if the serum CA125 level is elevated above 35 U/mL and for a patient with a strong family history of ovarian carcinoma
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Diet

Normal healthy diet

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Contributor Information and Disclosures
Author

C William Helm, MB, BCh, MA, FRCS(Edin), FRCS  Professor, Division of Gynecologic Oncology, Department of Obstetrics, Gynecology, and Women's Health, St Louis University School of Medicine, St. Louis, MO

C William Helm, MB, BCh, MA, FRCS(Edin), FRCS is a member of the following medical societies: American College of Obstetricians and Gynecologists, European Society of Gynaecologic Oncology, and International Gynecologic Cancer Society

Disclosure: ThermaSolutions, Inc Grant/research funds Research Registry of patients treated with hyperthemic intraperitoneal chemotherapy; Sanofi-Aventis, Inc Grant/research funds Support for and investigator initiated research study of HIPEC for consolidation in ovarian cancer; ThermaSolutions, Inc Honoraria Speaking and teaching; UpToDate Royalty Online Text Book Chapters; Genzyme, Inc Honoraria Speaking and teaching

Specialty Editor Board

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: eMedicine Salary Employment

A David Barnes, MD, PhD, MPH, FACOG  Consulting Staff, Department of Obstetrics and Gynecology, Mammoth Hospital (Mammoth Lakes, California), Pioneer Valley Hospital (Salt Lake City, Utah), Warren General Hospital (Warren, Pennsylvania), and Mountain West Hospital (Tooele, Utah)

A David Barnes, MD, PhD, MPH, FACOG is a member of the following medical societies: American College of Forensic Examiners, American College of Obstetricians and Gynecologists, American Medical Association, Association of Military Surgeons of the US, and Utah Medical Association

Disclosure: Nothing to disclose.

Frederick B Gaupp, MD  Consulting Staff, Department of Family Practice, Hancock Medical Center

Frederick B Gaupp, MD is a member of the following medical societies: American Academy of Family Physicians

Disclosure: Nothing to disclose.

Chief Editor

Michel E Rivlin, MD  Professor, Coordinator of Quality Assurance/Quality Improvement, Department of Obstetrics and Gynecology, University of Mississippi School of Medicine

Michel E Rivlin, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, Mississippi State Medical Association, and Royal College of Surgeons of Edinburgh

Disclosure: Nothing to disclose.

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An ovarian cyst that has undergone torsion (twisting of the vascular pedicle). The patient presented with a short history of severe lower abdominal pain. The twisted pedicle can be seen attached to the cyst, which has turned dusky due to ischemia. No viable epithelial lining was available for histologic diagnosis.
Endovaginal sonogram shows a striking echogenic mass lateral to the uterus, with posterior acoustic shadowing giving a "tip-of-the-iceberg" appearance. This is pathognomonic for dermoid cyst. Occasionally, this appearance may be mistaken for gas-filled bowel. Courtesy of Patrick O'Kane, MD.
A dermoid cyst (mature cystic teratoma) after opening the abdomen. Note the yellowish color of the contents seen through the wall.
A dermoid cyst has been opened in the operating room to reveal copious sebaceous fluid. This cyst also contained hair.
A dermoid cyst has been opened and contains teeth.
Theca-lutein cysts replacing an ovary in a patient with a molar pregnancy. Despite their size these cysts are benign and usually resolve after treatment of the underlying disease.
A 24-cm diameter multilocular right ovarian cyst is seen with adjacent Fallopian tube and uterus. The infundibulo-pelvic ligament carrying the ovarian artery and vein has been divided. Histology reported a mucinous cystadenocarcinoma of low malignant potential.
Transabdominal sonogram of a 24-cm diameter multilocular right ovarian cyst with adjacent Fallopian tube and uterus. The infundibulo-pelvic ligament carrying the ovarian artery and vein has been divided. This sonogram demonstrates a large, complex, cystic mass with vascularity within the septations. Red and blue colors show blood flow towards and away from the transducer. The resistive index was low. Histology reported a mucinous cystadenocarcinoma of low malignant potential. Courtesy Patrick O'Kane, MD.
The cyst in Images 7-8 has been removed and cut open. It has a smooth surface and a multicystic internal structure.
Cross-section of a clear cell carcinoma of the ovary. Note the cystic spaces intermingled with solid areas.
 
 
 
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