eMedicine Specialties > Emergency Medicine > Obstetrics & Gynecology

Ovarian Cysts: Follow-up

Author: Walter W Valesky Jr, MD, Clinical Assistant Instructor, Department of Emergency Medicine, State University of New York Downstate, Brooklyn
Coauthor(s): Mark A Silverberg, MD, FACEP, MMB, Assistant Professor, Assistant Residency Director, Department of Emergency Medicine, State University of New York Downstate College of Medicine; Consulting Staff, Department of Emergency Medicine, Staten Island University Hospital, Kings County Hospital, University Hospital, State University of New York Downstate at Brooklyn; Andrew A Aronson, MD, Assistant Professor of Emergency Medicine, Drexel University School of Medicine; Consulting Staff, Department of Emergency Medicine, Allegheny General Hospital
Contributor Information and Disclosures

Updated: Aug 11, 2009

Follow-up

Further Outpatient Care

Timing of outpatient care of ovarian cysts depends on the patient’s age and pregnancy status.

• In pregnant patients, most ovarian cysts resolve at 16-20 weeks’ gestation.
  • Patients with benign-appearing ovarian cysts that are unilocular and smaller than 5-6 cm in diameter require no further follow-up for the cyst during pregnancy and require only routine prenatal visits.
  • If the cyst is larger than 5-6 cm or is multicystic, the patient should undergo follow-up ultrasonography at 16 weeks' gestation to allow time for cyst resolution. Persistent complex masses may be further characterized by MRI, either during or after pregnancy, to search for distinctive features that would guide diagnosis.⁶
  • Ovarian cysts that are strongly suggestive of malignancy or that are larger than 8-10 cm in diameter, are symptomatic, or are at an increased risk for torsion, cyst rupture, or obstruction of labor are more likely to require surgical intervention¹⁷ and necessitate more urgent follow-up with an obstetrician and, possibly, a multidisciplinary approach in a timely fashion. If surgery is required, it is most advantageous to perform it in the early second trimester, as the risk of spontaneous abortion during this period is lower than in the first trimester. Surgical intervention is better to avoid during the third trimester, if possible, to prevent inducing preterm delivery and to avoid technical issues in dealing with a larger uterus.
• In postpartum patients, the size and complexity of the ovarian cyst and the CA-125 level are used to determine management. Unilocular cysts smaller than 5 cm in diameter should be monitored with transvaginal ultrasonography and CA-125 studies at 6-month intervals. Complex ovarian cysts that are smaller than 5 cm in diameter in the presence of normal CA-125 levels (defined as <35-65 U/mL) should be monitored in 4 weeks with repeat ultrasonography and CA-125 studies. Surgery may be indicated for complex ovarian tumors smaller than 5 cm in diameter when CA-125 levels are elevated (>35-65 U/mL) and for complex tumors larger than 5 cm in diameter.¹⁵
• In nonpregnant premenopausal patients, various studies have examined cyst resolution with various time frames being used as indices for cyst resolution. Most of these studies showed cyst resolution by 2-3 months, dictating ultrasonography with or without gynecological follow-up in these patients.¹⁸

Inpatient & Outpatient Medications

Epidemiological studies from the 1970s-1990s reported inverse relationships between oral contraceptive pill (OCP) use and surgically confirmed functional ovarian cysts. Short-term treatment with OCPs was thus used for initial management of ovarian cysts. However, recent meta-analyses have shown that there is no difference between OCP use and placebo in terms of treatment outcomes in ovarian cysts and that these masses should be monitored expectantly for several menstrual cycles. If a cystic mass does not resolve after this time frame, it is unlikely to be a functional cyst, and further workup may be indicated.¹⁸

Transfer

• When a female patient presents with abdominal pain and signs or symptoms of an intraperitoneal process of unclear etiology, transfer is indicated if any of the following conditions are met:
  • Backup surgical, obstetric, or gynecologic support is not available to the ED.
  • Operative capacity is not available at the health care delivery site.
  • Imaging capacity is not available at the facility.
• Unstable patients should not be transferred unless the facility is truly unable to provide appropriate treatment or evaluation. The patient is the responsibility of the transferring physician until arrival at the next hospital.

Complications

• 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 torsion involves the rotation of the ovarian vascular pedicle, causing obstruction to venous and, eventually, arterial flow that can lead to infarction. Most torsion cases occur in premenopausal females of child-bearing 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. Treatment consists of laparoscopic detorsion and adnexal preservation in premenopausal women and bilateral oophorectomy in postmenopausal women.
• 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 physiological 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.
• Malignancy is also among the differential diagnoses of ovarian cysts. While not an ED diagnosis, appropriate follow-up must be available to ensure resolution of cyst, or further evaluation must be undertaken.³

Prognosis

• The prognosis of ovarian cysts varies depending on the patient’s age and pregnancy status. 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 6 cm 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.¹⁹ 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.¹⁵  
• Ovarian cysts larger than 4 cm in diameter have been shown to have a torsion rate of approximately 15%. 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 patient may be discharged or admitted for laparoscopy.

Patient Education

For patient education resources, visit the eMedicine Women's Health Center and Cancer and Tumors Center; also, see the patient education articles Ovarian Cysts and Ovarian Cancer.

Miscellaneous

Medicolegal Pitfalls

• Delays in consultations, operative, or resuscitative interventions for patients in shock
• Failure to make the correct diagnosis, such as ectopic pregnancy
• Inadequate documentation of initial examinations, findings, consultations, and ED course
• Failure to provide patients with adequate discharge and follow-up instructions, including documentation of the potential risks of infertility, disability, and malignancy caused by delays or noncompliance

Special Concerns

• Fetal/neonatal
  • In female newborns, ovarian cysts are the most frequent type of abdominal tumor, with an estimated incidence of more than 30%.^5,9
  • Fetal ovarian cysts are believed to be caused by hormonal stimulation, such as fetal gonadotropins, maternal estrogen, and placental human chorionic gonadotropin. An association between fetal ovarian cysts and maternal diabetes and fetal hypothyroidism has been identified.
  • Most fetal ovarian cysts are small and involute within the first few months of life and are not of clinical significance. They are generally diagnosed in the third trimester of pregnancy, and most tend to resolve at 2-10 weeks postnatally.⁹
  • Differential diagnoses of these cysts include urachal cysts, intestinal duplication abnormalities, cystic teratoma, and intestinal obstruction. Intrauterine ultrasonography is necessary to differentiate ovarian cysts from these other possibilities.⁵
  • Aspiration of these cysts can be performed but is associated with complications such as reformation of cyst, infection, and premature labor.⁹
  • Once the diagnosis of a fetal ovarian cyst is made, it is important to perform serial ultrasonographic examinations to detect any structural changes in size or appearance or complications such as hydramnios, ascites, or torsion.⁵
  • Of these complications, ovarian torsion is the most serious complication of fetal ovarian cyst and may manifest as fetal tachycardia due to peritoneal irritation.
  • Proper management includes serial ultrasonography to look for signs of regression or postnatal surgery if the cyst is complicated or larger than 5 cm in diameter.⁹
• Pregnancy
  • The corpus luteum is responsible for progesterone production during pregnancy and normally regresses around 8 weeks’ gestation.⁶
  • Most pregnancy-associated cysts, such as corpus luteal and follicular cysts, resolve by gestational age 14-16 weeks and are hormonally responsive, allowing conservative management.⁶ By gestational age 16-20 weeks, up to 96% of masses resolve spontaneously. Simple cysts smaller than 6 cm in diameter have a risk of malignancy of less than 1%.¹⁹
  • Corpus luteal cysts tend to be larger and more symptomatic than follicular cysts and are more prone to hemorrhage and rupture. Follicular cysts are usually smaller, with internal hemorrhage being relatively uncommon.
  • Masses that persist longer may warrant further workup for potential neoplastic disease based on clinical findings and radiological evidence.⁶ Serum CA-125 studies are not recommended in pregnancy, as levels can fluctuate widely in normal pregnancy, particularly in the first and second trimesters, and can be elevated in many benign conditions. One group suggests observation with postpartum surgery in select patients with large persistent adnexal masses in whom ultrasonography findings are not highly suggestive of malignancy.⁴ If malignancy is a possibility and peripartum surgery is warranted, the risks of harming the pregnancy is weighed against a delay in treatment, but surgery is generally delayed until the mid-second trimester, when most cysts have resolved.¹⁹
  • Some ovarian conditions unique to pregnancy include the hyperstimulated ovary, ovarian hyperstimulation syndrome, hyperreactio luteinalis, theca lutein cysts, and luteoma of pregnancy. Hyperstimulated ovaries represent a normal ovarian response to circulating bhCG levels and are typically seen in women who have undergone ovulation induction.
  • 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 bedrest, 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 bhCG in the absence of ovulation induction therapy, with either normal or elevated bhCG 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.
  • Theca lutein cysts have a similar appearance to hyperreactio luteinalis, with bilaterally enlarged ovaries with multiple cysts. They are predisposed to torsion, hemorrhage, and rupture and represent a normal response of ovaries to elevated levels of bhCG and are also associated with gestational trophoblastic disease.
  • 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.⁶
• Postmenopause
  • Most studies estimate the prevalence of simple unilocular adnexal cysts in asymptomatic postmenopausal women at 3%-18%, with most being smaller than 5 cm in diameter.
  • Early studies have shown the risk of malignancy of these asymptomatic adnexal cysts in postmenopausal patients to be as high as 7%, but more recent studies show the prevalence to be less than 1% in small cysts.⁸
  • In these patients, repeat ultrasonography at 4-6 weeks can be performed along with CA-125 studies in an outpatient setting.
  • Half of asymptomatic cysts smaller than 5 cm resolve in 2 months, but rising CA-125 levels or increasing cyst size or complexity may warrant surgery.
  • Follow-up care is important, as the risk of an ovarian neoplasm being malignant rises from 13% in premenopausal patients to 45% in postmenopausal patients.¹⁵

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors, A Antoine Kazzi, MD, Robin Roberts, MD, and Kimberly Duklewski Abel, MD, to the development and writing of this article.

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