Ovarian Cysts Treatment & Management

Epidemiologic 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, meta-analyses have since 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 timeframe, it is unlikely to be a functional cyst, and further workup may be indicated. ^[47]

Many patients with simple ovarian cysts based on ultrasonographic findings do not require treatment. In a postmenopausal patient, a persistent simple cyst smaller than 10cm in dimension in the presence of a normal CA125 value may be monitored with serial ultrasonographic examinations. ^[4]

Premenopausal women with asymptomatic simple cysts smaller than 8cm 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, as stated above, the use of the OCPs, is not helpful in resolving the cyst. ^[47]

In female newborns, ovarian cysts are the most frequent type of abdominal tumor, with an estimated incidence of more than 30%. ^{[21, 16]}

Fetal ovarian cysts are believed to be caused by hormonal stimulation, such as fetal gonadotropins, maternal estrogen, and placental hCG. In addition, 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. ^[16]

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. ^[21]

Aspiration of these cysts can be performed but is associated with complications, such as reformation of cyst, infection, and premature labor. ^[16]

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. ^[21]

Of these complications, ovarian torsion is the most serious complication of a 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. ^[16]

The corpus luteum is responsible for progesterone production during pregnancy and normally regresses at around 8 weeks’ gestation. ^[14]

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. ^[14] By gestational age 16-20 weeks, up to 96% of masses resolve spontaneously. Resolution of cysts are less likely when larger than 5cm or of complex morphology. ^[4]  Simple cysts smaller than 6 cm in diameter have a risk of malignancy of less than 1%. ^[26]

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 radiologic evidence. ^[14] Serum CA125 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 who have large, persistent adnexal masses in whom ultrasonographic findings are not highly suggestive of malignancy. ^[6] However, in situations in which cysts are symptomatic, including causing pain and discomfort, or with rapid growth on serial ultrasound, surgical removal should be considered.

If malignancy is a possibility and peripartum surgery is warranted, the risk 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. ^[26]

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 hCG levels and are typically seen in women who have undergone ovulation induction.

Most studies estimate the prevalence of simple, unilocular adnexal cysts in asymptomatic, postmenopausal women at 3-18%, with most of these cysts being smaller than 5cm in diameter.

Early studies indicated the risk of malignancy for these asymptomatic adnexal cysts in postmenopausal patients to be as high as 7%, but subsequent studies showed the prevalence to be less than 1% in small cysts. ^[29]

In these patients, repeat ultrasonography at 4-6 weeks can be performed along with CA125 studies in an outpatient setting. Half of asymptomatic cysts smaller than 5 cm resolve in 2 months, but rising CA125 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. ^[20]

Bilateral oophorectomy

Bilateral oophorectomy and, often, hysterectomy are performed in many postmenopausal women with ovarian cysts because of the increased incidence of neoplasms in this population.

When a female patient presents in the emergency department (ED) 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 her arrival at the next hospital.

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 method is used, the goals remain the same; they 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. ^[48] However, it is essential that the disease outcome for the patient not be inferior to that achieved with laparotomy. ^[49]

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. The aim should be to remove all cysts intact, ^{[50, 51]} but 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 in order to allow removal of the intact cyst and ovary. Some now promote a laparoscopic approach with drainage of the cyst, allowing the ovary to be removed through a small incision. ^[52] 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—such as a dermoid or functional cyst or an endometrioma—with conservation of the ovary may be performed in patients who desire retention of their ovaries for future fertility or for other reasons.

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. Whenever possible, the patient should consult with the specialist prior to the surgery to allow all issues to be addressed. This will allow the appropriate surgery to be performed on patients found to have cancer.

The current use of oral contraceptive pills (OCPs) may protect against the development of functional ovarian cysts. As previously mentioned, however, existing functional cysts do not regress more quickly when treated with combined oral contraceptives than they do with expectant management, so OCPs should not be used for that purpose. ^[8]

Current and previous use of OCPs within 15 years reduces the risk of epithelial ovarian cystadenocarcinoma.

There is no established consensus for recommending annual gynecologic examination, and its role is questionable in asymptomatic women older than 21 years. ^{[53, 54]}

No generalized screening test is available for ovarian cystadenocarcinoma, but women at high risk based on family history or a previous history of breast cancer should undergo an annual ultrasonographic examination and CA125 test. Referral for genetic counseling should be considered.

Women at high risk for ovarian cystadenocarcinoma may be offered prophylactic oophorectomy, which will prevent the development of ovarian cancer but not peritoneal carcinoma.

The following consultations should be made:

• Infertility and reproductive endocrinologist - For endometrioma and polycystic ovarian syndrome

• Gynecologic oncologist - Postmenopausal patients with elevated CA125 and imaging findings concerning for malignancy, premenopausal patients with very elevated CA125 and concerning imaging studies, patients with an elevated risk assessment or those with a strong family history/genetic risk factors for malignancy

• General surgeon - Consult a general surgeon in the ED when the clinical presentation indicates an intraperitoneal process that is not clearly obstetric or gynecologic

• Obstetrician/gynecologist - When an ovarian-, uterine-, or pregnancy-related emergency is suspected

It is imperative to expedite hemodynamically unstable patients to the operating room, with consulting services mobilized, while the initial resuscitation in the ED is in progress.

The timing of outpatient care for patients with ovarian cysts depends on the specific 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. In nonpregnant patients and in patients following pregnancy, such cysts can be followed with serial ultrasound.

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. ^[14]

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, rupture, or obstruction of labor are more likely to require surgical intervention ^[55] ; they 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. It is better to avoid surgical intervention 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 CA125 level are used to determine management. Unilocular cysts that are smaller than 5 cm in diameter should be monitored with transvaginal ultrasonography and CA125 studies at 6-month intervals. Complex ovarian cysts that are smaller than 5 cm in diameter in the presence of normal CA125 levels (defined as < 35 U/mL) should be monitored in 4 weeks with repeat ultrasonography and CA125 studies. Surgery may be indicated for complex ovarian tumors that are smaller than 5 cm in diameter when CA125 levels are elevated (>35 U/mL) and for complex tumors larger than 5 cm in diameter. ^[20]

Studies have used various timeframes as indices for cyst resolution in nonpregnant, premenopausal patients. Most of these studies showed cyst resolution by 2-3 months, dictating ultrasonography with or without gynecologic follow-up in these patients. ^[47]