Friday, March 31, 2023

Ovarian Cysts

Practice Essentials

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.

A multilocular right ovarian cyst that is 24 cm in

A multilocular right ovarian cyst that is 24 cm in diameter. It is seen with the 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. Image courtesy of C. William Helm, MBBChir.

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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.
Cyst rupture can lead to peritoneal signs, abdominal distention, and bleeding (which is usually self-limited)

Discomfort with intercourse, particularly deep penetration

Changes in bowel movements such as constipation

Pelvic pressure causing tenesmus or urinary frequency

Menstrual irregularities

Precocious puberty and early 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

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

Underlying malignancy may be associated with early satiety, weight loss/cachexia, lymphadenopathy, or shortness of breath related to ascites or pleural effusion


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.


Per ACOG guidelines, transvaginal ultrasound is the preferred imaging modality for assessment of a suspected 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, may 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)


Endocervical swabs if infectious etiology is suspected

Serum biomarker testing

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

hCG, L-lactated dehydrogenase, alpha-fetoprotein, and inhibin may be helpful if a less common histology is suspected

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 10 cm in dimension in the presence of a normal CA125 value may be monitored with serial ultrasonographic examinations.

Pharmacologic therapy

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 10 cm (especially if symptomatic) and complex ovarian cysts should be considered for surgical removal. The surgical approaches include an open technique (laparotomy) or a minimally invasive technique (laparoscopy) with very small incisions. The latter approach is preferred in cases presumed benign.
Removing the cyst intact for pathologic analysis may mean removing the entire ovary, though a fertility sparing surgery should be attempted in younger women.

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.


Per ACOG Guidelines, referral to a gynecologic oncologist is recommended for the following patients:

Postmenopausal patient with elevated CA125, imaging findings consistent with malignancy, ascites, a nodular or fixed mass, or evidence of metastases

Premenopausal patient with very elevated CA125, imaging findings consistent with malignancy, ascites, a nodular or fixed mass, or evidence of metastases

Premenopausal or postmenopausal patient with elevated malignancy predictive score such as the multivariate index assay, risk of malignancy index, or the Risk of Ovarian Malignancy Algorithm, or one of the ultrasound-based scoring systems from the International Ovarian Tumor Analysis Group

See Treatment and Medication for more detail.

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