• Ovarian cysts are found in roughly 35% of premenopausal women and in 17% of postmenopausal women (Pavlik et al 2013).
• Ovarian cysts can be encountered as incidental findings or as symptomatic entities.
• Typically, they are benign. However, they have the potential to represent or to lead to serious pathology.

Pathophysiology

• There are both benign and malignant ovarian tumors. Ovarian cysts are benign tumors originating from one of three cell lines: epithelial, germ cell or sex cord stromal.
• Cysts can be classified as functional/physiologic (eg follicular or corpus luteum) or pathologic. They can be further classified as asymptomatic, symptomatic, hemorrhagic or ruptured.
• Most ovarian cysts are functional as related to normal menstrual cycle:
  • Follicular cyst:
    • begins when the follicle doesn’t rupture and continues to grow
    • often resolve within two or three menstrual cycles
  • Corpus luteum cyst:
    • fluid accumulates inside the ruptured follicle
  • Other benign cysts (not related to menstrual cycle):
    • Dermoid cysts or teratomas
    • Cystadenomas = benign epithelial neoplasms (cytopathological diagnosis)
    • Endometriomas secondary to endometriosis attachment
  • The biggest complication of large cysts is the development of ovarian torsion, a true gynecologic emergency.
  • Ovarian malignancies are outside the scope of this summary but require consultant management.

• Ovarian masses can present as asymptomatic incidentalomas or they may present with cyclic or non-cyclic abdominal pain or lower urinary tract symptoms.
• Bloating, early satiety and constitutional symptoms can be associated with ovarian malignancy.
• Physical exam findings are limited, but large ovarian masses can be palpable.
• Ascites and pelvic lymphadenopathy would be more suggestive of malignancy.
• Ultrasound is the first line in differentiating a benign vs malignant ovarian mass.
• Most benign masses demonstrate typical ultrasound findings (see table 1).
• Ruptured or hemorrhagic cysts will present with acute abdominal/pelvic pain with free fluid in the pelvis and collapsed ovarian cysts on ultrasound.

Treatment recommendations are all adapted from SOGC guidelines/Wolfman et al 2020.

A: Asymptomatic Cysts

• The Society of Obstetricians and Gynecologist of Canada (SOGC) recommends follow-up imaging for asymptomatic ovarian cysts < 10 cm in size based (see figure 1).
• Asymptomatic cysts >10 cm should be referred to an OBGYN due to the risk of possible ovarian torsion and increased risk of malignancy.

Figure 1: Recommended follow-up for benign, asymptomatic ovarian masses. Image from SOGC guidelines/Wolfman et al 2020.

B: Symptomatic Cysts

• Symptomatic, non-ruptured, cysts should be observed for persistence of symptoms as cysts often resolve on their own with expectant management.
• Avoid definitive intervention for functional cysts (ie physiologic cysts involved with menstrual cycle, such as follicular or corpus luteum cysts).
• NSAIDs should be first line analgesia and there is no role for hormonal management as this has no advantage compared to expectant management alone.
• Should consider referral for cystectomy for symptoms that persist.

C: Ruptured or Hemorrhagic Cysts

• Usually also managed expectantly with NSAIDs for analgesia.
• Admission for hemodynamic instability, uncontrolled pain, or diagnostic uncertainty.
• Obtain baseline labs, including hemoglobin, regardless of disposition.
• Indications for surgical intervention include: hemodynamic instability, increasing hemoperitoneum or declining hemoglobin, symptoms that persist >48 hours or diagnostic uncertainty, including risk suspicion of ovarian torsion.

1. Callahan, T and Caughey AB. 2013. Blueprints Obstetrics and Gynecology.6^th edition. Lippincott, Williams and Wilkins.

   
   

2. Pavlik EJ, Ueland FR, Miller RW, Ubellacker JM, DeSimone CP, Elder J, Hoff J, Baldwin L, Kryscio RJ, van Nagell JR Jr. 2013. Frequency and disposition of ovarian abnormalities followed with serial transvaginal ultrasonography. Obstet Gynecol;122(2 Pt 1):210. doi: 10.1097/AOG.0b013e318298def5.

   
   

3. Wolfman W, Thurston J, Yeung G, Glanc P. 2020. Guideline No. 404: Initial Investigation and Management of Benign Ovarian Masses. SOGC Clinical Practice Guideline. J Obstet Gynaecol Can 2020;42(8):1040−1050. doi.org/10.1016/j.jogc.2020.01.014