Ovarian Cysts
RCOG Ovarian Masses in Premenopausal Women, Management of Suspected (Green-top Guideline No. 62). Last reviewed: Dec 2011.
Ovarian Cysts
Ovarian cysts are fluid-containing structures within or on the ovary, and many are benign, incidental, and self-limiting.
Updated UKMLA guide to ovarian cysts, based primarily on RCOG guideline: classification, symptoms, investigation, management, and complications.
Ovarian cysts are a broad and heterogeneous topic. Different cyst types have their own clinical associations, characteristic features, and imaging findings.
However, detailed subtype-specific distinctions are usually not required at a non-specialist level and are therefore omitted here.
The key learning points are understanding ovarian cysts as a whole, their general assessment and management principles, and recognising features that may suggest malignancy (ovarian cancer).
Classification
Functional cysts (simple cysts):
- Follicular cysts
- Corpus luteum cysts
- Theca lutein cysts
Functional cysts tend to resolve spontaneously
Pathological cysts / benign ovarian masses:
- Surface epithelial tumours (serous cystadenoma, mucinous cystadenoma)
- Dermoid cyst (mature teratoma)
- Sex cord-stromal tumours (fibroma, thecoma)
- Endometrioma (chocolate cyst) – common in endometriosis
Note that these are benign; malignant (i.e. ovarian cancers) are covered in the Ovarian Cancer article
Clinical Features
Most ovarian cysts are asymptomatic and discovered incidentally on imaging.
If symptomatic: [Ref]
- Abdominal / pelvic pain
- Abdominal bloating / distension
- Menstrual irregularities
- Mass effect
- Urinary urgency, frequency
- Change in bowel habits
- Loss of appetite, early satiety
Possible physical examination findings: [Ref]
- Palpable abdominal / pelvic mass
- Adnexal mass
- Tenderness on pelvic examination
Red Flags and When to Refer
Suspected cancer pathway referral is indicated in the presence of:
- Ascites, and/or
- Pelvic or abdominal mass (which is not obviously uterine fibroids)
For further information, see the Ovarian Cancer article.
Assessment
If a female of reproductive age presents with abdominal or pelvic pain and/or pelvic mass, a pregnancy test should be performed as part of the immediate steps.
1st line investigation: TVUS
- A simple / functional cyst would typically have a thin-walled cyst without any internal structures
| Benign ultrasound findings | Malignant ultrasound findings |
|
|
If ANY of the malignant ultrasound findings listed above are present → refer to secondary care for query ovarian cancer (see the Ovarian Cancer article for more information)
Further imaging (CT / MRI) is only indicated if there are malignant findings or benign findings but >70 mm.
Management
Common management approach for presumed benign simple cysts:
| Conservative (expectant) management | Surgical management | |
|---|---|---|
| Indications | Simple cysts that are <70 mm in diameter |
|
| Description | <50 mm → no follow-up necessary (as they almost always resolve spontaneously within 3 menstrual cycles)
50-70 mm → yearly ultrasound follow-up |
Preferred approach: laparoscopic removal |
COCP should NOT be given to promote the resolution of functional ovarian cysts.
Complications
There are 3 main complications of an ovarian cyst:
- Torsion – see the Ovarian Torsion article
- Rupture
- Haemorrhage
Important gynaecological differentials for acute abdomen in females:
- Ectopic pregnancy (if reproductive age)
- Ruptured ovarian cyst
- Ovarian torsion
Ruptured Ovarian Cyst
| Most common cause | Corpus luteum cysts are the most common cause of ruptured ovarian cysts |
| Clinical presentation | Patient tends to present with acute abdominal / pelvic pain |
| Work-up | In reproductive-age women → first perform a pregnancy test to rule out ectopic pregnancy
1st line investigation: ultrasound Further test: CT |
| Management | Most cases are self-limiting and can be managed conservatively with analgesia and observation
Emergency exploratory laparoscopy is necessary in haemodynamically unstable patients or signs of haemoperitoneum (e.g. on CT) |