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Management of Adnexal Cysts

Sep 2010 – by V. von Gruenigen, MD

Editor: Pamela Berens, MD

REVISED PEARL – April 2015

Adnexal cysts may be identified based on gynecologic symptoms or may be incidentally noted during pelvic exam or imaging for other reasons. Further actions depend on imaging characteristics and symptoms. Most incidentally noted cysts are harmless and resolve on their own.

Adnexal cysts can be classified as benign or malignant. Malignant ovarian cysts are rare prior to menopause. The most commonly occurring ovarian cysts in menstruating women are physiologic / functional (follicular or corpus luteum) cysts, and usually resolve in 6-8 weeks. Other types of benign ovarian cysts include dermoids, cystadenomas and endometriomas. Paratubal cysts are another type, and are typically simple appearing by ultrasound and usually benign.

Most ovarian cysts are small and asymptomatic or cause brief symptoms that spontaneously resolve. Some cysts cause a dull or sharp ache in the pelvis. Functional cysts may cause acute onset mid-cycle pain which may be instigated by intercourse or other physical activities. Larger cysts may rarely undergo torsion causing acute pain or develop hemorrhagic rupture that my lead to surgical intervention.

An ovarian cyst may be diagnosed during pelvic exam and confirmed using transvaginal ultrasound. Unilocular, thin-walled sonolucent cysts with regular borders are usually benign, regardless of menopausal status or cyst size. Ultrasound findings that raise concern for ovarian cancer include a solid component, excrescences, ascites or mural nodules. CA-125 can be helpful distinguishing benign and malignant adnexal masses in postmenopausal women. CA-125 has low specificity, and is frequently elevated in many gynecological conditions such as uterine leiomyomata, endometriosis, pelvic inflammatory disease, ascites of any etiology and other types of inflammatory disease. A β-hCG should be routinely ordered premenopausal women with an adnexal cyst to rule out an early or ectopic pregnancy.

Treatment options for ovarian cysts include observation, medical management or surgery, depending upon the patient symptoms, type and size of the cyst, family history, and the patient’s age. Benign appearing ovarian cyst that are asymptomatic or causing mild cyclic symptoms can be followed as most functional cysts resolve after 1-3 menstrual cycles. For functional cysts, hormonal medications such as oral contraception may be an option to prevent new cysts. Resolved cysts require no additional imaging. If the ovarian cyst is large and causing significant symptoms, then surgery may be necessary. Minimally invasive surgery with laparoscopy is favored over an open surgical approach for benign appearing cysts. Ovarian cystectomy is the preferred procedure to preserve ovarian function. Cyst aspiration is not recommended due to poor sensitivity in detecting malignancy, failure to provide long term resolution and concern over spillage, spread and worsening prognosis if cancer were present.

Further Reading:

ACOG Practice Bulletin, Management of Adnexal Masses, Number 83, Reaffirmed 2013