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Ovarian Cysts-Premenopausal

A generally accepted definition of an ovarian cyst is a fluid containing structure more than 30 mm in diameter
How common ? Incidence of detection has increased due to increased use of transvaginal ultrasound and computed tomography In pre-menopausal women almost all ovarian masses and cysts are benign Overall incidence of a symptomatic ovarian cyst in a pre-menopausal women being malignant is approximately 1 : 1000 increasing to 3 : 1000 at the age of 50 Ten percent of suspected ovarian masses are ultimately found to be non-ovarian By the age of 65 yrs 4 % of all the women in England and Wales will have been admitted to hospital due to a functional ovarian cyst
Type of adnexal masses
Benign ovarian-functional cysts endometriomas serous cystadenoma mucinous cystadenoma
Benign non-ovarian –paratubal cysts hydrosalpinges tubo-ovarian abscess peritoneal pesudocysts appendiceal abscess diverticular abscess pelvic kidney
Primary malignant –Germ cell tumour epithelial carcinoma sex-cord tumour
Secondary malignant -Predominantly breast and gastrointestinal carcinoma

Risk factors ovarian cancerage ( 3 fold increase in perimenopausal women aged 45-50 ) personal h/o breast cancer family h/o breast or ovarian cancer ( 1st° relative ) BRCA1 or BRCA2 fgene carrier obesity hormone replacement therapy endometriosis hereditary nonpolyposis colon cancer Peutz-Jeghers syndrome MUTYH- associated polyposis
RMI IndexRisk of malignancy index is scoring system which combines 
 ultrasound findings menopausal status/ age serum Ca125 levels

to estimate the risk of malignancy in women with an adnexal mass
IOTA ClassificationInternational Ovarian Tumour Analysis ( see under links ) group has devised a system ( Simple rules ) to help identify adnexal masses and classify them as either benign (B) , malignant (M) or inconclusive based on ultrasound findings. 

Simple rules risk calculation ( SRisk ) 2016 was developed further to provide a predicted risk
Assessment –take a thorough medical history – paying special attention to risk factors for ovarian malignancy enquire about symptoms suggestive of endometriosis along with any symptoms suggestive of ovarian malignancy as
○ persistent abdominal distension
○ feeling full ( early satiety ) and or loss of appetite
○ pelvic or abdominal pain
○ increasing urinary urgency and / or frequency undertake a physical examination – abdominal and vaginal there is no need to routinely check Ca-125 level in women < 40 yrs with a complex ovarian mass – check ( CA 125 + )
○ Lactate dehydrogenase ( LDH )
○ Alpha-fetoprotein 
○ Human chorionic gonadotrophin ( hCG )
CA-125 is unreliable in differentiating benign from malignant ovarian masses in premenopausal women CA125 is also raised in numerous conditions as fibroids , endometriosis , adenomyosis and pelvic infection CA-125 is primarily a marker for epithelial ovarian carcinoma and is only raised in 50 % of early stage disease Important to note that only in stage III-iV endometriosis is it likely to be raised to several hundreds or thousands of units/ml If the level is less than 200 units/ ml- further investigations may be appropriate to exclude/treat the common differential diagnosis Level > 200 – discuss with a gynaecological oncologist
Simple cysts –Less than 5 cm simple 
ovarian cysts
 No follow up is required unless there is clinical concern These are very likely to be physiological and almost always resolve within 2-3 menstrual cycles
Simple ovarian cyst in an asymptomatic women 5-7 cm
 Rescan in 6-8 weeks If the cyst persists / symptomatic – referral If resolved no follow-up is needed

Simple cyst > 7 cm
Refer gynaecology
Dermoid cyst Mature cystic teratoma 
( dermoid cyst ) is a benign and common ovarian neoplasm most commonly occurring in young women . Management will depend upon
 Cyst size ( for e.g < 3 cm ,3-5 cm 
or > 5 cm ) CA-125 level Symptoms Malignant transformation can happen in 0.17 %-2 % of dermoids and is almost exclusively due to SCC- tends to occur in women older than 50 and in tumours > 10 cm Laparoscopic cystectomy with ovarian preservation is usually performed but laparotomy with or without oophorectomy might be needed if the cysts are large
Haemorrhagic cyst , EndometriomaEndometrioma – also known as chocolate cysts are benign ovarian cyst that contain thick , old blood that appears as a brown fluid Up to 17-44 % of patients with endometriosis can suffer from endometrioma and this represents a severe stage of endometriosis Endometriomas account for 35 % of all benign ovarian cysts A haemorrhagic cyst which fails to resolve in 6-8 weeks is likely to be an endometrioma Endometrioma has potential to become malignant and would be generally removed after diagnosis About 1 % of endometriomas are believed to undergo malignant transformation – usually endometroid or clear cell carcinoma Refer to general gynecology service
Complex ovarian cyst or solid 
tumour with features suspicious of ovarian malignancy.refer 2 week USC
Ovarian cysts 
that persist or increases
 in size are unlikely to be functional and may 
warrant surgical 


RCOG PIL Ovarian cysts before menopause a 5 page printable document
Central Manchester University Hospital Ovarian Cysts
NHS on ovarian cysts
American Collge of Obstetricians and Gynecologists
A useful page from BUPA
International Ovarian Tumour Analysis Simple rules
RCOG guidance on the management of Suspected Ovarian Masses in Premenopausal Women
Benign Ovarian Cysts Obstetrics Gynaecology and Reproductive Medicine
RMI Index via MD Calc

  1.  Management of Suspected Ovarian Masses in Premenopausal Women Freen-top Guideline No 62 RCOG November 2011
  2. Management of Ovarian Masses in Premenopausal Women Care Pathway and Referral Criteria Oxfordshire Clinical Commissioning Group July 2012

  3. Dora, S.K., Dandapat, A.B., Pande, B. et al. A prospective study to evaluate the risk malignancy index and its diagnostic implication in patients with suspected ovarian mass. J Ovarian Res 10, 55 (2017).
  4. Ovarian cancer risk factors from Cancer Org
  5. Target ovarian cancer
  6. What to do with incidental ovarian cysts from Pulse Todau
  7. The management of ovarian cysts in premenopausal women Alka Prakash, Tin-Chiu Li, William L Ledger via



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