Management of Adnexal Cysts
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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 or functional cysts. They are also known as follicular or corpus luteum cysts and usually resolve in six to eight weeks. Other types of benign ovarian cysts include dermoids (mature cystic teratomas), 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 mid-cycle pain which may be instigated by intercourse or other physical activities. Larger cysts are at risk for causing torsion, causing acute pain, or develop hemorrhagic rupture that may necessitate surgical intervention in the setting of hemodynamic instability.
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, increased vascularity, size greater than ten centimeters, 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 inflammatory diseases. A β-HCG should be routinely ordered in premenopausal women with an adnexal cyst to rule out an early or ectopic pregnancy. Other tumor markers such as AFP, LDH, inhibin and HCG may be useful in younger populations and if non-epithelial cancer is suspected.
Treatment options for ovarian cysts include observation or surgery, depending upon the patient’s symptoms, type and size of the cyst, family history, and the patient’s age. Benign appearing ovarian cysts that are asymptomatic or causing mild cyclic symptoms can be followed since most functional cysts resolve after one to three menstrual cycles. For functional cysts, ovulation suppression with hormonal medications such as oral contraceptives may be an option to prevent new cysts from forming. 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.
Adnexal cysts with features concerning for malignancy such as elevated tumor markers, worrisome ultrasound findings, or elevated risk on a formal risk assessment tool such as the multivariate index assay or the Risk of Ovarian Malignancy Algorithm may benefit from referral to a gynecologic oncologist.
American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins-Gynecology. Practice Bulletin No. 174: Evaluation and Management of Adnexal Masses., Obstet Gynecol. 2016 Nov;128(5):e210-e226.
Original Approval 09/10. Reviewed September 2016. Revised January 2018. Minor Revision July 2019. Reaffirmed March 2021, Revised September 2022
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