Although the majority of ovarian cysts are incidental findings on physical exam or at the time of pelvic imaging, a detailed medical history with particular attention placed on gynecological history, family history, and physical examination should still be performed at each visit. Ovarian cysts can be symptomatic or asymptomatic. Symptoms that women may experience include unilateral pain or pressure in the lower abdomen. Pain may be intermittent or constant and characterized as sharp or dull. If an ovarian cyst ruptures or ovarian torsion is present, the patient may experience a sudden onset of acute severe pain, possibly associated with nausea and vomiting. The menstrual cycle can become irregular, and abnormal vaginal bleed may occur.[20]

On physical examination, palpation of the ovaries on the bimanual exam should help determine location, shape (regular or irregular), size, consistency, level of tenderness, and mobility. The ovaries can be difficult to palpate depending on the patient’s body habitus, provider experience, and the patient’s pelvic anatomy; therefore, the pelvic examination has limited ability in diagnosing ovarian cysts.[3]

When an ovarian mass is suspected, the provider should first determine whether the patient is pre or post-menopausal. If the former is true, the first step is to perform is a serum beta hCG or urine pregnancy test. Once pregnancy is ruled out, imaging should be done for further evaluation. A complete blood count should focus on the hematocrit and hemoglobin levels to evaluate for anemia caused by acute bleeding. Urinalysis should be obtained to rule out urinary tract infection and kidney stones. Endocervical swabs should be collected to assess for pelvic inflammatory disease. Cancer antigen 125 (CA125) is a protein present on the cell membrane of healthy ovarian tissues and ovarian carcinomas. A blood level of less than 35U/ml is taken as normal. CA15 values are raised in 85% of patients with epithelial ovarian cancer, while it is raised in 50% of patients with stage I cancer confined to the ovary. The finding of an elevated CA 125 level is most useful when combined with an ultrasound while evaluating a postmenopausal woman with an ovarian cyst.[7][11]

Due to the proximity of the transvaginal probe to the ovaries, the most common imaging modality used for an initial evaluation is transvaginal ultrasonography. It is the imaging of choice when attempting to differentiate between benign or malignant mass. Abdominal ultrasonography can be used in conjunction if pelvic anatomy is distorted due to previous surgeries. Ultrasound evaluates for laterality, size, the composition of the mass (cystic, solid, or mixed, septations, papillary excrescences, mural nodules), presence of pelvic free fluid, and assessment of blood flow and vascularity via color doppler. Ultrasound findings that are consistent with benign cysts in any age group are thin, smooth walls, and absence of septations, solid components, and internal flow on color doppler.

It is important to note that the presence of flow on the doppler exam cannot rule out adnexal torsion. This is evident in a case-control study performed with 55 confirmed cases, and 48 controls showed normal doppler flow in 27% of left ovarian torsion cases and 61% of right ovarian torsion cases. The persistence of normal Doppler flow in suspected torsion can be due to intermittent torsion or to the double blood supply of the ovary. Cyst size greater than 10 cm, complex multilocular mass, papillary excrescences or solid components, irregularity, thick septations, evidence of ascites, and increased vascularity on color doppler should raise suspicion for malignancy and requires further evaluation. Additional imaging studies like magnetic resonance imaging or computed tomography can be performed but are not recommended as part of the initial evaluation.[3][21][22][23]

There are several different treatment options available, but ultimately management depends on the age of the patient, menopausal status, the size of the cyst, and whether the cyst has characteristics suspicious for malignancy. Unilocular cysts less than 10 cm are usually benign regardless of patient age; therefore, if the patient is asymptomatic, she can be monitored conservatively with serial transvaginal ultrasound since the majority of cysts resolve spontaneously without intervention. If a cyst does not resolve after several menstrual cycles, it is unlikely to be a functional cyst, and further workup is indicated.[24]

Fetal ovarian cysts are caused by hormonal stimulation. Also, an association between fetal ovarian cysts and maternal diabetes and fetal hypothyroidism has been found. Most fetal ovarian cysts are usually small and involute during the first few months of life and are of no significance. These cysts are diagnosed in the third trimester of pregnancy, and most tend to resolve at 2 to 10 weeks postnatally.[5]

Most pregnancy-associated cysts, corpus luteal and follicular resolve by 14 to 16 weeks of gestation spontaneously allowing conservative management.[25] The resolution of cysts is less likely when larger than 5cm or complex morphology. Simple cysts smaller than 6 cm have only less than 1% risk of malignancy.[26]

In women of all ages, endometriomas should have followed up sonograms 6 to 12 weeks after initial imaging, then yearly until surgically removed.  Dermoid cysts should also have a yearly follow-up with ultrasound until surgical removal.

Indications for surgery include suspected ovarian torsion, persistent adnexal mass, acute abdominal pain, and suspected malignancy. Surgery in pre-menopausal women prioritizes the preservation of fertility, and every attempt is made to remove minimal ovarian tissue. Pregnant patients can have cysts that may require surgical management. Although laparoscopy is safe in all trimesters of pregnancy, ideally, it is recommended to perform surgery in the second trimester.[27]

The ovarian cyst has a broad range of differential diagnosis, and these are broadly classified into gynecological and nongynaecological subcategories

Gynecological

• Benign: Functional cyst, endometrioma, tubo-ovarian abscess, mature teratoma, serous cystadenoma, mucinous cystadenoma, para tubal cyst, hydrosalpinx, leiomyomas
• Malignant: Epithelial carcinoma, germ cell tumor, sex cord or stromal tumor, metastatic cancer
• Pelvic inflammatory disease
• Ectopic pregnancy

Nongynecological

• Appendicitis
• Diverticulitis
• Pelvic kidney
• Gastrointestinal cancer
• UTI
• Nephrolithiasis
• Psoas abscess

Most ovarian cysts are found incidentally, are asymptomatic, and tend to be benign with spontaneous resolution leading to an overall favorable prognosis. Overall, 70% to 80% of follicular cysts resolve spontaneously. The potential of benign ovarian cystadenoma to become malignant has been postulated but remains unproven. Less aggressive tumors of low malignant potential run a benign course. The overall survival in these cases is 86.2% at five years.[25] Malignant change can occur in few cases of dermoid cysts (associated with extremely poor prognosis) and endometriosis. If an ovarian cyst is suspected to be malignant, then the prognosis is usually poor since ovarian cancer tends to be diagnosed in the advanced stages.

There are three classic complications of ovarian cysts that commonly present to the emergency department:

• Rupture
• Hemorrhage
• Torsion

The fifth most common gynecological emergency is ovarian torsion, which is defined as the complete or partial twisting of the ovarian vessels resulting is obstruction of blood flow to the ovary. The diagnosis is made clinically with the assistance of a history and physical examination, bloodwork, and imaging and is confirmed by diagnostic laparoscopy. The latest evidence supports a conservative approach during diagnostic laparoscopy, and detorsion of the ovary with or without cystectomy is recommended to preserve fertility. Ovarian cysts can also rupture or hemorrhage, with a majority of these cysts being physiological. Most cases are uncomplicated with mild to moderate symptoms, and those with stable vital signs can be managed expectantly. Occasionally, this can be complicated by significant blood loss resulting in hemodynamic instability requiring admission to the hospital, surgical evacuation, and blood transfusion.[7]

When a patient needs surgical management, laparoscopy or laparotomy can be performed, and both have significant advantages and disadvantages. Laparotomy is usually preferred when the patient is hemodynamically unstable since it allows for faster entry and direct visualization of the involved structure but results in larger incisions and increased duration of post-op pain, hospital stay, and recovery time. Laparoscopies are more lengthy procedures with smaller incisions with less risk of infection and blood loss when compared to laparotomies. However, the longer time spent in surgery leads to increased exposure to general anesthesia and increases the risk of damage to internal organs and blood vessels. When laparoscopy is performed, the hemodynamically stable patient is usually discharged home on the same day of surgery with typical post-surgical precautions and proper follow-up scheduled.

The management of patients with the ovarian cyst is multidisciplinary, and teamwork is required in the following specialties

• Obstetrician/gynecologist
• Infertility and reproductive endocrinologist
• Gynecologic oncologist
• General surgeon
• Radiologist
• Pathologist

Patients that are high risk for ovarian malignancy should have their case reviewed in conjunction with a gynecologic oncologist for further assessment and determination of optimal surgical management. Specific guidelines can help gynecologists differentiate when to refer patients with an adnexal mass. Typically, postmenopausal women with an elevated CA-125 or premenopausal women with significantly high CA-125, ultrasound characteristics suspicious for malignancy, nodular or fixed pelvic mass, ascites, evidence of abdominal or distant metastasis should be referred to gynecologic oncology. Ultrasound findings that are suspicious for malignancy include cysts larger than 10cm, irregularity of cyst, high color doppler flow, papillary or solid components, and presence of ascites.[3]

Ovarian cysts are fluid-filled sacs that can present within the ovary and are most commonly benign functional cysts that regress spontaneously. They are commonly found incidentally on examination or imaging. In certain instances, they may become so enlarged that the increased weight may cause the ovary to rotate on itself, cutting off the blood supply and resulting in a gynecologic emergency known as ovarian torsion, which requires surgical management. Ovarian cysts can also rupture and cause life-threatening hemorrhage. Large cysts should be removed to prevent complications. If one may experience a sudden onset of unilateral moderate to severe sharp lower abdominal pain, associated with or without nausea and vomiting and strenuous activity such as sexual intercourse or exercise, prompt evaluation is mandatory.

Although ovarian cysts are mostly benign and resolve spontaneously, they can sometimes lead to complications such as rupture, hemorrhage, and torsion that require urgent medical or surgical treatment. The purpose of the evaluation is to determine the most likely etiology of the patient's symptoms whenever an ovarian cyst is present. Acute lower abdominal pain is a common presentation to the emergency room and can be associated with a variety of generalized symptoms. The differential diagnosis is broad, and it can be difficult to determine the exact cause without proper imaging studies. Transvaginal ultrasound is the recommended first-line imaging modality for a suspected or an incidentally identified pelvic mass. [Level 1]

Findings that raise the level of suspicion for malignancy include cyst size more than 10 cm, presence of ascites, papillary excrescences or solid components, irregularity, and high color doppler flow. [level 1]. Surgical intervention for mature ovarian teratomas or endometriomas is warranted in the masses are large, symptomatic, and growing in size on serial imaging studies or if malignancy is suspected. If, however, expectant management is employed, follow-up surveillance is warranted.[22][23] [Level 2]