Guideline sources The following summarized guidelines for the evaluation and management of ovarian cysts are prepared by our editorial team based on guidelines from the Society of Obstetricians and Gynaecologists of Canada (SOGC 2023; 2020), the American Society of Clinical Oncology (ASCO 2021), the European Society of Gynaecological Oncology (ESGO 2017), the American College of Obstetricians and Gynecologists (ACOG 2017; 2016), the Royal College of Obstetricians and Gynaecologists (RCOG 2016), and the British Society for Gynaecological Endoscopy (BSGE/RCOG 2011). 1 2 3 4 5 6 7 8 Guidelines 1. Classification and risk stratification Risk assessment: As per ACOG 2017 guidelines: Elicit a detailed personal and family history for breast, gynecologic, and colon cancer to help categorize patients based on their risk (average risk or high risk) of developing epithelial ovarian cancer. E https://web.pathway.md/diseases/reca68nuRfOlnYkGc 1/6 6/30/23, 1:24 AM Ovarian cysts Pathway Maintain an appropriate level of suspicion when potentially relevant signs and symptoms of ovarian cancer are present. E As per RCOG 2016 guidelines, use the RMI I for risk assessment of patients with suspected ovarian cancer. A As per RCOG 2011 guidelines, use a risk stratification tool, such as the RMI I, to assess the risk of malignancy in patients with an ovarian mass. B Show 2 more 2. Diagnostic investigations History and physical examination: elicit a thorough medical history with specific attention to risk factors and symptoms suggestive of ovarian malignancy and a family history of ovarian, bowel, or breast cancer in patients with suspected ovarian cancer. B Show 2 more Diagnostic imaging: As per SOGC 2020 guidelines: Use risk prediction models, such as the International Ovarian Tumor Analysis group simple rules, for ultrasound evaluation of adnexal masses to allow operators with varying degrees of expertise to use uniform terminology and accurately classify these masses as "likely malignant," "benign," or "indeterminate.". B Obtain ultrasound evaluation by an expert operator (if available) or MRI in patients with adnexal masses with indeterminate features. B As per ESGO 2017 guidelines: Obtain routine pelvic (transvaginal and transabdominal) ultrasound as the first-line modality for evaluation of any adnexal mass. B Obtain specialized pelvic, abdominal, and thoracic complementary imaging in case of suspected carcinoma of the ovary or indeterminate or suspicious masses at routine ultrasound examination. B As per ACOG 2016 guidelines, obtain transvaginal ultrasound as the imaging modality of choice in patients with a suspected or incidentally identified pelvic mass. A Show 3 more As per RCOG 2011 guidelines: Obtain pelvic ultrasound, preferably transvaginal, for the evaluation of an ovarian mass. B Do not obtain routine CT or MRI for the evaluation of ovarian masses to improve ovarian malignancy detection of transvaginal ultrasound. D Tumor markers: As per SOGC 2020 guidelines, recognize that CA-125 is a nonspecific glycoprotein that can be elevated in benign and malignant gynecologic conditions and in non-gynecologic conditions. Recognize that only half of all patients with early-stage ovarian cancer and 80% of patients with advanced-stage ovarian cancer show elevated CA-125 levels. B https://web.pathway.md/diseases/reca68nuRfOlnYkGc 2/6 6/30/23, 1:24 AM Ovarian cysts Pathway Show 4 more As per ESGO 2017 guidelines: Obtain serum CA-125 as the tumor marker of choice. Recognize that HE4 has also been proposed. E Consider obtaining additional markers, such as AFP, hCG, LDH, CEA, CA 19-9, inhibin B or antimullerian hormone, estradiol, and testosterone, in specific circumstances such as young age or imaging suggesting a mucinous, or nonepithelial, tumor of extra-adnexal origin. E As per ACOG 2016 guidelines: Consider obtaining serum tumor panels as an alternative to CA-125 level alone in determining the need for referral to or consultation with a gynecologic oncologist when an adnexal mass requires surgery. C Treat postmenopausal patients with elevated CA-125 level and a pelvic mass in consultation with a gynecologic oncologist because of the high risk of malignancy. B As per RCOG 2011 guidelines: Avoid obtaining serum CA-125 in all premenopausal patients with an ultrasound diagnosis of a simple ovarian cyst. D Measure LDH, AFP, and hCG levels in all < 40 years old patients with a complex ovarian mass because of the possibility of a germ cell tumor. B 3. Diagnostic procedures Cyst fluid aspiration: Consider performing aspiration of an adnexal mass in patients with tubo-ovarian abscess. C Do not perform aspiration of cyst fluid for diagnosis in patients with suspected cancer. Consider performing aspiration of an adnexal mass only for diagnosis of suspected advanced ovarian cancer planned to undergo neoadjuvant therapy. D 4. Surgical interventions Indications for cystectomy: do not perform removal of non-endometriosis ovarian cysts for the sole purpose of increasing fertility. D Show 2 more 5. Specific circumstances Pregnant patients: consider obtaining imaging monitoring in most pregnant patients with adnexal masses, as these masses appear to have a low risk of malignancy or acute complications. C Postmenopausal patients (diagnostic imaging): obtain transvaginal pelvic ultrasound in the initial evaluation of ovarian cysts in postmenopausal patients. A Show 12 more https://web.pathway.md/diseases/reca68nuRfOlnYkGc 3/6 6/30/23, 1:24 AM Ovarian cysts Pathway Postmenopausal patients, tumor markers: As per ASCO 2021 guidelines, obtain CA-125 to assist in the diagnosis of postmenopausal patients with symptoms of ovarian cancer. E As per RCOG 2016 guidelines, obtain serum CA-125 level measurement in the initial evaluation of ovarian cysts in postmenopausal patients. A Show 3 more Postmenopausal patients (surveillance imaging): Recognize that asymptomatic, simple, unilateral, unilocular, < 5 cm ovarian cysts have a low risk of malignancy. Obtain repeat evaluation in 4-6 months in patients with normal serum CA-125 levels. Consider discontinuing surveillance after 1 year if the cyst remains unchanged or reduces in size, with normal CA-125, taking into consideration the patient's wishes and surgical fitness. B Obtain further surgical evaluation if the patient is symptomatic. B Postmenopausal patients (further evaluation): obtain appropriate tests in any postmenopausal patient developing symptoms within the last 12 months suggesting IBS, particularly in patients aged > 50 years or with a significant family history of ovarian, bowel, or breast cancer. B Postmenopausal patients (setting of care): Manage patients at higher risk in a cancer center by a trained gynecological oncologist unless the multidisciplinary team review is not supportive of a high probability of ovarian malignancy. B Refer patients to a cancer center for further management if a malignancy is revealed during laparoscopy or from subsequent histology. B Postmenopausal patients (surgical management): obtain surgical evaluation in patients with a suspicious or persistent complex adnexal mass. B Show 4 more Postmenopausal patients (cyst fluid aspiration): do not perform aspiration for the management of ovarian cysts in postmenopausal patients, except for the purposes of symptom control in patients with advanced malignancy unfit for surgery or further intervention. D 6. Follow-up and surveillance Indications for referral: As per SOGC 2020 guidelines, refer patients with a personal history of infertility, endometriosis, or cancer, or a family history of cancer, to a gynecologic oncologist for further evaluation, if possible. B Show 3 more As per ESGO 2017 guidelines, refer patients with nonemergency clinical presentation and suspected adnexal/peritoneal malignancy to a specialist in gynecologic oncology. B https://web.pathway.md/diseases/reca68nuRfOlnYkGc 4/6 6/30/23, 1:24 AM Ovarian cysts Pathway As per ACOG 2016 guidelines, refer patients with an adnexal mass meeting 1 of the following criteria to a gynecologic oncologist: postmenopausal with elevated levels of serum CA-125, ultrasound findings suggestive of malignancy, ascites, a nodular or fixed pelvic mass, or evidence of abdominal or distant metastasis premenopausal with very elevated levels of serum CA-125 level, ultrasound findings suggestive of malignancy, ascites, a nodular or fixed pelvic mass, or evidence of abdominal or distant metastasis premenopausal or postmenopausal with an elevated score on a formal risk assessment test, such as the MIA, the RMI, the ROMA, or one of the ultrasound-based scoring systems from the International Ovarian Tumor Analysis group. B As per RCOG 2011 guidelines, refer patients with a suspected malignant disease (based on ultrasound findings and tumor markers) to a gynecologic oncologist. B Surveillance imaging: As per ACOG 2016 guidelines, consider obtaining imaging monitoring in patients with simple cysts < 10 cm in diameter on transvaginal ultrasound (obtained by an experienced specialist), even in postmenopausal patients, as these cysts are likely benign. C As per RCOG 2011 guidelines, avoid obtaining monitoring in patients with small (< 5 cm diameter) simple ovarian cysts, as these cysts are very likely to be physiological and almost always resolve within 3 menstrual cycles. D Show 2 more Clinical findings Symptoms Past medical history LLQ pain Endometriosis Menstrual irregularity IBS RLQ pain Ovarian cancer Vaginal bleeding PCOS Pelvic inflammatory disease Past obstetric history Gynecologic exam Ectopic pregnancy Adnexal mass References 1. Royal College of Obstetricians and Gynaecologists/British Society of Gynaecological Endoscopy. Management of Suspected Ovarian Masses in Premenopausal Women. RCOG/BSGE. 2011 Nov. Open 2. Royal College of Obstetricians and Gynaecologists. The Management of Ovarian Cysts in Postmenopausal Women. RCOG. 2016 Jul. Open https://web.pathway.md/diseases/reca68nuRfOlnYkGc 5/6 6/30/23, 1:24 AM Ovarian cysts Pathway 3. Shannon Salvador, Stephanie Scott, Phyllis Glanc et al. Guideline No. 403 Initial Investigation and Management of Adnexal Masses. J Obstet Gynaecol Can. 2020 Aug;42 8 1021 1029.e3. Open 4. Denis Querleu, Fran ois Planchamp, Luis Chiva et al. European Society of Gynaecological Oncology ESGO Guidelines for Ovarian Cancer Surgery. Int J Gynecol Cancer. 2017 Sep;27 7 1534 1542. Open 5. 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. Open 6. Tarek Motan, Roland Antaki, Jinglan Han et al. Guideline No. 435 Minimally Invasive Surgery in Fertility Therapy. J Obstet Gynaecol Can. 2023 Apr;45 4 273 282.e2. Open 7. Committee on Gynecologic Practice Society of Gynecologic Oncology. Committee Opinion No. 716 The Role of the Obstetrician-Gynecologist in the Early Detection of Epithelial Ovarian Cancer in Women at Average Risk. Obstet Gynecol. 2017 Sep;130 3):e146-e149. Open 8. Verna D Vanderpuye, Jean Rene V Clemenceau, Sarah Temin et al. Assessment of Adult Women With Ovarian Masses and Treatment of Epithelial Ovarian Cancer: ASCO Resource-Stratified Guideline. JCO Glob Oncol. 2021 Jun;7 1032 1066. Open https://web.pathway.md/diseases/reca68nuRfOlnYkGc 6/6