1) Ovarian cysts are common in premenopausal women and are usually benign, with a risk of malignancy around 1 in 1000. Postmenopausal cysts require more evaluation due to higher risk of cancer. 2) Conservative management is recommended for small, unilateral, simple cysts in premenopausal women, with follow up ultrasound. Suspicious cysts based on features like size, complexity, CA125 levels should be referred to specialists. 3) Serial ultrasound can monitor simple, thin-walled cysts under 10cm in postmenopausal women, which often resolve spontaneously. But thicker-walled or larger cysts require further evaluation due to higher cancer risk.

1. Perimenopausal Ovarian cysts.
Shobhana Mohandas.MD.DGO.FICOG.Dip Endoscopy.
Sun Medical centre, Thrissur, Kerala

2. 10% of women will have some form of surgery
for the presence of an ovarian mass.
In premenopausal women almost all ovarian
masses and cysts are benign.
The overall incidence of a symptomatic ovarian
cyst in a premenopausal female being
malignant is approximately 1:1000 increasing to
3:1000 at the age of 50.
Green–top Guideline No. 62 RCOG/BSGE Joint Guideline I November 2011

3. Management
● Conservative management
● Use of laparoscopic techniques
● Referral to a gynaecological oncologist

4. Management
• Unilateral, unilocular < 5cm, normal CA125 – manage
conservatively
• < 1% cancer risk , > 50% resolve spontaneously
within 3 months
• Follow-up USS every 4 months for 1 year
• Same size after 3 USS – No more follow up

5. Post Menopausal Ovarian cysts.
Thin-walled, unilocular, sonolucent cysts less than 10 cm in
diameter with smooth, regular borders are usually benign
(malignancy rate = 0 to 1 percent, regardless of menopausal
status).
In one study, 2,763 postmenopausal women with this type of
cyst
were followed for a mean of 6.3 years and evaluated with
ultrasonography every six months. Almost 70 percent of the cysts
resolved spontaneously, and none of these simple cysts developed
into ovarian cancer.
Serial ultrasonography is sufficient to document the resolution of
cysts with these features.
Recommended intervals for ultrasonography
4-6 weeks initially,
3-6 months ,
Every 6 months American family physician Volume 84, Number 3 ◆
August 1, 2011

6. 65 year old woman
Year: 1980
Courtesy:
Dr.Jose, General
Surgeon
Tumor: Pseudo
Mucinous
Cystadenoma
Of ovary

7. Olden days …
Earlier palpable ovary in the post menopausal
age was an indication for surgery
Where are we today ?

8. No role for cystectomy after menopause

9. Cyst Aspiration and oral contraceptive pill useless

10. DePriest ultrasound morphology index
1 point 2 points 3 points 4 points
Tumour volume <10 cm3 10 to 50
cm3
>50 to 200
cm3
>200 cm3
Cyst wall
Structure and thickness
smooth <3
mm
smooth >3
mm
papillary <3
mm
papillary >3
mm
Septal structure No septa Thin septa
<3 mm
Thick septa
3 to 10 mm
solid area
>10 mm

11. An ultrasound morphology index score <5 in a
pre-menopausal woman is in keeping with a
benign aetiology.
Post menopausal woman: Malignancy Index
>5
Positive predictive value of malignancy:
0.45.
Thickened wall structure, Volume >10cm:
Malignancy likely

12. CA- 125
• Raised in > 80 % ovarian cancers
greater than 200 U per mL [200 kU per L] in premenopausal
women and
greater than 35 U per mL [35 kU per L]
in postmenopausal women
positive predictive value
49 % in premenopausal women
98 % in postmenopausal women.
• But raised in only 50 % Stage 1
• Also raised in benign conditions and other malignancies

13. 65 year old woman with 15 cm ovarian
cyst with some solid components
CA 125- 2 IU !!!!!!!!!!!!
Stage IV cystadenocarcinoma
Patient died 2 years later.

14. Risk of malignancy index (RMI)
RMI = U x M x CA-125
Ultrasound scans are scored 1 point for each of the following characteristics:
Multi-locular cyst
Evidence of solid areas
Evidence of metastases
Presence of ascites
Bi-lateral lesions.
U = 0 (for ultrasound score of 0);
U = 1 (for ultrasound score of 1);
U = 3 (for ultrasound score of 2 to 5).
M = 3 for all post-menopausal women dealt with by this guideline.
CA-125 is serum CA-125 measurement in U/mL.

15. Low-risk RMI = <25 (40% of women; risk of cancer is <3%).
Moderate-risk RMI = 25 to 250 (30% of women; risk of
cancer is 20%).
High-risk RMI = >250 (30% of women; risk of cancer is 75%).

16. 8 cm ovarian cyst with solid
components
Normal CA-125
Loss of weight- 6 months:
Kruckenberg tumour,
primary not found

17. • complete blood count,
• cervical cultures, and measurement of HCG
• low-density lipoprotein cholesterol,
• And α-fetoprotein.
• CA 125 levels
Pelvic examination
Primary
infertility
NulliparityOlder age
F H/O breast or ovarian
cancer
Non polyposis
colorectal cancer
Lynch syndrome
Endometriosis
History taking
Identification of metastasis.
Ultrasound Exam
Lab testing

18. Types of adnexal masses
Benign ovarian Benign non-ovarian
• Functional cysts Paratubal cyst
• Endometriomas Hydrosalpinges
• Serous cystadenoma Tubo-ovarian abscess
• Mucinous cystadenoma Peritoneal pseudocysts
• Mature teratoma Appendiceal abscess
Diverticular abscess
Pelvic kidney
Primary malignant Secondary malignant
Ovarian Germ cell tumour Predominantly breast and
gastrointestinal carcinoma.
Epithelial carcinoma
Sex-cord tumour

19. Post hysterectomy patient with
excruciating pain in abdomen
with 7cm ovarian cyst

25. • Resistance index Risk of malignancy
• Colour Doppler - to study the vascularity

26. Role of MRI/CT/PET not yet established

27. Post Hysterectomy
Ovarian
Cysts

28. 40Year old woman with history of hysterectomy comes
With abdominal pain and a simple ovarian cyst of 5 cms.
There is a vertical scar on the abdomen

30. 22 year old Unmarried girl comes with uniilateral
6cm Ovarian cyst with solid components.
CA 125- 65 IU
Minimal ascites
Staging Laparotomy?
Staging Laparoscopy?

32. 60 year old lady with 6 cm ovarian
cyst with
few solid components
CA – 125- 45 IU.
Laparoscopy?
Laparotomy?

33. Laparoscopic hysterectomy with BSO done.
Specimen removed through
endobag
Transitional cell tumour of the ovary
Post op CT: “recurrence “ of tumour 7cm!!!!
Chemotherapy
Alive and kicking 3 years later

34. ACOG and SGO guidelines
for referral to gynaecological oncology
Post-menopausal women with suspicious pelvic mass and:
Elevated CA-125 level (>35 U/mL)
Ascites
A nodular or fixed pelvic mass
Evidence of abdominal or distant metastasis
A family history of 1 or more first-degree relatives with
ovarian or breast cancer.

35. Pre-menopausal women with a suspicious pelvic mass
and:
Greatly elevated CA-125 level (> 200 U/mL)
Ascites
Evidence of abdominal or distant metastasis
A family history of 1 or more first-degree relatives with
ovarian or breast cancer

36. Thank you