Treatment Guideline Chart
Ovarian cysts are typically noted after clinical screening, or as a result of exam for a suspected pelvic mass, or an incidental finding in investigations done for other reasons.
Most ovarian masses manifest with few or mild nonspecific symptoms.
Ovarian masses in women of reproductive age are mostly benign but the risk of malignancy increases with age.
Ovarian cysts in the prepubertal patients especially after the first week of life are abnormal and likely to be neoplastic. In adolescent patients, majority of ovarian masses are functional cysts.

Ovarian%20mass Diagnosis


  • Patient may present with the following:  
    • Fevers, chills and vomiting may indicate possible tubo-ovarian abscess
    • Acute pain may be associated with ectopic pregnancy or ovarian torsion
    • Pelvic pain and acute or chronic dysmenorrhea could be from an endometrioma 
  • Perform a detailed review of patient’s medical and family history:  
    • A history of breast, gastrointestinal, hepatobiliary or gynecologic cancer may present as an adnexal mass consistent with metastatic disease to the ovaries
    • A personal history of infertility or endometriosis may suggest an epithelial ovarian neoplasm
    • A history of hereditary cancer syndrome in the family increases the risk of ovarian cancer
  • A gynecologic oncology referral may be indicated if patient has a personal history of infertility, endometriosis or cancer, a family history of cancer, or relevant risk factors

Physical Examination

  • Includes examination of the following:
    • Lymph nodes (eg supraclavicular and inguinal)  
    • Respiratory: Rule out consolidation or pleural effusion
    • Breast and axillary: Rule out breast cancer
    • Abdominal: Check for ascites, organomegaly
    • Pelvic exam (including bimanual and rectovaginal exams): Check for pelvic mass size, mobility, contour and abnormalities in the parametria, bladder and rectum 

Laboratory Tests

  • A complete blood count may show leukocytosis which may indicate infection  
  • Tests for sexually transmitted infections (eg gonorrhea and chlamydia) can identify a tubo-ovarian abscess
  • A positive pregnancy test can diagnose a possible ectopic pregnancy

Tumor Markers

Cancer Antigen 125 (CA 125)

  • An antigenic determinant found in both benign and malignant gynecologic conditions and in non-gynecologic conditions  
  • Elevated CA 125: >200 U/mL in premenopausal women or >35 U/mL in postmenopausal women
  • Raised in 80% of patients with advanced-stage ovarian cancers but is raised in only half the patients with early-stage disease  
  • Most important use of serum CA 125 is assessing the effectiveness of surgery and other therapies given to the patient; it also allows monitoring for recurrence of ovarian cancer in histologically known cases  

Other Tumor Markers  

  • Include alpha-fetoprotein (AFP) for a suspected yolk sac tumor, human chorionic gonadotropin (hCG) for non-gestational ovarian choriocarcinoma, inhibin for a granulosa cell tumor, and lactate dehydrogenase (LDH) for dysgerminoma  
  • For a pelvic mass that may be a metastasis from a different primary cancer or for bilateral masses with malignant features, the following markers may be requested: Carcinoembryonic antigen (CEA) for a suspected colorectal primary site, CA 19-9 for colorectal and pancreatic primary site, and CA 15-3 for a breast primary site



  • Transvaginal ultrasound (TVS) is the primary imaging modality to evaluate adnexal masses  
    • Has higher image resolution and gives more detailed characterization of pelvic structures and masses
  • Transabdominal ultrasound (TAS) provides overall assessment of organ size and anatomy and may be used if the mass is large or outside the field of view of a TVS  
    • May be used alone if TVS is contraindicated  
  • According to the International Ovarian Tumor Analysis (IOTA) group rules, benign sonographic features of an ovarian mass include a unilocular cyst, presence of solid components with <0.7 cm largest diameter, presence of acoustic shadows, smooth multilocular tumor with <10 cm largest diameter, and absence of blood flow  
    • Malignant masses have solid component with strong central vascularity, ≥4 papillary projections (>3 mm in height), septations which are thick, multiple and irregular, ascites and peritoneal nodularity, and masses with largest diameter >10 cm or multilocular (>10 locules)  
    • Refer to a gynecologic oncologist if a mass is characterized as malignant on ultrasound
  • Further imaging studies [eg computed tomography (CT), positron emission tomography (PET) CT, magnetic resonance imaging (MRI)] may be performed if ultrasound findings cannot adequately characterize the nature and origin of the adnexal mass  
    • MRI is highly sensitive and specific in diagnosing malignancy

Risk of Malignancy Index (RMI)

  • Ultrasound findings together with CA 125 and menopausal status may be used to determine ovarian cancer risk through the RMI  
    • RMI of 25-200 is moderate risk while RMI of >200 warrants a gynecologic oncology referral  
      • A CT scan of the abdomen and pelvis should be done in patients with RMI >200  
  • An alternative to RMI is the IOTA which has comparable specificity and sensitivity


Premenopausal Patient

Significant Pain

  • Rapid onset of acute pain may occur with ectopic pregnancy or adnexal torsion which must be treated surgically
  • Cyst rupture can result in a small amount of intraperitoneal bleeding or hemorrhage which can manifest as generalized abdominal pain or sudden, unilateral, sharp pelvic pain
  • If there are findings suggestive of hemoperitoneum, consider surgical intervention

Ultrasound Evaluation

  • The following require surgical exploration: 
    • Ovarian masses that are persistent, bilateral, solid, fixed, irregular and associated with ascites, cul-de-sac nodules and rapid rate of growth
    • Large cysts (>8 cm) and those with multiloculations, septae, papillae and increased blood flow

Serum CA 125 Measurement

  • Not recommended as routine screening for ovarian cancer in healthy premenopausal women
    • Elevated CA 125 levels have been observed in pregnancy, endometriosis, fibroids, adenomyosis, cystic teratoma and acute or chronic salpingitis   
    • May be measured in premenopausal women if ultrasound findings are suspicious for malignancy

Postmenopausal Patient

  • The incidence of ovarian cancer increases with age and is mostly a disease of postmenopausal women
  • Ovarian cysts in postmenopausal women should be assessed using TVS and CA 125

Ultrasound Evaluation

  • The ovaries become smaller after menopause
    • A postmenopausal ovary that is 2x the size of the contralateral one is suspicious
  • Patients with multilocular bilateral cysts >3-5 cm, who are symptomatic, have elevated CA 125, and have suspicious or persistent non-simple cyst on ultrasound should be investigated further with surgery

Serum CA 125 Measurement

  • Measurement of CA 125 is most useful in risk stratification of postmenopausal women with suspicious pelvic mass observed by ultrasound
    • In these patients, a CA 125 level >65 U/mL has a positive predictive value of 97%
    • Levels <35 U/mL are associated with benign conditions; however, sensitivity and specificity vary
    • A negative serum CA 125 result also does not rule out ovarian cancer
    • Up to 50% of early-stage ovarian cancer and 20-25% of late-stage cancers are found to have normal CA 125

Surgery may be considered if the patient has a strong family history of ovarian, breast, endometrial or colon cancer or if the mass appears to be enlarging

Presurgical Evaluation

  • In addition to history, pelvic exam, ultrasound and serum CA 125, other tumor markers eg AFP, β-hCG and CEA are determined preoperatively
    • Women <40 years old should undergo further testing with AFP, hCG and LDH tumor markers for potential germ cell tumors of the ovary and epithelial ovarian neoplasms
  • If any result points to malignancy, abdominal and pelvic CT scans are requested
  • In patients with CT scan finding showing malignancy, staging laparotomy or chemotherapy is indicated
  • In patients with negative CT scan finding, laparoscopy is planned and consent for possible laparotomy is obtained
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