Ovarian cyst

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Ovarian cysts are commonly encountered in gynaecological imaging, and vary widely in aetiology, from physiologic, to complex benign, to neoplastic.

Pathology

Small cystic ovarian structures should be considered normal ovarian follicles unless the patient is pre-pubertal, post-menopausal, pregnant, or the mean diameter is >3 cm (see the 1-2-3 rule).

Types of cysts

physiological cysts: mean diameter ≤3 cm
- ovarian follicle
- corpus luteum
functional cysts (can produce hormones):
- follicular cysts of the ovary (oestrogen): >3 cm
- corpus luteum cysts (progesterone)
- theca lutein cyst: gestational trophoblastic disease
- complications in functional cysts:
  - haemorrhagic ovarian cyst
  - enlargement
  - rupture
  - torsion
other cysts:
- multiple large ovarian cysts in ovarian hyperstimulation syndrome
- postmenopausal cyst: serous inclusion cysts of the ovary
- polycystic ovaries
- ovarian torsion
- ovarian cystic neoplasm

Radiographic features

Ultrasound is usually the first imaging modality for assessment of ovarian lesions.

Imaging features of simple ovarian ~~follicular~~ cysts:

anechoic
intraovarian or exophytic
imperceptible wall
posterior acoustic enhancement: may not be as obvious with harmonic or compound imaging
visible far wall

A cyst may become large enough to obscure the ovary from which it is arising.

Radiology report

The Society of Radiologists in Ultrasound made in 2019 the following recommendations regarding reporting of simple adnexal cysts of suspected ovarian origin based on size and menopausal status ²:

premenopausal women
- ≤3 cm: no need to report; if described, consider calling a "follicle" rather than a "cyst" to reduce patient anxiety
  - impression: normal ovaries/adnexa
  - recommendation: no follow-up
- >3 to ≤5 cm: report presence of simple cyst(s) and largest cyst diameter
  - impression: benign finding in the physiologic size range
  - recommendation: no follow-up
- >5 cm: report with all cyst diameters
  - impression: benign simple cyst
  - recommendation:
    - >5 to ≤7 cm: follow-up either in 2-6 months for resolution/re-characterization or in 6-12 months for growth rate assessment, but no follow up is needed if the cyst is exceptionally well-visualized/characterized and documented with confidence by the imager
    - >7 cm: follow-up either in 2-6 months for resolution/re-characterization or in 6-12 months for growth rate assessment
- follow-up of cyst (previously >5 cm): describe in report with all cyst diameters if not resolved
  - decreased in size
    - impression: benign inconsequential finding; decrease in size excludes neoplasm
    - recommendation: no further follow-up needed
  - similar in size
    - impression: benign simple cyst with stability over ≥12 months, most likely nonneoplastic or very slow growing benign neoplasm
    - recommendation: follow-up at 2 years from initial study to document stability and understand growth rate
  - increased in size
    - impression: enlarging simple cyst, most likely a benign neoplasm
    - recommendation: follow-up in 1 year to evaluate any further changes in size
postmenopausal women
- ≤1 cm: no need to report
  - impression: normal ovaries/adnexa
  - recommendation: no follow-up
- >1 to ≤3 cm: report presence of simple cyst(s) and largest cyst diameter
  - impression: benign inconsequential finding
  - recommendation: no follow-up
- >3 cm: report with all cyst diameters
  - impression: benign simple cyst
  - recommendation:
    - >3 to ≤5 cm: follow-up either in 3-6 months for resolution/re-characterization or in 6-12 months for growth rate assessment, but no follow up is needed if the cyst is exceptionally well-visualized/characterized and documented with confidence by the imager
    - >5 cm: follow-up either in 3-6 months for resolution/re-characterization or in 6-12 months for growth rate assessment
- follow-up of cyst (previously >3 cm): describe in report with all largest cyst diameters if not resolved
  - decreased in size
    - impression: benign simple cyst; decrease in size excludes neoplasm
    - recommendation: no further follow-up needed
  - similar in size
    - impression: benign simple cyst
    - recommendation: follow-up at 2 years from initial study to document stability
  - increased in size
    - impression: enlarging simple cyst, most likely a benign neoplasm
    - recommendation: follow-up in 1 year to evaluate any further changes in size

Note that these guidelines do not apply to haemorrhagic ovarian cysts.

Treatment and prognosis

large (>3 cm) or symptomatic cysts may undergo surgical resection
smaller asymptomatic cysts are treated conservatively
risk of malignancy in septated ovarian cysts with no papillary projections or solid components are also considered low and are usually followed up on ultrasound ^5,6

~~Follow-up guidelines~~

~~As of late 2017, the most widely used guidelines is the 2010 consensus statement by the Society of Radiologists in Ultrasound~~ ²~~. For simple ovarian cysts with no suspicious features on ultrasound, current follow-up guidelines are based on menopausal status and cyst size:~~

~~In women of reproductive age~~

~~≤3 cm~~

~~normal physiologic finding; at the discretion of the interpreting radiologist whether or not to describe them in the imaging report~~

~~do not need follow-up~~

~~>3 and ≤5 cm~~

~~should be described in the imaging report with a statement that they are almost certainly benign~~

~~do not need follow-up~~

~~>5 and ≤7 cm~~

~~should be described in the imaging report with a statement that they are almost certainly benign~~

~~increased risk of ovarian torsion~~ ⁴

~~yearly follow-up with ultrasound recommended~~

~~>7 cm~~
~~may be difficult to assess completely with ultrasound and further imaging with MR or surgical evaluation should be considered~~

~~In post-menopausal women~~

~~≤1 cm~~

~~are clinically inconsequential; at the discretion of the interpreting radiologist whether or not to describe them in the imaging report~~

~~do not need follow-up~~

~~>1 and ≤3 cm~~

~~should be described in the imaging report with a statement that they are almost certainly benign~~

~~yearly follow-up, at least initially, with ultrasound recommended~~

some practices may opt to increase the lower size threshold for follow-up from 1 cm to as high as 3 cm, as stated in the "Simple Adnexal Cysts: SRU Consensus Conference Update on Follow-up and Reporting"⁷

~~one may opt to continue follow-up annually or to decrease the frequency of follow-up once stability or decrease in size has been confirmed~~

~~cysts in the larger end of this range should still generally be followed on a regular basis~~

~~>7 cm~~
~~since these may be difficult to assess completely with ultrasound, further imaging with MRI or surgical evaluation should be considered~~

~~Haemorrhagic ovarian cysts~~ ~~have a different follow-up schedule than simple cysts.~~

~~-</ul><h4>Radiographic features</h4><p>Ultrasound is usually the first imaging modality for assessment of ovarian lesions.</p><p>Imaging features of simple ovarian follicular cysts:</p><ul>~~
+</ul><h4>Radiographic features</h4><p>Ultrasound is usually the first imaging modality for assessment of ovarian lesions.</p><p>Imaging features of simple ovarian cysts:</p><ul>
-<a title="Posterior acoustic enhancement" href="/articles/acoustic-enhancement">posterior acoustic enhancement</a>: may not be as obvious with <a href="/articles/harmonic-imaging">harmonic</a> or compound imaging</li>
+<a href="/articles/acoustic-enhancement">posterior acoustic enhancement</a>: may not be as obvious with <a href="/articles/harmonic-imaging">harmonic</a> or compound imaging</li>
~~-</ul><p>A cyst may become large enough to obscure the ovary from which it is arising.</p><h4>Treatment and prognosis</h4><ul>~~
~~-<li>large (>3 cm) or symptomatic cysts may undergo surgical resection</li>~~
~~-<li>smaller asymptomatic cysts are treated conservatively</li>~~
-<li>risk of malignancy in <a href="/articles/septated-ovarian-cysts">septated ovarian cysts</a> with no papillary projections or solid components are also considered low and are usually followed up on ultrasound <sup>5,6</sup>
+</ul><p>A cyst may become large enough to obscure the ovary from which it is arising.</p><h4>Radiology report</h4><p>The Society of Radiologists in Ultrasound made in 2019 the following recommendations regarding reporting of simple adnexal cysts of suspected ovarian origin based on size and menopausal status <sup>2</sup>:</p><ul>
+<li>premenopausal women<ul>
+<li>≤3 cm: no need to report; if described, consider calling a "follicle" rather than a "cyst" to reduce patient anxiety<ul>
+<li>impression: normal ovaries/adnexa</li>
+<li>recommendation: no follow-up</li>
+</ul>
+</li>
+<li>>3 to ≤5 cm: report presence of simple cyst(s) and largest cyst diameter<ul>
+<li>impression: benign finding in the physiologic size range</li>
+<li>recommendation: no follow-up</li>
+</ul>
+</li>
+<li>>5 cm: report with all cyst diameters<ul>
+<li>impression: benign simple cyst</li>
+<li>recommendation:<ul>
+<li>>5 to ≤7 cm: follow-up either in 2-6 months for resolution/re-characterization or in 6-12 months for growth rate assessment, but no follow up is needed if the cyst is exceptionally well-visualized/characterized and documented with confidence by the imager</li>
+<li>>7 cm: follow-up either in 2-6 months for resolution/re-characterization or in 6-12 months for growth rate assessment</li>
+</ul>
+</li>
+</ul>
+</li>
+<li>follow-up of cyst (previously >5 cm): describe in report with all cyst diameters if not resolved<ul>
+<li>decreased in size<ul>
+<li>impression: benign inconsequential finding; decrease in size excludes neoplasm</li>
+<li>recommendation: no further follow-up needed</li>
+</ul>
+</li>
+<li>similar in size<ul>
+<li>impression: benign simple cyst with stability over ≥12 months, most likely nonneoplastic or very slow growing benign neoplasm</li>
+<li>recommendation: follow-up at 2 years from initial study to document stability and understand growth rate</li>
+</ul>
-</ul><h5>Follow-up guidelines</h5><p>As of late 2017, the most widely used guidelines is the 2010 consensus statement by the Society of Radiologists in Ultrasound <sup>2</sup>. For simple ovarian cysts with no suspicious features on ultrasound, current follow-up guidelines are based on menopausal status and cyst size:</p><h6>In women of reproductive age</h6><ul>
~~-<li>≤3 cm<ul>~~
~~-<li>normal physiologic finding; at the discretion of the interpreting radiologist whether or not to describe them in the imaging report</li>~~
~~-<li>do not need follow-up</li>~~
+<li>increased in size<ul>
+<li>impression: enlarging simple cyst, most likely a benign neoplasm</li>
+<li>recommendation: follow-up in 1 year to evaluate any further changes in size</li>
~~-<li>>3 and ≤5 cm<ul>~~
~~-<li>should be described in the imaging report with a statement that they are almost certainly benign</li>~~
~~-<li>do not need follow-up</li>~~
~~-<li>>5 and ≤7 cm<ul>~~
~~-<li>should be described in the imaging report with a statement that they are almost certainly benign</li>~~
~~-<li>increased risk of ovarian torsion <sup>4</sup>~~
+</ul>
+</li>
+<li>postmenopausal women<ul>
+<li>≤1 cm: no need to report<ul>
+<li>impression: normal ovaries/adnexa</li>
+<li>recommendation: no follow-up</li>
+</ul>
+</li>
+<li>>1 to ≤3 cm: report presence of simple cyst(s) and largest cyst diameter<ul>
+<li>impression: benign inconsequential finding</li>
+<li>recommendation: no follow-up</li>
+</ul>
+</li>
+<li>>3 cm: report with all cyst diameters<ul>
+<li>impression: benign simple cyst</li>
+<li>recommendation:<ul>
+<li>>3 to ≤5 cm: follow-up either in 3-6 months for resolution/re-characterization or in 6-12 months for growth rate assessment, but no follow up is needed if the cyst is exceptionally well-visualized/characterized and documented with confidence by the imager</li>
+<li>>5 cm: follow-up either in 3-6 months for resolution/re-characterization or in 6-12 months for growth rate assessment</li>
+</ul>
~~-<li>yearly follow-up with ultrasound recommended</li>~~
~~-<li>>7 cm<ul><li>may be difficult to assess completely with ultrasound and further imaging with MR or surgical evaluation should be considered</li></ul>~~
+<li>follow-up of cyst (previously >3 cm): describe in report with all largest cyst diameters if not resolved<ul>
+<li>decreased in size<ul>
+<li>impression: benign simple cyst; decrease in size excludes neoplasm</li>
+<li>recommendation: no further follow-up needed</li>
+</ul>
+</li>
+<li>similar in size<ul>
+<li>impression: benign simple cyst</li>
+<li>recommendation: follow-up at 2 years from initial study to document stability</li>
+</ul>
~~-</ul><h6>In post-menopausal women</h6><ul>~~
~~-<li>≤1 cm<ul>~~
~~-<li>are clinically inconsequential; at the discretion of the interpreting radiologist whether or not to describe them in the imaging report</li>~~
~~-<li>do not need follow-up</li>~~
+<li>increased in size<ul>
+<li>impression: enlarging simple cyst, most likely a benign neoplasm</li>
+<li>recommendation: follow-up in 1 year to evaluate any further changes in size</li>
~~-<li>>1 and ≤3 cm<ul>~~
~~-<li>should be described in the imaging report with a statement that they are almost certainly benign</li>~~
~~-<li>yearly follow-up, at least initially, with ultrasound recommended</li>~~
-<li>some practices may opt to increase the lower size threshold for follow-up from 1 cm to as high as 3 cm, as stated in the "Simple Adnexal Cysts: SRU Consensus Conference Update on Follow-up and Reporting"<sup>7</sup>
+</ul>
~~-<li>one may opt to continue follow-up annually or to decrease the frequency of follow-up once stability or decrease in size has been confirmed</li>~~
~~-<li>cysts in the larger end of this range should still generally be followed on a regular basis</li>~~
~~-<li>>7 cm<ul><li>since these may be difficult to assess completely with ultrasound, further imaging with MRI or surgical evaluation should be considered</li></ul>~~
+</ul><p>Note that these guidelines do not apply to <a href="/articles/haemorrhagic-ovarian-cyst">haemorrhagic ovarian cysts</a>.</p><h4>Treatment and prognosis</h4><ul>
+<li>large (>3 cm) or symptomatic cysts may undergo surgical resection</li>
+<li>smaller asymptomatic cysts are treated conservatively</li>
+<li>risk of malignancy in <a href="/articles/septated-ovarian-cysts">septated ovarian cysts</a> with no papillary projections or solid components are also considered low and are usually followed up on ultrasound <sup>5,6</sup>
~~-</ul><p><a href="/articles/haemorrhagic-ovarian-cyst">Haemorrhagic ovarian cysts</a> have a different follow-up schedule than simple cysts.</p><h4>See also</h4><ul>~~
+</ul><h4>See also</h4><ul>

References changed:

2. Levine D, Patel MD, Suh-Burgmann EJ, Andreotti RF, Benacerraf BR, Benson CB, Brewster WR, Coleman BG, Doubilet PM, Goldstein SR, Hamper UM, Hecht JL, Horrow MM, Hur HC, Marnach ML, Pavlik E, Platt LD, Puscheck E, Smith-Bindman R, Brown DL. Simple Adnexal Cysts: SRU Consensus Conference Update on Follow-up and Reporting. (2019) Radiology. 293 (2): 359-371. <a href="https://doi.org/10.1148/radiol.2019191354">doi:10.1148/radiol.2019191354</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/31549945">Pubmed</a> <span class="ref_v4"></span>
2. Levine D, Brown DL, Andreotti RF et-al. Management of asymptomatic ovarian and other adnexal cysts imaged at US: Society of Radiologists in Ultrasound Consensus Conference Statement. Radiology. 2010;256 (3): 943-54. <a href="http://dx.doi.org/10.1148/radiol.10100213">doi:10.1148/radiol.10100213</a> - <a href="http://www.ncbi.nlm.nih.gov/pubmed/20505067">Pubmed citation</a><div class="ref_v2"></div>

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