Management of Adnexal Cysts

Risk Assessment and Classification

• For a premenopausal woman with a 5.7cm right adnexal cyst, follow-up ultrasound in 8-12 weeks is recommended to confirm if it is functional or to reassess for any wall abnormalities, as recommended by the American College of Radiology 1, 2
• In premenopausal women, cysts >5cm but <10cm require follow-up in 8-12 weeks, ideally during the proliferative phase after menstruation to allow functional cysts to resolve, according to the Radiology guidelines 1, 3
• In postmenopausal women, cysts >3cm but <10cm require at least 1-year follow-up showing stability or decrease in size, with consideration of annual follow-up for up to 5 years if stable, as suggested by the Radiology guidelines 1, 2
• A 5.7cm cyst falls into the O-RADS 2 category (almost certainly benign) if it has simple features (unilocular, anechoic, smooth thin wall, no internal elements), based on the O-RADS system 4, 5
• The risk of malignancy for simple cysts <10cm is extremely low (<1%), according to the Journal of the American College of Radiology 1, 6

Management Algorithm

• For premenopausal women with a simple cyst (5.7cm), follow-up ultrasound in 8-12 weeks is recommended, as suggested by the Radiology guidelines 1, 2
• For postmenopausal women with a simple cyst (5.7cm), follow-up in 1 year, with consideration of annual follow-up for up to 5 years if stable, according to the Radiology guidelines 1, 2
• Complex cysts in both premenopausal and postmenopausal women should be referred to a gynecologist for further evaluation, as recommended by the Journal of the American College of Radiology 5, 6

Important Considerations

• Transvaginal ultrasound is preferred for evaluation, but may be augmented by transabdominal or transrectal approaches as needed, according to the Radiology guidelines 4, 6
• The size of the lesion should be measured by the largest diameter regardless of the plane, as suggested by the Radiology guidelines 4
• In cases of multiple lesions, each should be separately characterized, with management driven by the lesion with the highest O-RADS score, based on the O-RADS system 4

Pitfalls to Avoid

• Failing to perform adequate follow-up for cysts >5cm, as larger cysts may be more challenging to evaluate completely, according to the Radiology guidelines 1, 2
• Unnecessary surgical intervention for simple cysts, as the vast majority are benign even in postmenopausal women, as recommended by the Journal of the American College of Radiology 6
• Overlooking the possibility of functional cysts in premenopausal women, which typically resolve within 8-12 weeks, according to the Radiology guidelines 1, 6

Management of Ovarian Cysts

Risk Stratification and Management

• In premenopausal women, simple cysts <5 cm require no follow-up, while those 5-10 cm should be followed with ultrasound in 8-12 weeks, as recommended by the American College of Radiology 7
• Simple cysts have an extremely low risk of malignancy (<1%) regardless of size, according to the American College of Radiology 7
• Hemorrhagic functional cysts typically decrease or resolve on sonographic follow-up in 8-12 weeks, as stated by the American College of Radiology 7
• The risk of malignancy in benign-appearing lesions managed conservatively is approximately 0.3-0.4%, as reported by the American College of Radiology 7
• Endometriomas require yearly follow-up due to a small risk of malignant transformation, as recommended by the American College of Radiology 7
• Dermoids, if not surgically removed, can be safely followed with yearly ultrasound, according to the American College of Radiology 7
• The Ovarian-Adnexal Reporting and Data System (O-RADS) should be used to classify the cyst and determine malignancy risk, as suggested by the Radiology society 8
• Transvaginal ultrasound with color or power Doppler should be performed to evaluate vascularity of any solid components, as recommended by the American College of Radiology and Radiology society 7, 8
• Ultrasound is the first-line imaging modality for characterization and follow-up of ovarian cysts, as stated by the American College of Radiology and Radiology society 7, 8
• The risk of acute complications such as torsion or cyst rupture in benign-appearing lesions is approximately 0.2-0.4%, as reported by the American College of Radiology 7