Management of Ovarian Cysts in Adolescents

Initial Assessment and Risk Stratification

The American College of Radiology recommends that simple cysts ≤3 cm are considered physiologic and require no additional management in premenopausal women 1
Simple cysts >3 cm but ≤5 cm require no further management in premenopausal women, according to the American College of Radiology 1
The ultrasound report should specify whether the cyst is simple or complex, with characteristics such as septations, solid components, wall irregularity, or vascularity, as recommended by the American College of Radiology 2, 1

Most ovarian cysts in premenopausal women, including adolescents, are functional in nature and resolve spontaneously, with 98.7% of simple cysts being benign, according to the American College of Radiology 2
The risk of malignancy in unilocular cysts in premenopausal women is only 0.5-0.6%, as reported by the American College of Radiology 1
No simple cysts were diagnosed as cancer in women under 50 years among 12,957 cysts, according to the American College of Radiology 1

If a simple cyst is ≤5 cm, no follow-up imaging is needed, and the patient can be reassured that this is a normal physiologic finding, as recommended by the American College of Radiology 1
If a simple cyst is >5 cm but <10 cm, follow-up ultrasound at 8-12 weeks is recommended to confirm functional nature or assess for cyst wall abnormalities, according to the American College of Radiology 1
Surgical management is indicated for cysts ≥10 cm, regardless of other features, as recommended by the American College of Radiology 3

The American College of Radiology recommends avoiding premature surgery on simple cysts <10 cm without an appropriate observation period, as the risk of malignancy is extraordinarily low, and most will resolve spontaneously 1
The American College of Radiology also recommends not assuming persistent cysts are pathological, as many benign neoplasms can be safely followed, with a risk of malignancy in classic benign-appearing lesions managed conservatively being <1% 1
Tumor markers like CA-125 should not be ordered in adolescents with simple cysts, as they are not indicated for benign-appearing functional cysts in premenopausal women, according to the American College of Radiology 1

The American College of Radiology recommends explaining that ovarian cysts are extremely common in menstruating girls and women, with about 7% of women having an ovarian cyst at some point in their lives, and that the vast majority are physiologic, related to normal ovarian function, and resolve without treatment 3

The presence of complex features such as septations, solid components/nodules, wall irregularity, or internal vascularity, which would change the risk stratification, should be documented, as per Radiology guidelines 4
O-RADS classification, a standardized system that guides management, should be used if available, with O-RADS 2 (almost certainly benign, <1% malignancy risk) requiring no follow-up or surveillance only, while O-RADS 3-5 require escalating levels of specialist involvement, as per Radiology guidelines 4