Ovarian cysts/masses management

In premenopausal women the majority of ovarian cysts are benign. The incidence of malignancy in asymptomatic ovarian cysts in premenopausal women is 1:1000. Simple ovarian cysts measuring less than 5cm maximum diameter typically resolve over 2-3 menstrual cycles without intervention.

Ovarian cysts are also common in postmenopausal women (estimated 5 - 17% prevalence). The incidence of malignancy in ovarian masses in post menopausal women (over 50 years old) is 3:1000.

The RCOG advocates for the use of conservative management where appropriate (particularly in premenopausal women). In cases where surgical management is required, the use of laparoscopic techniques is recommended. In suspected malignancy or borderline masses, timely referral to Gynaecology Oncology is suggested.

Ovarian cysts and cancers often present with vague abdominal symptoms. Common presenting symptoms of ovarian masses include: persistent abdominal distension / sensation of fullness, change in appetite, pelvic / abdominal pain and increased urinary urgency or frequency.

Ovarian cysts should be considered in any postmenopausal woman who has developed symptoms of irritable bowel syndrome in the last 12 months (in particular those over 50 with significant family history of ovarian / bowel / breast cancer).

In premenopausal women, symptoms suggestive of endometriosis should be considered to exclude possible endometrioma.

In cases of presentation with acute onset pain, consider differentials of torsion, rupture or haemorrhage (see below for management of suspected ovarian torsion)

A thorough history including risk factors for ovarian malignancy should be taken. Risk factors for ovarian malignancy - postmenopausal, obesity, smoking (increases risk of mucinous cancers), nulliparous / older age at first pregnancy, HRT, family history of ovarian, breast, or colorectal cancer.

Physical examination should include abdominal examination including presence of groin node lymphadenopathy, bimanual examination and speculum examination including high vaginal swabs and STI screen in sexually active patients. In cases where palpable abdominal mass is found on examination, assess for mobility and presence of ascites.

Blood tests:

- Premenopausal women:

CA 125 - should be undertaken in all premenopausal women with finding of a complex ovarian mass. CA 125 should not be performed in premenopausal women where the USS findings are of a simple ovarian cyst.

Other tumour markers - LDH, a-FP (alpha fetoprotein) and HCG should be measured in all premenopausal women with complex masses to help with the diagnosis of germ cell tumours.

Alternative causes of raised CA 125 in premenopausal women includes fibroids, endometriosis, adenomyosis and pelvic infections. CA 125 may also be raised without an identifiable cause.

- Postmenopausal women:

All post menopausal women with any finding of ovarian mass (even if the mass appears simple on ultrasound scanning) should have CA 125 performed.

In post menopausal women, CA 125 should be used in conjunction with ultrasound scan findings to calculate RMI (risk malignancy index).

Calculating RMI (as required for submission of MDM form):

RMI combines three pre-surgical features: serum CA125, menopausal status (M) and ultrasound score (U)

RMI = U x M x CA 125.

The ultrasound result is scored 1 point for each of the following features:

• Multilocular cyst
• Solid areas
• Metastases
• Ascites
• Bilateral lesions

U = 0 for ultrasound score of 0
U = 1 for ultrasound score of 1
U = 3 for ultrasound score of 2-5

Menopausal status is scored as 1 = premenopausal, 3 = postmenopausal.

Postmenopausal is classified as any women with no period for > 12 months or a woman over 50 who has had a hysterectomy.

An RMI score of >200 is recommended to predict likelihood of ovarian cancer (sensitivity 78%, specificity 87%)

Imaging:

All women with suspected ovarian masses should be offered trans-vaginal ultrasound scanning at time of first presentation.

Where trans-vaginal ultrasound scanning is declined by the patient or not possible, trans abdominal ultrasound scanning may be performed however this has reduced sensitivity in detecting malignant features.

See Appendix 2 for Management Guidelines for Ultrasound Scan Findings of Ovarian Cyst.

South-East Scotland Gynaecology Oncology MDM takes place on Thursday mornings. All MDM forms should be submitted by the preceding Friday at 5pm for consideration at the next meeting. See Appendix 1 for current MDM form and contact details. All forms should be emailed to the Gynaecology secretaries in the first instance (rather than direct submission to MDM).

Where ovarian malignancy is suspected (ultrasound scan features of malignant disease or RMI score >200) CT chest / abdo / pelvis and MRI abdomen / pelvis should be considered for full staging.

See Appendix 2 for updated guidelines for management of ultrasound scan findings.

- Premenopausal women:

Premenopausal women with small (less than 5cm) simple ovarian cysts do not require routine follow up. These are usually physiological and will typically resolve within 3 menstrual cycles.

Premenopausal women with 5-7cm sized simple ovarian cysts should be offered routine interval ultrasound scan follow up (3-6 monthly) to monitor cyst size and resolution.

Premenopausal women with a cyst >7cm should be considered for surgical management due to risk of ovarian torsion.

Ovarian cysts which persist or increase in size are unlikely to be physiological and may require surgical management.

RCOG advocates for laparoscopic management of ovarian cysts where possible, although acknowledges this is dependent on patient wishes / BMI / size and nature of the cyst.

Aspiration of ovarian cysts is associated with greater incidence of recurrence (53-83% reoccurrence rate in laparoscopic aspiration).

All women should be consented for possibility of requiring oophorectomy.

- Postmenopausal women:

Asymptomatic, simple, unilateral, unilocular ovarian cysts, less than 5cm in diameter with normal CA 125 have a low risk of malignancy. These cysts should be managed conservatively with routine interval scanning 3-6 monthly.

RCOG recommends that it is reasonable to discharge the patient if the cyst remains unchanged or reduces in size after 1 year.

Any symptomatic or suspicious / persistent complex adnexal mass in postmenopausal woman should be considered for surgical management.

Aspiration should not be used to manage ovarian cysts in post menopausal women other than to offer symptom control in advanced malignancy.

All postmenopausal women should be offered bilateral salpingo-oophorectomy at time of surgery.

Optimal surgical management of post menopausal women suspicious of malignancy should be discussed by the regional Gynaecology Oncology MDM, with a view to procedure undertaken (full staging procedure vs. pelvic clearance), timing and location of surgery and surgeon.

Where a borderline ovarian tumour is suspected or diagnosed at histology, referral to Gynaecology Oncology is recommended. Although 20% of borderline ovarian cysts appear to be simple on ultrasound, the majority will have malignant / suspicious feature on imaging.

Ovarian cysts can be found in up to 5% of pregnancies but are rarely malignant. Rates of ovarian torsion are 1-3%. The risk of torsion reduces with increasing gestation (unusual after 20 weeks). Most adnexal masses in pregnancy will resolve spontaneously or can be managed conservatively during pregnancy.

MRI scanning may be useful in second and third trimesters of pregnancy in diagnosing abdominal pain where the ovaries / appendix are more difficult to image via ultrasound scan.

CA 125 is not valid in pregnancy where borderline elevation (upper levels 100u/ml) may be normal.

Surgery in pregnancy should only be performed in cases of acute abdomen or high suspicion for malignancy.

Common causes of adnexal masses in pregnancy:

• Corpus luteum cyst - Usually spontaneously resolve by 8th week of pregnancy. Surgical resection may result in miscarriage.
• Follicular cyst - Usually measure 2.5-6cm simple cyst, tend to resolve spontaneously by 16 weeks gestation.
• Haemorrhagic cyst - May present with acute onset abdominal pain, resolving over several days. Can be managed conservatively.

In non-typical presentations, consider the possibility of luteoma’s of pregnancy, heterotopic pregnancy, dermoid cyst, malignant germ cell tumours and acute PID.

Management of simple ovarian cysts of less than 5cm in pregnancy should be conservative and no follow up is required. For cysts >5cm, a follow up ultrasound should be offered after 6 weeks gestation. If unchanged on repeat scan, gynaecology follow up should be arranged post partum. Where intervention is required due to symptoms, this should be delayed until 14-16 weeks gestation where possible.

Malignant ovarian lesions in pregnancy are usually borderline or early stage disease with good prognosis. MRI chest / abdo / pelvis is considered gold-standard for imaging suspected malignant lesions. Management should be decided by regional Gynaecology Oncology MDT.

Ovarian torsion is a clinical emergency and requires rapid diagnosis and intervention to save ovarian function. It is most commonly seen in women of reproductive age (20-40) but can occur in pregnancy and post menopausal women.

Presentation:

Women may present with symptoms to A+E, directly to Gynaecology or via referral from other specialties ie. General Surgery.

Ovarian torsion usually presents with abdominal / pelvic pain, nausea and vomiting, although symptoms may be non-specific. Pain often radiates to the loin or thigh. History taking may reveal similar episodic symptoms in the preceding months (representing the ovarian cyst torting and untorting).

In premenopausal patients, consider chronic symptoms of endometriosis which may be suggestive of endometrioma torsion (although this is uncommon due to pelvic adhesions).

Fibroid degeneration rarely causes pain outside pregnancy, but torsion of pedunculated fibroids should be considered in women with known fibroids.

Other differential diagnoses include PID, ovarian cyst haemorrhage, appendicitis and renal colic.

Women with suspected ovarian torsion should be admitted to Acute Gynaecology for analgesia and investigation. IV access should be secured. Women should be kept ‘nil by mouth’ during investigations pending possible surgical management.

Registrars should be called to assess a patient promptly if ovarian torsion is suspected. Early Consultant involvement in recommended.

Examination:

A full abdominal and pelvic examination including bimanual examination and speculum examination with high vaginal swabs (and STI screening in sexually active patients) should be performed.

Symptoms may be accompanied by pyrexia, tachycardia and abdominal rebound / guarding. On examination a palpable mass may be present. Cervical motion tenderness is common.

Investigations:

Blood tests: Full blood count, U+E’s, LFT’s, CRP.
Note - WCC and CRP are only raised in 50% of women presenting with ovarian torsion.
Urine dip including urinary HCG
Urgent transvaginal / transabdominal ultrasound scan with doppler - Note, management should not be delayed due to lack of out of hours scanning availability. Where ovarian torsion is suspected, the On-Call consultant should be contacted directly to perform a bedside ultrasound scan.

A normal ultrasound scan does not exclude all possible adnexal torsion, and decision to operate may be based on clinical grounds if symptoms are severe. CT or MRI may be useful in diagnosing adnexal torsion.

Management:

Definitive management of ovarian torsion is surgical, usually involving oophorectomy / salpingo-oophorectomy.

Surgical management of acute ovarian torsion should not be delayed and should be performed on CEPOD surgical list in the next appropriate space.

Intraoperative appearances of torsion do not correlate well with likelihood of ovarian recovery. The likelihood of preserving ovarian function with conservative management decreases over time. Greater than 48 hours since onset of symptoms is associated with poor outcomes for ovarian function.

Laparoscopic approaches reduce admission time, post operative pain and risk of adhesions in long term recovery.

Gynaecology Oncology MDM form: PDF

Please email to BGH Gynaecology secretaries Elaine Wight
(elaine.wight@borders.scot.nhs.uk) or Anne Renfrew
(anne.renfrew@borders.scot.nhs.uk) in the first instance.

Forms will then be forwarded to Gynaecology MDM

Premenopausal:

Unilocular cysts:

If < 5cms - Report as normal follicle.
If 5 - 7cms - Routine interval scan 3-6 monthly. If unchanged or smaller after 12 months discharge.
If > 7cms - Recommend non-urgent referral to gynaecology

Complex cysts: (ie thick septation, mural nodules, irregular wall thickening, echogenic components, solid):

If < 3cms - Recheck in 3 months. If unchanged or smaller, discharge
If > 3cms - Recommend non-urgent referral to gynaecologist

Post-menopausal:

Unilocular cysts:

If < 5cms - Check CA125. Routine interval scanning 3-6 monthly. If unchanged or smaller after 12 months discharge. Otherwise suggest referral to gynaecology.

If > 5cms - Referral to gynaecology and check CA125

Complex cysts: (ie. thick septation, mural nodules, irregular wall thickening, echogenic components, solid):

All Complex cysts should have CA 125 checked and referral to gynaecology for ongoing follow up.

For any suspicious lesions comment on the presence of ascites, liver mets, peritoneal metastases, hydronephrosis, pleural effusions and appearance of contralateral ovary.