Ovarian cysts

Investigations:

• For women presenting with ovarian cysts, a thorough clinical assessment including a pelvic and abdominal examination should be performed to identify any palpable masses or ascites. If ascites or a pelvic/abdominal mass is detected (not explained by fibroids), an urgent suspected cancer pathway referral is warranted.
• Measurement of serum CA125 is recommended especially for women aged 18 years and over presenting with symptoms suggestive of ovarian pathology or cancer.
• If serum CA125 is 35 IU/ml or greater, an ultrasound scan of the abdomen and pelvis should be arranged promptly to evaluate the cyst and exclude malignancy.
• In women under 40 with suspected ovarian cancer, additionally measuring alpha fetoprotein (AFP) and beta human chorionic gonadotrophin (beta-hCG) is advised to differentiate non-epithelial ovarian cancers.
• Ultrasound is the primary imaging test; if ovarian cancer is suspected after these investigations, further staging includes CT scanning of the abdomen and pelvis, and sometimes the thorax.

Management options:

• If ovarian cancer is suspected based on ultrasound and CA125 or clinical findings, urgent referral to a specialist multidisciplinary team is essential for further evaluation, tissue diagnosis, and management planning, which may include surgery or chemotherapy.
• In cases where ovarian cysts are benign-appearing and serum CA125 is normal or raised but ultrasound is normal, alternative causes should be explored and patients advised to return if symptoms worsen or persist.
• For benign ovarian cysts without indications of malignancy, conservative management with watchful waiting is often appropriate, especially if symptoms are mild and imaging suggests low risk.
• For women with deep endometriosis-related cysts (endometriomas), specialist pelvic ultrasound or MRI may be considered before any surgical intervention.

Follow-up strategies:

• Women with benign ovarian cysts without alarming features should be advised to monitor symptoms and report new or worsening signs for reassessment.
• For confirmed endometriomas larger than 3 cm or deep endometriosis, outpatient follow-up with or without repeat imaging is recommended.
• Women treated surgically for ovarian cysts or cancer should have individualized follow-up plans according to pathology, treatment, and multidisciplinary team recommendations.

This approach balances early detection of malignancy with avoiding unnecessary interventions in benign cases.

NICE CKS,NICE CKS,NICE CG122,NICE NG73