Guideline: Management of Cystic Ovarian Lesions Imaged with Ultrasound

Reference: Management of Asymptomatic Ovarian and Other Adnexal Cysts Imaged at US:

Society of Radiologists in Ultrasound Consensus, Levine et al., Radiology: Volume 256: Number 3—September 2010, 944-654

Macro name: Guideline ovarian ultrasound

Macro last updated: 6/18/2014

Note: All measurements are based on long axis dimension.

Premenopausal simple </= 5 cm

Based on consensus guidelines, simple cysts measuring 5 cm or less in reproductive age patients require no imaging follow-up (Radiology: Vol 256: Sep 2010, 943-955). 

Note: Thin-walled cysts with a single thin nonvascular septation (<3 mm) or focal mural calcification can be treated as simple cysts.

Premenopausal simple 5-7 cm
Based on consensus guidelines, simple cysts measuring 5-7 cm in reproductive age patients can be followed with yearly ultrasound (Radiology: Vol 256: Sep 2010, 943-955). 

Note: Thin-walled cysts with a single thin nonvascular septation (<3 mm) or focal mural calcification can be treated as simple cysts.

Postmenopausal simple </= 3 cm
Based on consensus guidelines, simple cysts measuring 3 cm or less in postmenopausal patients require no imaging follow-up (Radiology: Vol 256: Sep 2010, 943-955).

Note: Thin-walled cysts with a single thin nonvascular septation (<3 mm) or focal mural calcification can be treated as simple cysts.

Postmenopausal simple 3-7 cm
Based on consensus guidelines, simple cysts measuring 3-7 cm in postmenopausal patients can be followed with yearly ultrasound (Radiology: Vol 256: Sep 2010, 943-955).

Note: Thin-walled cysts with a single thin nonvascular septation (<3 mm) or focal mural calcification can be treated as simple cysts.

Simple > 7 cm
Based on consensus guidelines, cysts measuring greater than 7 cm should be evaluated with pelvic MRI regardless of patient age. Alternatively, surgical consultation may be considered (Radiology: Vol 256: Sep 2010, 943-955).

Premenopausal hemorrhagic </= 5 cm
Based on consensus guidelines, typical hemorrhagic cysts measuring 5 cm or less in reproductive age patients require no imaging follow-up (Radiology: Vol 256: Sep 2010, 943-955).

Premenopausal hemorrhagic > 5 cm
Based on consensus guidelines, hemorrhagic cysts measuring greater than 5 cm in reproductive age patients should be further evaluated with ultrasound in 6-12 weeks to ensure resolution (Radiology: Vol 256: Sep 2010, 943-955).

Postmenopausal hemorrhagic
Based on consensus guidelines, hemorrhagic cysts of any size in postmenopausal patients should be followed with repeat pelvic ultrasound. In late postmenopausal patients, surgical consultation could also be considered (Radiology: Vol 256: Sep 2010, 943-955).

Endometrioma
Based on consensus guidelines, suspected endometriomas should be further evaluated with repeat pelvic ultrasound in 6-12 weeks, then with annual ultrasound if not surgically removed (Radiology: Vol 256: Sep 2010, 943-955).

Dermoid
Based on consensus guidelines, suspected ovarian dermoids should be followed with annual ultrasound to ensure stability, unless surgically removed (Radiology: Vol 256: Sep 2010, 943-955).

Probably benign, hemorrhagic cyst vs. endometrioma vs. dermoid
Based on consensus guidelines, nonspecific cystic ovarian lesions suggestive of but not classic for hemorrhagic cyst, endometrioma or dermoid should be evaluated with repeat ultrasound in 6-12 weeks. If unchanged, hemorrhagic cyst would be unlikely, and continued follow-up with ultrasound or pelvic MRI would be recommended. Surgical consultation could also be considered for lesions that remain uncharacterized, particularly in postmenopausal patients (Radiology: Vol 256: Sep 2010, 943-955).

Complex, possible low-grade neoplasm
Based on consensus guidelines, complex ovarian cysts with multiple thin septations or non-vascular, non-echogenic mural nodules should be further assessed with pelvic MRI. Surgical consultation could also be considered (Radiology: Vol 256: Sep 2010, 943-955).

Complex, suspicious for malignancy
Based on consensus guidelines, suspicious ovarian lesions with thick or irregular septations or vascularized mural nodules should be considered for surgical resection. Pelvic MRI could be considered for further characterization as well, if clinically indicated (Radiology: Vol 256: Sep 2010, 943-955).