Objective: To evaluate and follow up the native behaviour of large
ovarian cysts in postmenopausal women and establish the best approach based on
advanced imaging technology. Study Design: The number of patients that
were evaluated from January 2015 to September 2019 were 417. At the end of this
study period, 375 patients were considered for this prospective evaluation. The
patients with an ultrasound diagnosis of unilateral and unilocular ovarian cysts
with regular septa
We know that 85% of the ovarian malignancies are diagnosed at postmenopausal period . Thus, postmenopausal ovarian cysts are particularly associated with the risk of unnecessary surgery due to malignancy concerns. The majority of ovarian cysts, without absolute malignancy characteristics, such as solid areas, papillary structures or thick irregular septation, in postmenopausal women are benign. Ultimate improvement in imaging system and based on use of highly resolution transvaginal ultrasonography in gynaecological examinatıon have raised the sensitivity and specificity of adnexal cysts in asymptomatic postmenopausal women .
Worldwide prevalence of simple ovarian cysts in postmenopausal women may range
from 3% to 15% . About 7% of women have ovarian cysts at some age during
their lives . Actually, the probability of unilocular ovarian cysts being
malignant is regarded very low and it has been recommended that unilocular cysts
It is very clear that particular ultrasound images of ovarian cysts, such as papillary projections, solid areas or thick irregular septation are more evident clues for surgical approach. The aim of this study was to evaluate the value of long-term follow-ups; in the management of unilateral and uniocular large ovarian cysts without absolute malignancy or morphological change and observe the natural progress of these cysts in postmenopausal women.
This research was undertaken in the Department of Obstetrics and Gynaecology of Medicana-Atılım University Hospital, Ankara, Turkey.
All participants provided informed consent and the study was approved by
ethical committee of the hospital. The women who had a cessation of menstruation of
12 sequential months or more in women
All sonographic examinations were performed by two obstetrics and gynaecology specialists on GE Volusion 730 Pro and Volusion E 8 ultrasound machines were equipped with an IC5-9, RIC5-9 and 4-9 MHz endovaginal probes respectively along with colour and spectral Doppler capabilities. The scoring system of uniocular simple cysts were defined by following ultrasonographic morphologic criteria of International Ovarian Tumour Analysis (IOTA) group .
To evaluate each ovarian cyst atransvaginal ultrasound was performed for
dimension and ovarian morphology. After collecting all the dates
regarding the distribution of the diameter of the cysts, we proceeded to
categorize the cysts randomLy into three groups; 10–12.9 cm, 13–15.9 cm and
The patients who had ovarian cysts diagnosed by ultrasonography, CA-125 levels
were measured while CA-125 levels
The cysts, which did not develop significant morphological changes, underwent
conservative monitoring by ultrasonography. During the follow-up examinations,
dimensions and morphology of the ovarian cysts were scored and saved.
During the follow-ups, some of the patients with
Four hundred and seventeen (417) cases simple ovarian cyst cases were diagnosed with tranvaginal ultrasound and enrolled in this study. During the follow-ups 42 patients who presented significant change in cyst morphology, abnormal MRI findings or elevated CA-125, levels were referred for surgery.
During the follow up exams, forty-two patients underwent surgery but no malignancy was observed in this group. In the surgery group the mean age of the patients was 68 years ranging from 63 to 79 years. The reason for patients who underwent surgery included solid areas or papillary projections in the cysts in twenty-nine patients (69%), irregular septal formation or progressing from simple cyst to complex cyst in six patients (14.2%), raising in CA-125 in four patients (9.5%) and abnormal MRI findings in three patients (7.1%). In the surgery group, serous cystadenoma was the most common pathology, which were 30 out of 42 cysts (71.4%). The other cases were reported as mucinous cystadenoma, endometrioma, follicular cyst, dermoid cyst, inclusion cyst and cyst adenofibroma respectively. In both endometrioma and dermoid cyst cases, most of the component of these cysts were serous cystadenoma but in addition to that, a small dermoid and endometrioma component were also detected in these cysts (Table 1).
|-Age||Mean: 68 range: 63–79|
|-Parity||Mean: 3 range: 3–7|
|Indication for surgery|
|-Morphological change||29 (69)|
|-Irregular septal formation|
|or progressing to complex cyst||6 (14.2)|
|-Increase CA-125 level||4 (9.5)|
|-Abnormal MR findings||3 (7.1)|
|-Serous cystadenoma||30 (71.4)|
|-Mucinous cystadenoma||5 (11.9)|
|-Follicular cyst||2 (4.7)|
|-Dermoid cyst||1 (2.3)|
|-Inclusion cyst||1 (2.3)|
375 patients underwent follow-up study. In the follow-up study group, the mean
age was 62 years with range of 45–74. Out of 375 cysts one hundred eleven
(29.6%) of the cysts had spontaneous resolution. Within the spontaneous
resolution group in 34 patients, we detected a small amount of free fluid in the
Douglas that could be the sign of cyst rupture before resolution of the cysts.
None of these patients was hospitalized during their follow-ups. One hundred
twenty-five (33.3%) cysts significantly decreased in size and one hundred
thirty-nine (37%) cysts were persistently unchanged over the follow up period.
The mean cyst diameter was 15.4 cm (range 10.4 and 18.4 cm). The cysts were
categorized into three groups according to their diameters; 10–12.9 cm in 233
patients (62%), 13–15.9 cm in 90 patients (24.1%) and
|-Total number of the patients||417|
|-Number of patients excluded from the study||42|
|and underwent for surgery|
|-Number of patients underwent follow-up study||375|
|-Age (years)||Mean: 62 range: 45–74|
|-Parity||Mean: 4 range: 2–8|
|10–12.9 cm||233 (62.1)|
|13–15.9 cm||90 (24.1)|
|≥ 16 cm||52 (13.8)|
|Spontaneous resolution||111 (29.6)|
|Decrease in size||125 (33.3)|
Spontaneous resolution rate was high in cysts with diameter 10–12.9 cm where as
significant decrease in size was observed in
|Cyst behaviour||Cyst diameter|
|10–12.9 cm||13–15.9 cm||16 |
|-Spontaneous resolution||75 (67.5)||25 (22.5)||11 (9.9)|
|-Decrease in size||13 (10.4)||43 (34.4)||69 (55.2)|
|-Persistence||44 (31.6)||66 (47.4)||29 (20.8)|
Unilocular-simple cysts of the ovary at postmenopausal period is common finding.
The information about of the natural behaviour of a postmenopausal ovarian cyst
is very crucial for distinguishing the surgical cases from the conservative
approach cases. We know that majority of these cysts are benign, all these cases
require careful evaluation before addressing for surgery or long meticulous
follow-ups. The use of ultrasound to differentiate malignant and benign ovarian
cysts originated by the papers in 1989. Since than extensive papers have been
published on this subject . We know that Doppler flow study or measurement of
CA-125 level increases specificity but does not increase sensitivity. However, it
still seems like the best strategy is the transvaginal ultrasound with the use of
a morphological index which was defined by IOTA group. In our opinion, this is a
unique investigation with respect to its study design and with selected patient
group when we compare it with the similar studies in the literature. In our
current investigation, we aimed to use all the conservative approaches as long as
we can while carefully evaluating the selected
In a meta-analysis study by Fabio P. et al., it was pointed out that, in uniocular adnexal cysts including borderline conditions the oncogenic risk was about 1% . In this systematic review, the papers for the last 30 years comprehended in the study. There was a potential limitation of this analysis because of the heterogeneity of the results. Another remarkable point was the classification of uniocular cysts in different ways, which once again limits the analysis. Another issue that emerged in this meta-analysis was pertaining to quality of ultrasound images, especially when including older data. The tumours other than simple uniocular tumours were enrolled in the studies. In our opinion when considering the factors mentioned above, the older technical quality of the ultrasounds in the past, most probably would have influenced them to take oncogenic risk of ovarian cysts to a higher level in this meta-analysis. It is evident that systematic reviews with meta-analyses provide a specific method for synthesizing evidence and overcomes the low power of the single study, but on the other hand as a single large observational study could be more worthy.
At present, it is still not clearly established how to manage the
ovarian cysts larger than 5 cm. Some guidelines  recommend surgical approach
for the cysts in postmenopausal women, others [8,9] have insist that the simple
cysts up to 7 or 10 cm in could be managed conservatively. Unfortunately, when we
review the literature, there was no specific study that evaluates
In our study, 73.8% of the histopathological diagnosis of cyst in the surgery group was serous cystadenoma while only two molecular studies’ results encouraged that serous cystadenomas does not have the risk of high-grade serous carcinomas [12,13].
When there is an uncertainty or inadequate imaging for ovarian cysts by tranvaginal ultrasound, a valuable tool Magnetic resonance imaging (MRI) should be considered. In suspicious adnexial masses, transvaginal ultrasound followed by MRI decreases the risk of misdiagnosing a benign mass as malignant and increases the specificity of a benign diagnosis . MRI is also highly sensitive (96.6%) and specific (83.7%–94.0%) in differentiating the malign cases from the benign ones [15,16]. In a meta-analyze, which was conducted by Anthoulakis and Nikoloudis it was pointed out that MRI with contrast enhancement provides higher post test probability of ovarian cancer confirmation than sonography with Doppler imaging, computed tomography or positron emission tomography in the subsequent evaluation of ultrasound indeterminate adnexal masses . In our study, three patients were referred to MRI because of unsatisfactory information about the morphological changes of the cysts. After MRI exams, none of the patients went for surgery and they were all kept in the follow-up group.
Modesitt et al. reported with the study group of 15,106 women
Sharma et al.  and Jacobs et al.  enrolled 48,053
postmenopausal women in their study, from these patients 2,531 had unilocular
cysts. In the first three years of this follow up, in 5 patients a borderline
tumour, and in 4 patients 2 epithelial ovarian serous cyst adenocarcinoma was
detected, pointing out the risk of associated ovarian cancer for simple large
cysts was 0.35% (9 out of 2,531). The study addressed that in the evolution of
ovarian malignancy we are expecting a prominent structural change in the large
simple cysts. Regardless of the above observations, there is two-highlighted
issue: (a) simple or unilocular cyst should not be referred immediately for
surgery; (b) transvaginal ultrasounds, which were performed meticulously during
the follow-ups, are indigenous to diagnose very small cysts (
In conclusion, in the light of the literature and our study we can strongly state that the most appropriate diagnostic approach for evaluating postmenopausal large simple cyst is transvaginal ultrasound. In assessing difficult cases, MRI plays a much better role in sophisticated investigation of uniocular cysts with small solid areas and it should be used to increase the accuracy of diagnosis before referring the patient for surgery. TVU data from large cancer screening trial confirms that simple ovarian cysts are common incidental findings among women over age 55 upon transvaginal ultrasonography, and it remains common after several screening rounds as women age. Most probably unilateral and unilocular cysts regardless of the size, in fact never harbor malignant component, and this concept needs to be assimilate by both patients and doctors. However, it is very important to perform a high-quality transvaginal ultrasound to confirm the absence of any solid/papillary structures before deciding a cyst as a simple innocent cyst. In order to prevent over diagnosis and over treatment, performing serial meticulous transvaginal ultrasound is an ideal modality however, hitherto there are limited prospective data to point out an exact interval and duration for these unilocular and unilateral cysts. The risk of transforming to cancer is extremely low and frequently these cysts resolves by time or persists without any progression; therefore, initially, at least a certain period of follow-up should be sine qua non.
We believe that in the very near future; clinical practice will eventually be integrating the artificial intelligence in the imaging systems and will encourage most of the physicians to agree on long-term follow-ups of uniocular ovarian cysts in postmenopausal women regardless of the size of the cysts.
MSO designed the study, drafted the manuscript, performed the sonographic examinations, carried out the statistical analysis and the follow-ups. TE participated in the sonographic examinations and helped to carry out the follow-ups. GTS helped to draft the manuscript and collected the medical documentations.
All participants provided informed consent and the study was approved by ethical committee of the hospital.
The authors gratefully thank all the patients participating in this study and the staff at our center for their work and support with the preparation of this manuscript.
The authors thank to radiology department for the critical readings and comments of this manuscript.
Thanks numerous individuals participated in this study. I would like to express my gratitude to all those who helped me during the writing of this manuscript.
Thanks to all the peer reviewers for their opinions and suggestions.
This research received no external funding.
The authors declare no conflict of interest.