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Title of Guideline (must include the word Guideline (not Assessment, referral and initial

protocol, policy, procedure etc) management of ultrasound detected

ovarian cysts for NUH gynaecology teams

Author: Contact Name and Job Title Kate Stewart ST7, David Nunns Consultant
Gynaecological Oncologist, NUH

Directorate & Speciality Family Health

Date of submission 2.9.16

Explicit definition of patient group to which it applies (e.g. Women seen in gynaecology clinics or
inclusion and exclusion criteria, diagnosis) emergency admissions areas

Version 7

If this version supersedes another clinical guideline please be NA

explicit about which guideline it replaces including version
Statement of the evidence base of the guideline has the 1) RCOG (2003), Green-Top Guideline no.
guideline been peer reviewed by colleagues? 34, Ovarian cysts in post -menopausal
women, The Royal College of Obstetricians
Evidence base: (1-6) and Gynaecologists
1 NICE Guidance, Royal College Guideline, SIGN
(please state which source). 1) RCOG (2011) Green-Top Guideline no.
2a meta analysis of randomised controlled trials 62, Management of Suspected Ovarian
2b at least one randomised controlled trial Masses in Pre-menopausal women, The
3a at least one well-designed controlled study without Royal College of Obstetricians and
randomisation Gynaecologists
3b at least one other type of well-designed quasi-
1) NICE 2011 NICE Clinical Guideline
experimental study
number 122: Ovarian Cancer: the
4 well designed non-experimental descriptive
recognition and initial management of
studies (ie comparative / correlation and case
ovarian cancer National Institute for Health
and Clinical Excellence
5 expert committee reports or opinions and / or 5) IOTA
clinical experiences of respected authorities
6 recommended best practise based on the clinical onal-material
experience of the guideline developer

Consultation Process Senior medical staff, radiology

Ratified by: Gynae risk management group

Date: 21 November 2016
Target audience General gynaecologists

Review Date: (to be applied by the Integrated Governance

A review date of 5 years will be applied by the Trust.
Directorates can choose to apply a shorter review date,
however this must be managed through Directorate
Governance processes.

This guideline has been registered with the trust. However, clinical guidelines are guidelines only.
The interpretation and application of clinical guidelines will remain the responsibility of the individual
clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines
after the review date.
Aims and purpose
To guide the clinician (general gynaecologists all grades) on the
assessment, referral and initial management of ultrasound scan
detected ovarian cysts.
Algorithm for the management of ovarian cysts on USS (please see
main text for detail)

Up to 10% of women will have some form of surgery for the presence
of an ovarian mass. In premenopausal women almost all ovarian
masses and cysts are benign and many ovarian masses in this group
can be managed conservatively
The underlying management rationale is to minimise patient morbidity
o conservative management where possible providing necessary
o use of laparoscopic techniques where appropriate, thus avoiding
o referral to a gynaecological oncologist where appropriate.
It should be noted that almost all pelvic ultrasound scan requests
will require a transvaginal scan (TVS). TVS is almost always
superior to transabdominal ultrasound (TAS) for examining the pelvic
organs. However, some women cannot accommodate a vaginal scan
probe and can only have an abdominal scan.
At the present time the routine use of CT and MRI for assessment of
ovarian masses does not improve the sensitivity or specificity obtained
by transvaginal ultrasonography in the detection of ovarian
malignancy and should be reserved as second line investigation after
discussion with a senior colleague. However, if the mass is larger
than the array of the scanning probe or if there are diagnostic
difficulties with the USS then a CT/MRI may be indicated.
It is important to consider borderline ovarian tumours as a histological
diagnosis when undertaking any surgery for ovarian masses and,
when such a histological diagnosis is made or strongly suspected,
discussion with the gynaeoncology team is recommended.
Although up to 20% of borderline ovarian tumours appear as simple
cysts on ultrasonography, the majority of such tumours will have
suspicious ultrasonographic findings.

1.Tumour markers
Tumours marker (such as Ca125) is used as a part of patient triage
and risk assessment. They are not diagnostic and lack good sensitivity
and specificity.
Measure serum CA125 in all women with suspected ovarian cancer
A serum CA-125 assay does not need to be undertaken in all
premenopausal women when an USS diagnosis of a simple ovarian
cyst has been made.
In women under age of 40 years with suspected ovarian cancer also
measure: levels of alpha fetoprotein (AFP), beta human chorionic
gonadotrophin (beta-hCG) as well as serum CA125, to identify germ
cell tumours.

2. Evaluation of ovarian masses in premenopausal women

Please consider this triage tool for premenopausal women with
ovarian cysts. The International Ovarian Tumour Analysis Group has
published the largest study to date investigating the use of ultrasound
in differentiating benign and malignant ovarian masses based on five
ultrasound features of malignancy (M-features) and five ultrasound
features suggestive of a benign lesion (B-features).
An adnexal mass is classified as malignant if at least one M-feature
and no B-features are present and vice versa. Using these rules the
reported sensitivity was 95% and specificity 91% (see table below).
Some scan reports may not contain this level of detail. If unsure
please discuss with a senior colleague.
IOTA Group ultrasound rules to classify masses as benign (B-
rules) or malignant (M-rules)

B-rules M-rules

Unilocular cysts Irregular solid mass (solid

Presence of solid component 80% of the
components where the tumour)
largest solid component <7 Presence of ascites
mm At least 4 papillary structures
Presence of acoustic with a height equal or more
shadowing than 3mm
Smooth multilocular tumour Irregular multi-locular solid
with a largest diameter tumour with a maximum
<100mm diameter > 10cm
No blood flow Strong vascularity
Women with an ovarian mass with any of the M-rules ultrasound
findings should be discussed with the gynaecological oncological
service. Please check the patients Ca -125 when referring.
2.1 Premenopausal cysts follow up
The following cysts should be treated as simple cysts:
Ovarian/para-ovarian cyst, cysts containing daughter cysts,
Cysts with one thin septation (<3mm, with no vascularity),
Cysts with small calcification in wall. If there is an obvious area of
calcification; consider whether this may be a dermoid cyst.

Cyst criteria apply even if cysts are multiple (cysts completely separate
from each other) or bilateral.
Pre-menopausal cysts Less than 5cm 5 - 7cm more than 7cm
Simple/ No follow up Suggest rescanning in Suggest benign
Haemorrhagic cyst required unless four months. gynaecological team
there is clinicalIf smaller or resolved no review re: surgery
concern. further follow up required. depending on clinical
Findings are If larger or persisting assessment
likely to be suggest further
physiological in gynaecological review.
nature and Ovarian cysts that persist
almost always or increase in size are
resolve within 3 unlikely to be functional
menstrual and may warrant surgical
cycles. management. If
symptomatic, for benign
gynaecological review.
Endometrioma/ Manage on clinical grounds
dermoid No routine rescans indicated as less likely to change in size
Ovarian cysts with any Take CA-125 and calculate RMI. Consider germ cell tumour markers
malignant features (see IOTA (AFP, HCG and LDH). Discuss with the gynaeoncology team.
criteria in above table)

3. Evaluation of ovarian masses in post-menopausal women

3.1 Calculate the Risk of Malignancy Index Score (RMI)

Please consider the RMI triage tool for postmenopausal women
with ovarian cysts to identify patients at risk of ovarian cancer.
Calculate a risk of malignancy index I (RMI) score and refer all women
with an RMI score of 200 or greater to the gynaeoncology MDT using
the intranet referral form. The use of RMI scoring is not appropriate
when obvious metastatic disease has been identified by ultrasound.

In this case a CT scan chest abdomen and pelvis would be more
appropriate (patients require a GFR for IV contrast).
The pooled sensitivities and specificities of an RMI I score of 200 in
the detection of ovarian malignancy are sensitivity 78% (95% CI 71-
85%) and specificity 87% (CI 83-91%)
The value is less in premenopausal women where Ca-125 levels may
be raised with benign conditions eg, endometriosis.
RMI score = ultrasound score x menopausal score x CA125 in

Feature RMI score

multilocular cyst 0= none
solid areas 1= one abnormality
bilateral lesions 3= two or more abnormalities
intra-abdominal metastases
Premenopausal 1
Post menopausal 3
Ca 125 U/ml

A full physical examination of the woman is essential and should

include body mass index, abdominal examination to detect ascites
and characterise any palpable mass, and vaginal examination.
A thorough medical history should be taken from the woman, with
specific attention to risk factors and symptoms suggestive of ovarian
malignancy, and a family history of ovarian, bowel or breast cancer.
Where family history is significant, referral to the Regional Cancer
Genetics service should be considered.
3.2 Follow up for post-menopausal Ovarian Cysts
Assess ovarian cysts in postmenopausal women using CA125
and transvaginal ultrasound scan and calculate the RMI
There is no routine role yet for Doppler, MRI, CT or PET.
The risk of malignancy in these studies of cysts that are less than 5
cm, unilateral, unilocular and echo-free with no solid parts or papillary
formations is less than 1%. In addition, more than 50% of these cysts
will resolve spontaneously within three months. Thus, it is reasonable
to manage cysts of 25 cm conservatively. Conservative
management should entail repeat ultrasound scans and serum CA125
measurement every four months for one year. If the cyst does not fit
the above criteria or if the woman requests surgery then laparoscopic
oophorectomy is acceptable.

Postmenopausal cysts Less than 3cm 3-5cm More than 5cm
Simple ovarian cysts If the cyst is smallSuggest rescan Suggest benign
with no worrying with CA-125 gynaecological team
features, this is measurement in referral. Calculate
most likely to be a four and eight RMI and discuss if
residual follicle. No
months. appropriate with the
further scan is If no change gynaeoncology team
indicated. demonstrated in
these scans, no
further imaging
indicated unless
clinical concern.
Dermoid cysts No immediate action Suggest Suggest benign
is indicated gynaecological gynaecological team
manage on clinical referral. referral. Calculate
grounds No rescan RMI and discuss if
indicated appropriate with the
oncological team
Ovarian cysts with any Take CA-125 and calculate RMI. Discuss with the gynaeoncology
malignant features (see IOTA team.
criteria in above table) or not

4. Special scenarios

4.1 Patients with co-morbidities

The decision for surgery may be weighed against the patients co-
morbidities and a conservative option of management may be taken
after discussion with the patient and her consultant.
4.2 Emergency management of cysts
Any cyst that is causing severe symptoms may warrant emergency
surgery. This should be done in daytime hours.
If woman attends as an emergency with an ovarian cyst causing pain
but does not warrant surgery she can be followed up as per guidelines
above in Miss Jhambs Thursday afternoon scan clinic (book with A23
4.3 Ovarian torsion
Ovarian torsion accounts for approximately 1 in 5 of emergency
gynaecology admissions. It is frequently described as unilateral
ovarian enlargement and oedema on USS and has a strong
association with large (>5cm) ovarian cysts.
These cysts become haemorrhagic with venous congestion.

Traditionally, surgery has involved partial or complete oophorectomy
or salpingo-oophorectomy.
There is evidence to suggest that the clinical appearances of torted
adnexae do not correlate well with the likelihood of residual ovarian
function and recovery and there are good outcome data to support
conservative management with laparoscopic de-torsion in the majority
of cases with little short or long-term associated morbidity even if the
ovary appears dark purple or black.
True cysts can be drained at the time to maximise ovarian
Follow up after detorsion should be by scan in Miss Jhambs
emergency gynaecology Thursday afternoon clinic to determine the
presence of any true cysts that may require interval cystectomy.
4.4 Management of cysts in pregnancy
Asymptomatic adnexal masses are frequently diagnosed in
pregnancy, either at the dating scan or at the time of caesarean
section. They are mostly ovarian in origin. Although the overall
incidence of adnexal masses in pregnancy is approximately 4%, the
incidence of complex or simple persistent cysts measuring more than
6 cm is only 0.07%. Three-quarters of these persistent cysts are
complex in nature and the majority of complex cysts are either benign
teratomas or endometriomas.
Ovarian cysts in pregnancy can result in cyst rupture, cyst
haemorrhage, torsion (up to 5%), obstructed labour and fetal
The majority of ovarian cysts in pregnancy are benign and can be
managed conservatively. Ovarian cancer is extremely rare in women
of childbearing age, the overall reported incidence of ovarian cancer in
pregnant women varies from 0.0040.04%, If there is a suspicion of
malignancy or there is a significant cyst complication, such as torsion,
and surgery is planned, this should take place during the second
trimester to minimise the risk of miscarriage.
4.4.1 MRI in pregnancy
MRI is considered safe in pregnancy (without contrast) and can be
helpful in the assessment of an ovarian mass that is thought to be
4.4.2 Tumour markers in pregnancy
Effect of pregnancy
CA 125 Raised during pregnancy due to decidual cell
(epithelial cancer) production.
Some researchers have suggested using a cut-off
level of 112 U/ml
(germ cells tumours)
(germ cells tumours) Serum AFP, betahCG and inhibin levels are all raised
Inhibin due to placental synthesis
(granulosa and
(malignant germ cell Due to the rarity of this neoplasm, data regarding this
tumours) association is sparse

NB. Is it worth doing tumour markers as a normal result will be

4.4.3 Algorithm for management of ovarian cyst in pregnancy
(Ref: TOG article, Spencer et al)

Inform women that the majority of ovarian cysts resolve

Dermoid cysts that are less than 6cm on rescan can be followed
up 3 months postnatally to determine further management.
Large simple cysts can be drained by USS guided needle
aspiration if very symptomatic and is done by the interventional
radiologist after multidisciplinary discussion. This should be done
after 14weeks to minimise disturbance to the corpus luteum.
If a complex cyst is causing severe symptoms it can be operated
upon after 14 weeks to minimise the risk of fetal loss due to
miscarriage, although this risk is very small.
In some situations, there may be grounds for performing an
elective caesarean section at term in addition to deal with a large,

complex ovarian tumour that has persisted during the pregnancy
but which has not required earlier operative intervention.

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The Royal College of Obstetricians and Gynaecologists: Green-Top

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Review date 3.9.17