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960 Original article

Different modalities in the management of functional

ovarian cysts
Zakria F. Sanada, Said A. Saleha, Adham Mostafab
a
Department of Obstetrics and Gynecology,
Faculty of Medicine, Menofiya University,
Menofiya, bDepartment of Obstetrics and
Gynecology, Shobra Hospital, Cairo, Egypt
Correspondence to Adham Mostafa, MBBCh,
26-St.masr w elsodan, Elmahala Elkobra,
Elgharbia, 11672, Egypt
Tel: +20 106 454 5158;
e-mail: dr_adham_82@yahoo.com
Received 18 September 2014
Accepted 18 December 2014
Menoufia Medical Journal 2015, 28:960–964
Objective
The aim of this work is to compare the different modalities in the management of functional
ovarian cysts.
Background
A functional ovarian cyst is a growth on an ovary that develops during a woman’s ovulation
cycle. Women who develop a functional ovarian cyst generally remain asymptomatic and only
learn of its presence during their annual female examination. Most functional ovarian cysts
are small and benign, require no treatment, and dissolve on their own. If the cyst is small to
moderate in size and causes no symptoms, a watchful approach will usually be adopted.
Materials and methods
This study included 80 patients with functional ovarian cysts: 40 patients followed up by
transvaginal ultrasound only (expectant group) and 40 patients who received combined oral
contraceptive pills (oral contraceptive group) and followed up by transvaginal ultrasound for
3 months. Persistent functional ovarian cysts will be managed by transvaginal ultrasound-
guided needle cyst aspiration and then followed up by transvaginal ultrasound for 3 months.
Results
There was no statistically significances between different modalities of management as regards
short-term expectant management (31\40) and combined oral contraceptive management
(34\40) for functional ovarian cysts. Persistent functional ovarian cysts were managed by
transvaginal-guided ultrasound needle aspiration, which showed a high recurrence rate in
both groups, 5\9 and 3\6, respectively, after short-term follow-up.
Conclusion
The results of the study suggest that optimal management for functional ovarian cysts in
reproductive age is expectant management.

Keywords:
cilest, expectant management, functional ovarian cyst, transvaginal-guided ultrasound needle
aspiration

Menoufia Med J 28:960–964

© 2015 Faculty of Medicine, Menoufia University
1110-2098

routine physical examination. The common ovarian

Introduction
A functional ovarian cyst is a unilateral, unilocular,
thin-walled, and echogenic sac measuring about
2.5–6 cm. A mature graffian follicle is a sac that forms
on the surface of a woman’s ovary during ovulation.
After ovulation, the ovum is released, and the sac may
close and swell up with fluid to form a functional
ovarian cyst. They are not neoplasms and are mostly
harmless. They do not cause symptoms and may
disappear without treatment [1].
The appropriate management of functional ovarian
cysts is one of the most controversial problems facing
gynecologists today despite the different treatment
modalities that are available [2].
Functional ovarian cysts typically disappear within
60 days without any treatment. Oral contraceptive pills
may be prescribed to help establish a normal menstrual
cycle and decrease the development of functional
ovarian cysts, although many cysts are detected at
1110-2098 © 2015 Faculty of Medicine, Menoufia University
masses detected are germ cell tumors (27.5%) and
functional ovarian cysts (25%) [3].
Many previous studies have indicated that the use of
oral contraceptive pills is associated with a lower risk of
occurrence of functional ovarian cysts. However, few studies
have considered the treatment effect of oral contraceptive
pills on functional ovarian cysts. In current clinical practice,
gynecologists treat functional ovarian cysts with either oral
contraceptive pills or expectant management alone. Only
a few recent studies have used low-dose oral contraceptive
pills compared with observation alone [4].
Therapeutic transvaginal ultrasound-guided cyst
aspiration is indicated in women either because
of coexisting medical problems or when refusing
conservative management. However, the recurrence
rate is high, especially when the aspirated fluid is blood
stained  [5]. The aim of this study was to compare
different modalities in the management of functional
ovarian cysts.
DOI: 10.4103/1110-2098.173686
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Participants and methods
This study was carried out from October 2011 to
October 2013; 80 patients with functional ovarian
cysts were included in this study. They were selected
from among patients attending the outpatients’ clinic
of the Department of Obstetrics and Gynecology in
Menoufiya University Hospital. Most of the women
examined represented a homogenous group of the
community. None of the women in this study had
received management for ovarian cysts before. All
patients provided their formal consent. The protocol
was approved by the Ethical Committee of the Faculty
of Medicine, Menofiya University. A full assessment
of history was performed for all women, with a special
focus on age, occupation, address, marital status,
chronic pelvic pain, backache, dyspareunia, leukorrhea,
abnormal uterine bleeding, amenorrhea, infertility,
midmenstrual pain, obstetric history, menstrual
history, and history of contraception. Patients attended
the outpatient clinic after the end of menstruation;
a transvaginal ultrasound was performed for the
selection of cases according to the following inclusion
criteria: women of reproductive age and those with
unilateral ovarian cysts, 2.5–6 cm in diameter, thin-
walled, unilocular without internal echoes, and no
solid parts. Exclusion criteria included premenarche,
postmenopause, and neoplastic ovarian swelling (any
swelling more than 8 cm or that was multilocular).
The patients were divided into two equal groups. Each
group included 40 women as follows: group A included
women who were managed expectantly. Group B
included women who were administered combined
oral contraceptive pills.
Women managed by either of the two modalities were
followed up by transvaginal ultrasound monthly for
3 successive months.
After 3 months, persistent functional ovarian cysts
from two groups were managed by transvaginal
ultrasound-guided needle cyst aspiration and then the
patients were followed up by transvaginal ultrasound
monthly for 3 successive months.
The t-test was used to assess the statistical significance
of differences between two means. On the basis of
the t-test and the degree of freedom, the P-value was
calculated using special tables; thus, the significance
of the results was determined from the ‘t’ distribution
tables.
P < 0.05 = insignificant difference, P > 0.05 = significant
difference.
P > 0.01 = highly significant difference, P > 0.001 =
very highly significant difference.
Management of functional ovarian cysts Sanad et al. 961
Results
The current study was carried out at Menoufiya
University Maternity Hospital during the period
between October 2011 and October 2013. A total of
80 women with functional ovarian cysts were included
in the study.
Statistical analysis
Data were analyzed using IBM© SPSS© Statistics,
version 21 (IBM© Corp., Armonk, New York, USA).
Continuous numerical data were presented as mean
and SD and between-group differences were compared
using the unpaired Student t-test.
Qualitative data were presented as number and
percentage or as ratio. Fisher’s exact test was used for
analysis of 2 × 2 tables. Larger contingency tables were
analyzed using the χ2-test.
P less than 0.05 was considered statistically significant.
Descriptive data
The age of the women in group A showed a mean ± SD
of 26.3 ± 2.1 years and the age of the women in group B
showed a mean ± SD of 27.1 ± 2.7. Statistical analysis
of these data showed no significance difference among
the two groups with respect to age (P = 0.143).
Table 1 shows ultrasonographic findings in the two
study groups. In group A, the average diameter showed
a mean ± SD of 3.4 ± 0.9 cm and in group B the
average diameter showed a mean ± SD of 3.1 ± 0.8 cm.
Statistical analysis indicated no significance difference
between the size of functional ovarian cysts in the two
study groups (P = 0.119). In group A, the location of
the cyst in 21 patients was on the right side and in 19
patients, the location of the cyst was on the left side;
in group B, in 23 patients, the location of the cyst was
on the right side and in 17 patients, the location of the
cyst was on the left side.
On assessment of the outcome of therapy after
1  month, the cysts were found to be in remission
in 21 of the 40 women in group A and in 26 of the
Table 1 Ultrasonographic findings in the two study groups
Ultrasonographic Group A Group B t d.f. P-value
finding expectant group COC group
(n = 40) (n = 40)
Size of the cyst 3.4 (0.9) 3.1 (0.8) –1.576 78 0.119¶
Location of the 21/19 23/17 — — 0.822§
cyst (right/left)
Data are presented as mean [SD] or ratio; ¶Unpaired t-test;
§
Fisher’s exact test.
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962 Menoufia Medical Journal

40 women in group B. A total of 13 women in group
A and six women in group B still had cysts. None
of the women in expectant group and two women
in group B showed regression. Six women in group
A and six women in group B showed progression.
None of the ultrasonic findings was statistically
significant.
On assessment of the outcome of therapy after 2
months in the two study groups, the cysts were found
to be in remission in 27 women in group A and in 29
women in group B. A total of 13 women in group A
and 11 women in group B still had cysts. None of the
women in group A and none of the women in group B
showed regression. None of the women in group A and
none of the women in group B showed progression.
None of the outcomes was statistically significant
(P = 0.060).
women in group A and in three women in group B.
The difference was not statistically significant (P = 1.0)
(Figs. 1–3).
Discussion
Ovarian cysts are a common gynecological problem. In
women of reproductive age, the prevalence of ovarian
cysts is around 7% [6].
Most of these cysts (80–85%) are benign, particularly
functional ovarian cysts [7].
Conservative management, however, is a source of
anxiety for patients and clinicians. In contrast, surgical
intervention for benign disease places an unnecessary
burden on resources [8].

Table 2 shows the outcome of therapy after 3 months

Table 2 Outcome of management after 3 months in the two
in the two study groups. The cysts were found to be in study groups
remission in 31 women in group A and in 34 women Outcome Group A Group B χ2 d.f. P-valuea
in group B. Nine women in group A and six women in after 3 expectant COC group
group B still had cysts. None of the women in group A months group (n = 40) (n = 40)

and none of the women in group B showed regression. Remission 31 (77.5) 34 (85.0) 0.328 1 0.567
None of the women in group A and none of the women Persistence 9 (22.5) 6 (15.0)
in group B showed progression. None of the outcomes Regression 0 (0.0) 0 (0.0)
Progression 0 (0.0) 0 (0.0)
was statistically significant (P = 0.567).
Data are presented as number (%); aχ2-test.

Table 3 shows the recurrence rate after transvaginal

aspiration in the two study groups. After 1 month, Table 3 Recurrence rate after transvaginal aspiration in the
the cyst showed recurrence in four women in group A two study groups
compared with two women in group B. The difference Time after Group A Group B P-valuea
aspiration expectant COC group
was not statistically significant (P = 1.0). After group (n = 9) (n = 6)
2 months, the cyst showed recurrence in four women
1 month 4 (44.4) 2 (33.3) 1.0
in group A compared with three women in group B.
2 months 4 (44.4) 3 (50.0) 1.0
The difference was not statistically significant (P = 1.0). 3 months 5 (55.6) 3 (50.0) 1.0
After 3 months, the cyst showed recurrence in five Data are presented as number (%); aFisher’s exact test.

Figure 1 Figure 2

Transvaginal needle aspiration of persistent functional ovarian cysts. Pattern of clinical presentation in the two study groups.
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Figure 3
Incidence of vaginal bleeding after transvaginal needle aspiration in
the two study groups.
The primary aim of this prospective randomized-
controlled trial study was to evaluate different
modalities in the management of functional ovarian
cysts by comparing the remission rates of spontaneously
occurring functional ovarian cysts between treatment
with combined oral contraceptives (group B) and
expectant management (group A) at 1, 2, and 3 months.
Furthermore, functional ovarian cyst recurrence can
be observed following transvaginal drainage for those
cysts with a failed remission.
The remission percentages of functional ovarian cysts
were as follows:
After 1 month, 52.5 and 65% in group A and group B,
respectively.
After 2 months, 67.5 and 72.5% in group A and
group B, respectively.
After 3 months, 77.5 and 85% in group A and group B,
respectively.
Our finding is in agreement with that of Ayline
et al. [9], who reported that 36 patients with functional
ovarian cysts were randomized to receive expectant
management (group I, n = 18) or to receive oral
contraceptives (group II, n = 18). After one cycle of
therapy, resolution of the cysts was observed in 44.4%
(n = 8) and 55.5% (n = 10) of the 18 patients in
groups  I and II, respectively. Complete resolution of
the cysts was observed in 66.6% (n = 12) of the women
in group  I and in 72.2% (n = 13) of the women in
group II after two cycles.
Another prospective study similar to the study of
Ayline et al. [9] was carried out by Naz et al. [10] in
Management of functional ovarian cysts Sanad et al. 963
which 47 patients with functional ovarian cysts were
included. Overall, 22 patients (46.80%) received
counseling for expectant management (group A)
and oral contraceptives (group B) were prescribed in
25  patients (53.19%). Cyst resolution at 2 months
by ultrasound was observed in 72.72% of the women
in group A and in 80.0% of the women in group B.
There was no statistically significant difference in cyst
resolution in the two groups. These results were in
agreement with those of our study.
The studies by Mackenna and colleagues [11,12] are
two earlier randomized-controlled trials on the effect
of combined oral contraceptive pills on the resolution
of functional ovarian cysts compared with that of
expectant management; they found that a similar
number of functional ovarian cysts had resolved within
1 month. Moreover, all the remaining cysts resolved
after 2 months; this is not in agreement with the
finding of the present study.
Turan et al. [12] showed that remission rates of
spontaneously formed functional cysts either at 5 or
10 weeks of therapy with oral contraceptive pills were
similar to those of expectant management. At 5 weeks
of therapy, functional ovarian cysts disappeared in
88.9% of women using low-dose monophasic oral
contraceptive pills and in 76% of women on expectant
management. At 10 weeks of therapy, the disappearance
rates were more similar: 100 and 94.1%, respectively.
The lack of statistical significance can be attributed to
an insufficient number of participants enrolled in the
study.
Our findings are not in agreement with the
randomized-controlled trial conducted by Taskin
et al. [13], who examined the effectiveness of combined
oral contraceptive versus expectant management of
functional ovarian cysts; this study included 25 women
in the oral contraceptive group and 20 women in the
expectant group. The remission rates after 3 months
were 13\25 (52%) in the combined oral contraceptive
group and 10\20 (50%) in the expectant group; there
were no statistically significant differences.
Our findings are in agreement with those of a
randomized-controlled trial conducted by Sanersak
et al. [14]. This study included 70 women. The remission
rates after 2 months were 24\33 (72.2%) in the
combined oral contraceptive group and 23\34 (67.6%)
in the expectant group; there were no statistically
significant differences.
In our study, we determined the recurrence rate after
transvaginal aspiration in the two study groups. After
1 month, the cyst showed recurrence in 4 (44.4%)
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964 Menoufia Medical Journal
women in group A compared with 2 (33.3%) women
in group B. After 2 months, the cyst showed recurrence
in 4 (44.4%) women in group A compared with
3 (50.0%) women in group B. After 3 months, the cyst
showed recurrence in 5 (55.6%) women in group A
and 3 (50.0%) women in group B.
Our findings are not in agreement with those of Balat
et al. [15], who treated 19 cases with transvaginal
ultrasound-guided needle cyst aspiration, with
recurrence in five cases (26.5%) after short-term
follow-up.
Our findings are not in agreement with those of Dulbaz
et al. [16], who treated 35 cases with functional cysts
with Ca-125 level less than 35 U/ml with transvaginal
ultrasound-guided needle cyst aspiration. All patients
were followed up by transvaginal ultrasound for
3 months. Three recurrences (8%) were identified.
Conclusion
For functional ovarian cysts, conservative management
is adequate as most cases will resolve spontaneously.
There is no proven advantage in the use of combined
oral contraceptives. Surgery should be reserved for
patients with large or symptomatic functional ovarian
cysts.
Therapeutic ultrasound-guided cyst aspiration may
have a small place in women in whom surgery is
considered to be high risk. However, the recurrence
rate is high.
Acknowledgements
Conflicts of interest
There are no conflicts of interest.
References
1 Melnikow J, Penava D, et al. MPH – family medicine. Obstet Gynecol
2008; 46:946–953.
2 Crawford RA, Gore ME, Shepherd JH. Ovarian cancers related to minimal
access surgery. Br J Obstet Gynaecol 1995; 102:726–730.
3 Skiadas VT, Koutoulidis V, Eleytheriades M, Gouliamos A,
Moulopoulos LA, Deligeoroglou E, et al. Ovarian masses in young
adolescents: imaging findings with surgical confirmation. Eur J Gynaecol
Oncol 2004; 25:201-206.
4 De Guia BC. A randomized placebo-controlled trial of low dose
monophasic pills in the treatment of functional ovarian cysts. Int Congr
Ser 2004; 1271:15–18.
5 Girdling JC, Soutter WP. Benign tumours of ovary. In Shaw RW,
Soutter WP, Stanton SL, eds Gynecology. 2nd ed. Edinburgh: Churchill
Livingstone; 1997. 615–625.
6 Borgfeldt C, Andolf E. Transvaginalsonographic ovarian finding in a
random sample of women 25–40 years old. Ultrasound Obstet Gynecol
1999; 13:345–350.
7 Hillard PJ, Berek JS. Benign disease of the female reproductive tract:
symptoms and signs. Novak’s gynecology. 13th ed. Philadelphia:
LippincottWilliams Wilkins; 2002. 351–420.
8 Eriksson L, Kjellgren O, von Schultz B. Functional cysts or ovarian cancer.
Histopathological finding during 1 year of surgery. Gynecol Obstet Invest
1985; 19:155–159.
9 Ayline Pelin CIL, Ozturkoglu E, Demir B, Gunes M, Haberal A. Is hormonal
therapy needed in the management of functional ovarian cyst. In Feldman-
Winter L, Schanler RJ, O’Connor KG, Lawrence RA, eds. Turkey: Ankara
Etlik Maternity and Women’s Health Teaching and Research Hospital;
2008. 1301–3314.
10 Naz T, Akhter Z, Jamal T. Oral contraceptives versus expectant treatment
in management of functional ovarian cysts. Department of Gynecology,
Khyber Teaching Hospital, Peshawar – Pakistan. J Med Sci (Peshawar,
Print) 2011; 19:185–188.
11 MacKenna A, Fabres C, Alam V, Morales V. Clinical management of
functional ovarian cysts: a prospective and randomized study. Hum
Reprod 2000; 15:2567–2569.
12 Turan C, Zorlu CG, Ugur M, Ozcan T, Kaleli B, Gökmen O. Expectant
management of functional ovarian cysts: an alternative to hormonal
therapy. Int J Gynaecol Obstet 1994; 47:257–260.
13 Taskin O, Young DC, Mangal R, Aruh I. Prevention and treatment of
ovarian cysts with oral contraceptive: a prospective randomized study.
J Gynecol Surg 1996; 12:21–24.
14 Sanersak S, Wattanakumtornkul S, Korsakul C. Comparison of low-dose
monophasic oral contraceptive pills and expectant management in
treatment of functional ovarian cysts. J Med Assoc Thai 2006; 89:741–747.
15 Balat O, Sarac K, Sonmez S. Female reproductionPrinciples of physiology.
St Louis, MO: CV Mosby Company; 1996. 599.
16 Dulbaz S, Alibkan E, Dulbaz B, Aykan B, Suvaslioulu A, Haberal A.
Laparoscopic and transvaginal ultrasound guided aspiration cytology
of ovarian cysts. Ankara, Turkey: SSK Maternity and Women’s Health
Training Hospital; 2003.