ABSTRACT
Objective
To provide recommendations for a systematic approach to the initial investigation
and management of a benign ovarian mass and facilitate patient referral to a gynaecologic
oncologist for management.
Intended Users
Obstetricians, gynaecologists, family physicians, internists, nurse practitioners,
radiologists, general surgeons, medical students, medical residents, fellows, and
other health care providers.
Target Population
Women ≥18 years of age presenting for evaluation of an ovarian mass (including simple
and unilocular cystic masses, endometriomas, dermoids, fibromas, and hemorrhagic cysts)
who are not acutely symptomatic and without known genetic predisposition to ovarian
cancer.
Outcomes
This guideline aims to encourage conservative management and help reduce unnecessary
surgery and long-term health complications, maintain fertility, and decrease operative
costs and improve overall patient care and outcomes by providing criteria for referral
of patients with ultrasound imaging findings suggestive of a malignant mass to a gynaecologic
oncologist.
Evidence
Databases searched: Medline, Cochrane, and PubMed. Medical terms used: benign asymptomatic and symptomatic ovarian cysts, adnexal masses, oophorectomy, ultrasound
diagnosis of cysts, simple ultrasound rules, surgical and medical therapies for cysts,
screening for ovarian cancer, ovarian torsion, and menopause. Initial search was completed by 2017 and updated in 2018. Exclusion criteria were
malignant ovarian cystic masses, endometriosis therapies, and other adnexal pathologies
unrelated to the ovary.
Validation Methods
The content and recommendations were drafted and agreed upon by the authors. The Society
of Obstetricians and Gynaecologists of Canada's Board of Directors approved the final
draft for publication. The quality of evidence was rated using the criteria described
in the Grading of Recommendations Assessment, Development and Evaluation methodology
framework.
Benefits, Harms, Costs
Implementation of the recommendations could reduce costs due to unnecessary surgeries
and hospitalizations and reduce lost work days and the risk of loss of fertility,
early menopause, and surgical complications.
SUMMARY STATEMENTS (GRADE ratings in parentheses)
- 1The following ovarian masses typically demonstrate classic benign features on ultrasound: simple or unilocular cystic mass, hemorrhagic cyst, endometrioma, mature cystic teratoma (dermoid), and fibroma (high).
- 2The risk of malignancy for simple ovarian cystic masses is low (<1%) for <10 cm in diameter (high).
- 3Patients with an ovarian mass ≥5 cm in diameter are at increased risk for ovarian torsion (moderate).
- 4Laparoscopy is the recommended approach for surgical management of symptomatic benign ovarian masses because it not only is technically feasible and safe but also provides the advantages of shorter hospital stays, faster recovery times, and less pain and bleeding compared with laparotomy (high).
- 5Comprehensive preoperative evaluation is necessary in order to determine the risk of malignancy of an ovarian mass before deciding on the appropriate surgical management (high).
- 6Electrocautery for hemostasis should be used sparingly in order to reduce the risk of damage to healthy ovarian tissue and minimize adhesion formation (high).
RECOMMENDATIONS (GRADE ratings in parentheses)
- 1In the asymptomatic patient, masses characterized as benign on ultrasound can be followed initially by repeat ultrasound in 8 to 12 weeks, preferably in the proliferative phase of the menstrual cycle for premenopausal women. Follow-up ultrasound can then be done yearly for masses that remain stable and do not develop malignant features (strong, moderate).
- 2Most asymptomatic masses <10 cm in diameter and characterized as benign can be managed conservatively (strong, high).
- 3If surgery is performed for a symptomatic mass characterized as benign on ultrasound, unilateral or bilateral oophorectomy can be considered for postmenopausal women (strong, low) and ovarian cystectomy can be considered for premenopausal women if technically feasible (strong, low). For perimenopausal women, the decision to perform a cystectomy with a possible salpingectomy versus an oophorectomy should be part of a shared decision-making discussion between the patient and her health care provider (strong, low).
- 4Laparoscopic ovarian cystectomy is the recommended surgical approach for removal of cystic masses, rather than fenestration and aspiration (strong, moderate).
- 5Laparoscopic management should involve examination of the peritoneal surfaces, appendix, upper abdomen, posterior cul-de-sac, and bladder in addition to uterus, tubes, and ovaries for evidence of disease. In addition to pelvic washing for cytology, a biopsy of peritoneal surfaces should be taken for histopathology only if malignancy is suspected (strong, high).
- 6Peritoneal washing for cytology and frozen section for analysis should be undertaken at the time of surgical management of an ovarian mass if there is a suspicion of malignancy. To improve the diagnostic accuracy, specimens should be interpreted by a pathologist with gynaecologic expertise, if resources permit (strong, high).
- 7When pathology results reveal malignancy in an ovarian mass that had originally been presumed benign, comprehensive surgical staging should be performed by a surgeon with expertise in gynaecologic oncology, if resources permit (strong, high).
Keywords
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Journal of Obstetrics and Gynaecology CanadaAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
REFERENCES
- Practice bulletin no. 174: evaluation and management of adnexal masses.Obstet Gynecol. 2016; 128: e210-e226
- Predicting the risk of malignancy in adnexal masses based on the Simple Rules from the International Ovarian Tumor Analysis group.Am J Obstet Gynecol. 2016; 214: 424-437
- First international consensus report on adnexal masses: management recommendations.J Ultrasound Med. 2017; 36: 849-863
- Psychological morbidity associated with ovarian cancer screening: results from more than 23,000 women in the randomised trial of ovarian cancer screening (UKCTOCS).BJOG. 2014; 121: 1071-1079
- Ovarian cancer screening in the Prostate, Lung, Colorectal and Ovarian (PLCO) cancer screening trial: findings from the initial screen of a randomized trial.Am J Obstet Gynecol. 2005; 193: 1630-1639
- Sensitivity and specificity of multimodal and ultrasound screening for ovarian cancer, and stage distribution of detected cancers: results of the prevalence screen of the UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS).Lancet Oncol. 2009; 10: 327-340
- Management of asymptomatic ovarian and other adnexal cysts imaged at US: Society of Radiologists in Ultrasound consensus conference statement.Radiology. 2010; 256: 943-954
- Simple ultrasound-based rules for the diagnosis of ovarian cancer.Ultrasound Obstet Gynecol. 2008; 31: 681-690
- A formula for predicting the risk of a positive second-look laparotomy in epithelial ovarian cancer: implications for a randomized trial.Obstet Gynecol. 1992; 80: 944-948
- Is expectant management of sonographically benign adnexal cysts an option in selected asymptomatic premenopausal women?.Hum Reprod. 2005; 20: 3231-3234
- Serial ultrasonographic evaluation of ovarian abnormalities with a morphology index.Gynecol Oncol. 2014; 135: 8-12
- The value of ultrasound monitoring of adnexal masses for early detection of ovarian cancer.Front Oncol. 2016; 6: 25
- Evaluation and management of ultrasonographically detected ovarian tumors in asymptomatic women.Obstet Gynecol. 2016; 127: 848-858
- Evaluating the risk of ovarian cancer before surgery using the ADNEX model to differentiate between benign, borderline, early and advanced stage invasive, and secondary metastatic tumours: prospective multicentre diagnostic study.BMJ. 2014; 349: g5920
- Imaging of benign adnexal masses: characteristic presentations on ultrasound, computed tomography, and magnetic resonance imaging.Clin Obstet Gynecol. 2009; 52: 21-39
- Malignancy risk of sonographically benign appearing purely solid adnexal masses in asymptomatic postmenopausal women.Menopause. 2017; 24: 613-616
- Terms, definitions and measurements to describe the sonographic features of adnexal tumors: a consensus opinion from the International Ovarian Tumor Analysis (IOTA) Group.Ultrasound Obstet Gynecol. 2000; 16: 500-505
- Risk of malignancy in unilocular ovarian cystic tumors less than 10 centimeters in diameter.Obstet Gynecol. 2003; 102: 594-599
- Prevalence, incidence, and natural history of simple ovarian cysts among women >55 years old in a large cancer screening trial.Am J Obstet Gynecol. 2010; 202: 373.e1-373.e9
- Natural history of sonographically detected simple unilocular adnexal cysts in asymptomatic postmenopausal women.Gynecol Oncol. 2004; 92: 965-969
- Ovarian cancer screening and mortality in the UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS): a randomised controlled trial.Lancet. 2016; 387: 945-956
- Risk of epithelial ovarian cancer in asymptomatic women with ultrasound-detected ovarian masses: a prospective cohort study within the UK collaborative trial of ovarian cancer screening (UKCTOCS).Ultrasound Obstet Gynecol. 2012; 40: 338-344
- Frequency and disposition of ovarian abnormalities followed with serial transvaginal ultrasonography.Obstet Gynecol. 2013; 122: 210-217
- Long-term survival of women with epithelial ovarian cancer detected by ultrasonographic screening.Obstet Gynecol. 2011; 118: 1212-1221
- Effect of screening on ovarian cancer mortality: the Prostate, Lung, Colorectal and Ovarian (PLCO) cancer screening randomized controlled trial.JAMA. 2011; 305: 2295-2303
- Clinicopathologic features of ovarian cancer in patients with ovarian endometrioma.J Obstet Gynaecol Res. 2008; 34: 872-877
- Ovarian endometrioma–risks factors of ovarian cancer development.Eur J Obstet Gynecol Reprod Biol. 2008; 138: 187-193
- Malignant transformation of mature cystic teratoma of the ovary: experience at a single institution.Eur J Obstet Gynecol Reprod Biol. 2008; 141: 173-178
- Ovarian torsion: a fifteen-year review.Ann Emerg Med. 2001; 38: 156-159
- Ovarian torsion: 10-year perspective.Emerg Med Australas. 2005; 17: 231-237
- Uterine adnexal torsion: pathologic and gray-scale ultrasonographic findings.Clin Exp Obstet Gynecol. 2004; 31: 34-38
- The risk of malignancy in post-menopausal women presenting with adnexal torsion.Gynecol Oncol. 2007; 106: 211-214
- Clinical characteristics and the risk for malignancy in postmenopausal women with adnexal torsion.Maturitas. 2015; 81: 57-61
- Adnexal torsion in postmenopausal women: clinical presentation and risk of ovarian malignancy.J Minim Invasive Gynecol. 2017; 24: 94-97
- 341-diagnosis and management of adnexal torsion in children, adolescents, and adults.J Obstet Gynaecol Can. 2017; 39: 82-90
- Risks and benefits of screening asymptomatic women for ovarian cancer: a systematic review and meta-analysis.Gynecol Oncol. 2013; 130: 674-681
- Ultrasound follow up of an adnexal mass has the potential to save lives.Am J Obstet Gynecol. 2015; 213 (657.e1): 657-661
- Diagnosis and management of ovarian cyst accidents.Best Pract Res Clin Obstet Gynaecol. 2009; 23: 711-724
- The impact of excision of benign nonendometriotic ovarian cysts on ovarian reserve: a systematic review.Am J Obstet Gynecol. 2016; 215: 169-176
- Incidence, time trends, laterality, indications, and pathological findings of unilateral oophorectomy before menopause.Menopause. 2014; 21: 442-449
- Ovary and unilateral oophorectomy: is having one the same as having two?.Menopause. 2014; 21: 435-436
- Inappropriate oophorectomy at time of benign premenopausal hysterectomy.Menopause. 2017; 24: 947-953
- Tubal ligation, hysterectomy, unilateral oophorectomy, and risk of ovarian cancer in the Nurses’ Health Studies.Fertil Steril. 2014; 102 (192–8.e3)
- Ovarian cancer rates after hysterectomy with and without salpingo-oophorectomy.Obstet Gynecol. 2014; 123: 65-72
- Frequency, sequence, and side of ovulation in women menstruating normally.Br Med J (Clin Res Ed). 1987; 294: 219
- Significantly superior response in the right ovary compared with the left ovary after stimulation with follicle-stimulating hormone in a pituitary down-regulation regimen.Fertil Steril. 2010; 93: 2269-2273
- Salpingo-oophorectomy at the time of benign hysterectomy: a systematic review.Obstet Gynecol. 2016; 128: 476-485
- Accelerated accumulation of multimorbidity after bilateral oophorectomy: a population-based cohort study.Mayo Clin Proc. 2016; 91: 1577-1589
- Long-term health consequences of premature or early menopause and considerations for management.Climacteric. 2015; 18: 483-491
- Removal of all ovarian tissue versus conserving ovarian tissue at time of hysterectomy in premenopausal patients with benign disease: study using routine data and data linkage.BMJ. 2017; 356: j372
- Oral contraceptives versus expectant treatment in the management of functional ovarian cysts.J Med Sci. 2011; 19: 185-188
- Surgical technique for single-port laparoscopy in huge ovarian tumors: SW Kim's technique and comparison to laparotomy.Obstet Gynecol Sci. 2017; 60: 178-186
- The effect of bipolar electrocoagulation during ovarian cystectomy on ovarian reserve: a systematic review.Am J Obstet Gynecol. 2015; 213: 620-628
- Clinical study of the impact on ovarian reserve by different hemostasis methods in laparoscopic cystectomy for ovarian endometrioma.Taiwan J Obstet Gynecol. 2016; 55: 507-511
- Ovarian endometrioma ablation using plasma energy versus cystectomy: a step toward better preservation of the ovarian parenchyma in women wishing to conceive.Fertil Steril. 2011; 96: 1396-1400
- Comparison of the effects of laparoscopic bipolar electrocoagulation and intracorporeal suture application to ovarian reserve in benign ovarian cysts.Arch Gynecol Obstet. 2013; 287: 729-732
- Hemostasis by bipolar coagulation versus suture after surgical stripping of bilateral ovarian endometriomas: a randomized controlled trial.J Minim Invasive Gynecol. 2012; 19: 722-730
- Intraoperative frozen section analysis for the diagnosis of early stage ovarian cancer in suspicious pelvic masses.Cochrane Database Syst Rev. 2016; CD010360
- Costs, effectiveness, and workload impact of management strategies for women with an adnexal mass.J Natl Cancer Inst. 2015; 107: 322
- Risk of spread of ovarian cancer after laparoscopic surgery.Curr Opin Obstet Gynecol. 2001; 13: 9-14
- Laparoscopic surgery for large benign ovarian cysts.Gynecol Oncol. 2008; 108: 72-76
- Laparoscopic management of large ovarian cysts.Surg In. nov 2012; 19: 370-374
- A modified technique to reduce spillage and the operative time in laparoscopic dermoid cyst excision.J Laparoendosc Adv Surg Tech A. 2015; 25: 143-146
- Laparoscopic adnexectomy of suspect ovarian masses: surgical technique used to avert spillage.J Minim Invasive Gynecol. 2011; 18: 372-377
- Management of presumed benign giant ovarian cysts: a minimally invasive technique using the Alexis Laparoscopic System.J Minim Invasive Gynecol. 2015; 22: 540
- Laparoendoscopic single-site surgery for extremely large ovarian cysts: a feasibility, safety, and patient satisfaction study.Gynecol Obstet Invest. 2014; 78: 81-87
- Dermoid tumors of the ovary: evaluation of the gasless lift-laparoscopic approach.Surg Technol Int. 2008; 17: 203-207
- Mesial side ovarian incision for laparoscopic dermoid cystectomy: a safe and ovarian tissue-preserving technique.Fertil Steril. 2012; 98 (1336–40.e1)
- Laparoscopic treatment of ovarian dermoid cysts is a safe procedure.Bosn J Basic Med Sci. 2011; 11: 245-247
- Laparoscopic excision of benign dermoid cysts with controlled intraoperative spillage.J Am Assoc Gynecol Laparosc. 1995; 2: 479-481
- Excision of ovarian dermoid cyst by laparoscopy and by laparotomy.Am J Obstet Gynecol. 1995; 173: 769-771
- Marsupialization of the cyst as a step in laparoscopic management of ovarian cysts.J Am Assoc Gynecol Laparosc. 2001; 8: 568-572
- Surgical technique to prevent spillage of cyst fluid during operation for cystic ovarian tumors.Pediatr Surg Int. 2013; 29: 645-649
- An easy new approach to the laparoscopic treatment of large adnexal cysts.Minim Invasive Ther Allied Technol. 2011; 20: 150-154
- Posterior colpotomy revisited: a forgotten route for retrieving larger benign ovarian lesions following laparoscopic excision.Arch Gynecol Obstet. 2010; 281: 609-611
- Surgical treatment of ovarian dermoid cysts: a comparison between laparoscopic and vaginal removal.Eur J Obstet Gynecol Reprod Biol. 2003; 109: 88-91
- Management of ovarian dermoids without laparoscopy or laparotomy.Eur J Obstet Gynecol Reprod Biol. 2001; 99: 106-108
- Excision of mature teratoma using culdotomy, with and without laparoscopy: a prospective randomised trial.BJOG. 2001; 108: 91-94
- Haemoperitoneum associated with ovulation in women with bleeding disorders: the case for conservative management and the role of the contraceptive pill.Haemophilia. 2007; 13: 93-97
- Ultrasound demonstration of increased frequency of functional ovarian cysts in women using progestogen-only oral contraception.Br J Obstet Gynaecol. 1985; 92: 1003-1009
- Endometriosis: diagnosis and management.J Obstet Gynaecol Can. 2010; 32: S1-32
- No. 344-opportunistic salpingectomy and other methods of risk reduction for ovarian/fallopian tube/peritoneal cancer in the general population.J Obstet Gynaecol Can. 2017; 39: 480-493
- Validation of the performance of international ovarian tumor analysis (IOTA) methods in the diagnosis of early stage ovarian cancer in a non-screening population.Diagnostics (Basel). 2017; 7: 32
- Surgery by consultant gynecologic oncologists improves survival in patients with ovarian carcinoma.Cancer. 2006; 106: 589-598
Article info
Publication history
No. 404, August 2020
Footnotes
This document reflects emerging clinical and scientific advances as of the publication date and is subject to change. The information is not meant to dictate an exclusive course of treatment or procedure. Institutions are free to amend the recommendations. The SOGC suggests, however, that they adequately document any such amendments.
Informed Consent: Everyone has the right and responsibility to make informed decisions about their care together with their health care providers. In order to facilitate this, the SOGC recommends that they provide their patients with information and support that is evidence-based, culturally appropriate, and personalized.
Language and Inclusivity: This document uses gendered language in order to facilitate plain language writing but is meant to be inclusive of all individuals, including those who do not identify as a woman/female. The SOGC recognizes and respects the rights of all people for whom the information in this document may apply, including but not limited to transgender, non-binary, and intersex people. The SOGC encourages health care providers to engage in respectful conversation with their patients about their gender identity and preferred gender pronouns and to apply these guidelines in a way that is sensitive to each person's needs.
Copyright: The contents of this document cannot be reproduced in any form, in whole or in part, without prior written permission of the publisher of the Journal of Obstetrics and Gynaecology Canada.
Identification
Copyright
© 2020 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc. All rights reserved.
