Once a woman enters menopause, there is an expectation that the
ovaries become inactive. While they do have a lower level of activity,
they are still capable of producing cysts. Fortunately, the great
majority of these are benign and need no therapy. Dr. Holtz presents for
us what is considered normal and what signs should cause concern. —
Beverly Vaughn, MD, Medical
Coordinator, Menopause and You Program
With the increased use of imaging and the recognition by primary care
doctors that ovarian cancers present with subtle symptoms, more ovarian
masses are being detected in postmenopausal women. In screening studies,
5-20% of women over the age of 50 with no other symptoms will have an
ovarian mass detected on ultrasound. However, only a percentage of these
will prove to be ovarian cancer after surgery. Thus, it is important for
us to try to distinguish ovarian cysts that can be monitored with repeat
ultrasound studies from masses that need to be surgically evaluated due
to their elevated risk of early ovarian cancer.
Importance of Health History
A women’s history can give clues as to the nature of an ovarian mass.
Some factors are protective against cancer: pregnancy and childbirth in
a woman’s 20s, use of birth control pills, and a history of tubal
ligation or hysterectomy. A strong family history of cancers of the
breast, ovary, colon, or endometrium may be part of a hereditary cancer
syndrome; however, only 5-10% of ovarian cancers are related to
Evaluating Cysts and Masses
Transabdominal and transvaginal ultrasound have become a mainstay for
the evaluation of pelvic masses due to their low cost and minimal
invasiveness. When reviewing ultrasound reports, there are five
characteristics that are important in differentiating ovarian cysts with
a low likelihood of harboring an ovarian cancer from masses with a
higher risk. These characteristics are:
Complexity of the cyst (one simple bubble of fluid versus
many bubbles of fluid)
Projections into the fluid called papillations
Ovarian blood flow as measured by colored Doppler assessment
In postmenopausal women with simple ovarian cysts less than 5 cm, the
risk of an ovarian cancer is very small (0-1%). In a large study
conducted at the University of Kentucky, no women with simple ovarian
cysts less than 10 cm in diameter developed ovarian cancer. However,
10-40% of complex cysts with solid areas and papillations will harbor a
CA125 is a blood test that can be performed to help the physician to
determine the risk of ovarian cancer. However, an elevated CA125 is
nonspecific and can be elevated in the face of many common benign
findings, such as pregnancy, uterine fibroids, menses, and
endometriosis. It can also be elevated by non-ovarian malignancies such
as stomach cancer, colon cancer, and cancer of the liver.
In postmenopausal patients, however, the accuracy of predicting ovarian
malignancy increases considerably. The higher the level of CA125, the
more it is likely that an ovarian mass is malignant. A note of caution,
however: CA125 is elevated above normal in only 50% of patients with
Stage 1 ovarian cancer and may miss half of the patients with a
localized tumor. In other words, when the CA125 is elevated, it raises
your concern; but if the CA125 is normal, it is not a guarantee of
Some patients may benefit from further imagining studies. The elderly,
the sick, or patients who simply refuse surgery may benefit from an MRI.
An MRI of the ovary is not diagnostic for cancer; however, it is very
sensitive for benign ovarian masses such as dermoids or uterine fibroids
that can be confused with ovarian masses. Thus, MRI’s should be reserved
for patients with indeterminate ultrasound findings who cannot have
surgery because of the costs, the need for intravenous dye, and
claustrophobia of the machine.
Consulting with a doctor
Women who have concerns with ultrasound or CA125 studies should have a
consultation with a fellowship-trained subspecialist in women’s cancers.
Gynecologic oncologists have specialized training in the management of
and surgery for women’s cancers. Consultation can help a patient
understand her risks for a cancer and plan for the proper surgical
procedure. Gynecologic oncologists are five times more likely to
completely remove ovarian tumors, and 80% of ovarian cancer patients
receive inadequate surgical staging from non-gynecologic oncologist
surgeons. Most importantly, survival outcomes are vastly improved when
gynecologic oncologists are involved in a patient’s care.
Treatment of ovarian cysts has been made more convenient with the
introduction of laparoscopy in the 1980s. Through the laparoscope the
entire abdomen can be viewed, and the ovaries can be removed and sent
for pathology – all through incisions less than a half inch in size.
This greatly reduces the length of time that a woman has to spend in the
hospital, the length of time that she has to remain out of work, and the
risk of postoperative infections and hernias. Laparoscopy is not
appropriate for everyone. Most gynecologists hesitate to perform
laparoscopic surgery on larger ovarian cysts. Some gynecologic
oncologists are trained to perform staging (biopsies and removal of
lymph nodes) laparoscopically if an ovarian mass should prove to be a
cancer. Studies have shown that the outcomes after laparoscopic staging
are the same as the equivalent open surgery. In summary, ovarian cysts
are common in postmenopausal women. Simple cysts less than 5
cm in diameter without concerning features can safely be followed with
repeated ultrasounds. Other ovarian masses should be referred to
gynecologic oncologists for appropriate surgery, which may include
laparoscopic removal of the ovaries with staging procedure if necessary.
This article is part of the Menopause and Youlibrary,
a web-based program sponsored by Women’s Health Source.
It is intended as an information resource providing guidelines for
women. As always, check with your own health care practitioner with your
specific concerns and questions.
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