Ovarian Cancer Prevention — Postgraduate MCQ Quiz

Section 1: Epidemiology & Risk Factors

• A) Repeated chromosomal damage from estrogen exposure during ovulation
• B) Chronic ovulation causes repetitive microtrauma and repair of the ovarian epithelium, increasing mutation risk
• C) Excess LH from incessant ovulation drives malignant transformation
• D) Persistent corpus luteum secretion of progesterone promotes neoplasia
• E) Retrograde menstruation seeds the ovarian surface epithelium

Answer: B — The leading mechanistic hypothesis is that chronic ovulatory microtrauma requires repeated epithelial repair cycles, increasing the opportunity for oncogenic mutations. — Berek & Novak's Gynecology

• A) 0.9
• B) 0.7
• C) 0.5
• D) 0.3
• E) 0.1

Answer: D — Two children (RR 0.3–0.4 reduction) combined with ≥5 years of OC use gives an overall relative risk as low as 0.3 (a 70% reduction). — Berek & Novak's Gynecology

• A) Nulliparity
• B) Late menopause
• C) Talc use
• D) Genetic predisposition (BRCA1/2 mutation)
• E) Infertility treatment with clomiphene

Answer: D — Genetic predisposition is "the most important known risk" for ovarian cancer; 18–24% of ovarian carcinomas arise in the context of a hereditary predisposition. — Schwartz's Principles of Surgery

• A) Breastfeeding and multiparity
• B) Early menarche and late menopause
• C) Combined OCP use and tubal ligation
• D) Progesterone-only pill use
• E) Surgical menopause before age 45

Answer: B — Early menarche and late menopause extend the reproductive career, increasing cumulative ovulatory cycles and ovarian cancer risk. — Berek & Novak's Gynecology

• A) Type I (low-grade serous)
• B) Type I (clear cell carcinoma)
• C) Type II (high-grade serous and high-grade endometrioid)
• D) Type I (mucinous carcinoma)
• E) Both Type I and Type II equally

Answer: C — Type II ovarian cancers (high-grade serous, which account for ~70%, plus high-grade endometrioid and carcinosarcoma) are defined by TP53 mutations, which are rare in Type I tumors. — Schwartz's Principles of Surgery

Section 2: Oral Contraceptives as Chemoprevention

• A) 1 year
• B) 2 years
• C) 3 years
• D) 5 years
• E) 10 years

Answer: D — Women who use oral contraceptives for 5 or more years reduce their relative risk to 0.5 (a 50% reduction). — Berek & Novak's Gynecology

• A) 5 years
• B) 10 years
• C) Up to 15 years
• D) Up to 30 years
• E) The reduction disappears within 5 years

Answer: D — The risk reduction from OC use persists for up to 30 years after cessation. — Schwartz's Principles of Surgery

• A) 0.7 (30% reduction)
• B) 0.6 (40% reduction)
• C) 0.5 (50% reduction)
• D) 0.4 (60% reduction)
• E) 0.2 (80% reduction)

Answer: D — In BRCA carriers, OC use for ≥5 years yields a relative risk of 0.4, or a 60% reduction in disease incidence. — Berek & Novak's Gynecology

• A) It should only be recommended to women who also need contraception
• B) It is a reasonable recommendation specifically for women with a strong family history of ovarian cancer
• C) It is contraindicated in BRCA mutation carriers due to breast cancer risk
• D) The benefit applies only to mucinous ovarian cancer histotype
• E) It reduces risk only in pre-menopausal women under age 30

Answer: B — OCP use should be emphasised when counselling women with a strong family history of ovarian cancer, making this benefit part of routine contraceptive counselling. — Berek & Novak's Gynecology

Section 3: Surgical Prevention

• A) 50%
• B) 70%
• C) 80%
• D) 90%
• E) 96%

Answer: E — RRBSO reduced the risk of BRCA-related gynecologic cancer by 96% in a prospective series. — Berek & Novak's Gynecology

• A) 0.1%
• B) 0.8–1%
• C) 3–5%
• D) 8–10%
• E) 15%

Answer: B — The subsequent development of peritoneal carcinoma after RRBSO was reported to be 0.8% and 1% in published series, reflecting that the entire peritoneum remains at risk. — Berek & Novak's Gynecology

• A) 25–30 years
• B) 30–35 years
• C) 35–40 years
• D) 40–45 years
• E) 50–55 years

Answer: C — RRBSO is recommended at 35–40 years for BRCA1 carriers, given their earlier age of cancer onset. — Berek & Novak's Gynecology

• A) BRCA2 carriers have a lower lifetime risk overall
• B) BRCA2-related ovarian cancers tend to occur at a later age (often after age 50)
• C) BRCA2 mutations primarily cause breast, not ovarian, cancer
• D) OCP chemoprevention is more effective in BRCA2 carriers
• E) BRCA2 carriers have a higher sensitivity to platinum-based chemotherapy

Answer: B — BRCA1-related ovarian cancers occur at an earlier age; BRCA2-related cancers tend to occur after age 50, justifying a later surgical intervention. — Berek & Novak's Gynecology

• A) Omentectomy and para-aortic lymph node sampling
• B) Complete serial sectioning of ovaries and fallopian tubes with microscopic examination
• C) Appendectomy if mucinous histology is suspected
• D) Peritoneal biopsy from the cul-de-sac only
• E) Frozen section of the ovarian hilum

Answer: B — Guidelines specify that all ovarian and fallopian tube tissue must be removed and subjected to complete serial sectioning with microscopic examination to detect occult cancer. — Berek & Novak's Gynecology

• A) Equal for BRCA1 and BRCA2 carriers regardless of age
• B) Greatest in BRCA2 carriers diagnosed at age <50 years (HR ~0.18)
• C) Greatest in BRCA1 carriers at any age
• D) Not observed in any subgroup of BRCA carriers
• E) Only relevant if mastectomy is also performed

Answer: B — Oophorectomy was associated with significantly reduced breast cancer risk in BRCA2 carriers diagnosed at age <50 (HR 0.18; p=0.007) but not significantly so in BRCA1 carriers <50. — Berek & Novak's Gynecology

• A) Salpingectomy reduces endometrial cancer risk
• B) Scandinavian population-based cohort studies demonstrate a significant decrease in epithelial ovarian cancer following salpingectomy
• C) RCTs confirm a 50% mortality reduction with salpingectomy
• D) It is mandated by ACOG for all women undergoing hysterectomy
• E) The fallopian tube is the origin of all ovarian cancer histotypes

Answer: B — Scandinavian population-based cohort studies have demonstrated a significant decrease in epithelial ovarian cancer following salpingectomy; it is feasible at the time of tubal ligation, hysterectomy, or other pelvic surgery. — Schwartz's Principles of Surgery

Section 4: Screening & Genetics

• A) Annual CA-125 combined with transvaginal ultrasound from age 40
• B) Biennial CA-125 from age 50
• C) Screening is recommended only for women with first-degree relatives with ovarian cancer
• D) Screening with pelvic examination, ultrasound, or CA-125 is NOT recommended due to lack of mortality benefit and moderate harms
• E) Transvaginal ultrasound alone is recommended every 2 years from age 45

Answer: D — The USPSTF recommends against screening asymptomatic average-risk women, concluding there is no mortality benefit and that harms (false-positives, unnecessary surgery) are at least moderate. — Berek & Novak's Gynecology

• A) 20%
• B) 35%
• C) 50%
• D) 70%
• E) 90%

Answer: C — CA-125 is elevated in 50% of patients with stage I disease and 80–90% of patients with advanced serous cancers. — Berek & Novak's Gynecology

• A) Only those with a first-degree relative with breast or ovarian cancer
• B) Only those with high-grade serous histology
• C) All women with epithelial ovarian cancer, excluding mucinous cancers, irrespective of family history
• D) Only women diagnosed before age 50
• E) Only FIGO stage III–IV patients

Answer: C — Current guidelines recommend testing all women with epithelial ovarian cancer, excluding mucinous cancers, regardless of family history, since up to 50% of BRCA-positive patients have no family history. — Berek & Novak's Gynecology

• A) Age 20–25 years
• B) Age 25–29 years
• C) Age 30–35 years
• D) Age 40–45 years
• E) Age 50 years

Answer: C — ACOG guidelines recommend surveillance (TVU every 6 months ± CA-125) starting at age 30–35 years as a short-term strategy for women at high risk who wish to preserve fertility. — Berek & Novak's Gynecology

• A) Age 25–30 years
• B) Her early to mid-40s, after completion of childbearing
• C) Age 50 years, consistent with general population screening
• D) Only after an endometrial polyp or hyperplasia is diagnosed
• E) No surgical risk reduction is indicated in Lynch syndrome

Answer: B — For Lynch syndrome, risk-reducing hysterectomy and BSO should be discussed by the early to mid-40s after childbearing is complete. Endometrial biopsy every 1–2 years from age 30–35 and colonoscopy are also recommended. — Berek & Novak's Gynecology

• A) 30% and 10%
• B) 40% and 15%
• C) 54% and 23%
• D) 70% and 40%
• E) 80% and 60%

Answer: C — The lifetime risk is 54% for BRCA1 and 23% for BRCA2 mutation carriers; together these groups also carry an 82% lifetime risk of breast cancer. — Berek & Novak's Gynecology

• A) Type I tumors are defined by TP53 mutations; Type II by KRAS/BRAF mutations
• B) Type II tumors are more strongly associated with endometriosis; Type I with BRCA mutations
• C) Endometriosis and hormonal factors predispose to Type I; germline mutations are more common in Type II
• D) Type I tumors are exclusively hereditary; Type II are sporadic
• E) There is no distinction in risk factors between Type I and Type II

Answer: C — Endometriosis and hormonal factors predispose to Type I (clear cell, low-grade serous, mucinous); germline mutations are far more common in Type II (high-grade serous). — Schwartz's Principles of Surgery

Bonus Questions

• A) Microscopic ovarian tissue is always left behind surgically
• B) The entire peritoneum is at risk and peritoneal carcinomas can arise even after BSO
• C) Endometrial cancer risk increases post-BSO
• D) BRCA mutations directly transform peritoneal mesothelium
• E) Hormone replacement therapy post-BSO restores cancer risk to baseline

Answer: B — The entire peritoneum is an at-risk surface; peritoneal carcinomas occur in 2–3% of women even after prophylactic BSO. — Berek & Novak's Gynecology

• A) Bilateral oophorectomy should always be performed to prevent ovarian cancer
• B) The ovaries may protect from cardiovascular disease and osteoporosis; long-term mortality may not be improved by prophylactic oophorectomy in average-risk women
• C) Unilateral oophorectomy halves the risk of ovarian cancer
• D) The decision is irrelevant as OCP use post-hysterectomy will cover residual risk
• E) ACOG mandates oophorectomy in all women ≥45 undergoing hysterectomy

Answer: B — A thorough risk-benefit discussion is required. Ovaries may protect from cardiovascular disease and osteoporosis, and long-term mortality is not demonstrably decreased by prophylactic oophorectomy in average-risk women. — Berek & Novak's Gynecology

Quick Reference Summary

Tamoxifen & Endometrial Cancer Risk — MCQ Quiz

• A) Estrogen antagonist in breast, bone, and endometrium
• B) Estrogen agonist in breast, and antagonist in bone and endometrium
• C) Estrogen antagonist in breast tissue, and agonist in bone and endometrium
• D) Full agonist in all tissues except the ovary
• E) Neutral (no agonist or antagonist activity) in endometrial tissue

Answer: C — Tamoxifen is an estrogen antagonist in breast tissue and a partial agonist in bone and the endometrium. This endometrial agonism is the mechanistic basis for its uterotrophic adverse effects. — Lippincott Illustrated Reviews: Pharmacology

• A) No increased risk
• B) 1.5-fold increased risk
• C) 2- to 3-fold increased risk
• D) 5- to 6-fold increased risk
• E) 10-fold increased risk

Answer: C — Tamoxifen is associated with a 2- to 3-fold increased risk for endometrial cancer (relative risk 2–3 in risk factor tables). — Berek & Novak's Gynecology

• A) 0.5%
• B) 1.2%
• C) 2.0%
• D) 3.8%
• E) 6.5%

Answer: D — In the EBCTCG meta-analysis, the absolute incidence of endometrial cancer was 3.8% in postmenopausal women aged 55–69 years on adjuvant tamoxifen. — Current Surgical Therapy, 14th ed.

• A) Premenopausal women under age 40
• B) Early-stage endometrial cancer in premenopausal women
• C) Early-stage cancers in postmenopausal women
• D) All women regardless of menopausal status
• E) Only women concurrently using HRT

Answer: C — The increased risk for endometrial cancer is restricted to early-stage cancers in postmenopausal women. — Schwartz's Principles of Surgery

• A) Reassure her that vaginal bleeding is an expected side effect of tamoxifen
• B) Switch immediately to an aromatase inhibitor without further investigation
• C) Promptly investigate as vaginal bleeding is an early sign of endometrial cancer in women on tamoxifen
• D) Start progestins to counteract tamoxifen's endometrial stimulation
• E) Order a serum CA-125 as first-line investigation

Answer: C — Women on tamoxifen should be closely monitored for early signs of endometrial cancer including vaginal bleeding, which should be promptly evaluated. — Current Surgical Therapy, 14th ed.

• A) Endometrial atrophy only
• B) Endometrial polyps only
• C) Endometrial polyps, hyperplasia, and carcinoma
• D) Endometrial sarcoma only
• E) Cervical stenosis and pyometra

Answer: C — Tamoxifen's endometrial agonism can lead to endometrial polyps, hyperplasia, and cancer. Raloxifene, by contrast, does not stimulate the endometrium and carries none of these risks. — Berek & Novak's Gynecology

• A) No difference in endometrial cancer risk between the two drugs
• B) Raloxifene had a higher rate of endometrial cancer than tamoxifen
• C) The risk of endometrial cancer was significantly higher with tamoxifen than raloxifene
• D) Both agents had equivalent endometrial risk but different thromboembolic profiles
• E) Raloxifene increased endometrial cancer risk in premenopausal women only

Answer: C — At longer follow-up, the risk of developing endometrial cancer was significantly higher with tamoxifen; raloxifene achieved a 45% reduction in endometrial cancer risk relative to tamoxifen. — Sabiston Textbook of Surgery

• A) Raloxifene does not bind to the estrogen receptor
• B) Raloxifene has full estrogen antagonist activity in the endometrium (no uterine agonism)
• C) Raloxifene inhibits aromatase in endometrial tissue
• D) Raloxifene selectively downregulates progesterone receptors
• E) Raloxifene is not orally bioavailable and does not reach the uterus

Answer: B — Unlike tamoxifen, raloxifene blocks estrogen effects in uterine tissue (no agonist activity in the endometrium), so it does not increase the risk of endometrial cancer or cause vaginal discharge. — Lippincott Illustrated Reviews: Pharmacology

• A) CYP1A2
• B) CYP2C9
• C) CYP2D6
• D) CYP3A5
• E) CYP2E1

Answer: C — Tamoxifen is converted to 4-hydroxytamoxifen (endoxifen) via CYP2D6. Strong CYP2D6 inhibitors (e.g., fluoxetine, paroxetine) reduce endoxifen levels and should be avoided. — Katzung's Basic and Clinical Pharmacology

• A) Endometrial polyp formation
• B) Increased risk of uterine sarcoma
• C) Osteoporosis and osteoporotic fractures
• D) Hyperprolactinaemia
• E) Adrenal insufficiency

Answer: C — AIs are not associated with endometrial cancer or thromboembolic events, but are associated with increased risk of osteoporosis and osteoporotic fractures, for which adjuvant bisphosphonate therapy is recommended in at-risk patients. — Current Surgical Therapy, 14th ed.

Summary Table

Endometrial Thickness Threshold for Biopsy in Asymptomatic Postmenopausal Women

The key distinction: symptomatic vs. asymptomatic

For women WITH postmenopausal bleeding (established thresholds)

For ASYMPTOMATIC postmenopausal women (no bleeding)

• The ACOG Practice Bulletin guidance, which acknowledges that a thicker endometrium is needed to justify biopsy in the absence of bleeding because the pre-test probability of cancer is lower
• The SGO (Society of Gynecologic Oncology) and IETA (International Endometrial Tumor Analysis) consensus: ≥ 11 mm warrants investigation in asymptomatic women
• Background prevalence of endometrial cancer in asymptomatic postmenopausal women is only ~0.002–0.6% even with a thick endometrium, compared with 5–10% in those with bleeding

2023 Meta-Analysis Evidence (PMID: 35932873)

• At a threshold of ≥ 3 mm, the risk of atypical hyperplasia/endometrial cancer was 3.77× higher than below the cutoff
• Sensitivity was highest at 3–5.9 mm (Se 0.81) but specificity was highest at ≥ 14 mm (Sp 0.86)
• The optimal diagnostic odds ratio was seen at 3–5.9 mm (DOR 10) and 10–13.9 mm (DOR 11)
• Conclusion: a single universal cutoff is insufficient; clinical context and additional risk factors must guide the decision

Practical Summary

Important caveats

1. Tamoxifen users — tamoxifen causes subendometrial changes that falsely thicken the apparent endometrial stripe on TVUS; routine screening ultrasound is not recommended in asymptomatic tamoxifen users; biopsy is indicated only when symptoms (vaginal bleeding/discharge) develop.
2. HRT users — the endometrium may appear thicker due to exogenous hormonal stimulation; the 4–5 mm cutoff is less specific in this group and biopsy is advisable if irregular bleeding supervenes.
3. Race/ethnicity — recent data show the 4 mm cutoff under-diagnoses endometrial cancer in Black patients, warranting a lower threshold in this population.
4. Morphology matters — an irregular, inhomogeneous, or vascular endometrium on TVUS warrants further evaluation even if below the thickness threshold.

Endometrial Thickness Cutoff for Biopsy in a Woman on Tamoxifen with No Postmenopausal Bleeding

Short answer

"Women with sonographic endometrial thickness > 4 mm using tamoxifen should undergo hysteroscopic endometrial biopsy." — Vitale SG et al., J Gynecol Obstet Hum Reprod 2023 [PMID: 37061093] (Evidence-based Practice Guideline)

Why tamoxifen users need a lower threshold than other asymptomatic postmenopausal women

1. Tamoxifen is an endometrial estrogen agonist — it directly stimulates endometrial proliferation, raising the baseline risk of polyps, hyperplasia, and carcinoma (RR 2–3× compared to the general postmenopausal population).
2. Tamoxifen distorts ultrasound assessment — it causes subendometrial cystic changes and stromal oedema, creating a characteristic sonographic appearance that falsely exaggerates the apparent endometrial stripe (the "tamoxifen effect"). A measured thickness of even 4–5 mm in this context may represent a functionally thicker or more pathological endometrium than the same measurement implies in an untreated woman.
3. Routine ultrasound screening is unreliable in tamoxifen users — because of this distortion, TVUS has lower specificity in this group. When the stripe is thick on TVUS, the false-positive and false-negative rates are higher than in untreated women, making hysteroscopy + directed biopsy the preferred investigation.

The recommended investigation: Hysteroscopy, not blind biopsy

• Tamoxifen-associated pathology is often focal (polyps, focal hyperplasia)
• Blind sampling misses focal lesions in up to 25–40% of cases
• Hysteroscopy allows direct visualisation and targeted sampling of suspicious areas

What about routine TVUS surveillance in asymptomatic tamoxifen users?

• TVUS has poor specificity due to tamoxifen-related subendometrial changes
• Screening programs in asymptomatic users generate a high false-positive rate, leading to unnecessary invasive procedures
• The absolute risk of endometrial cancer in tamoxifen users, while elevated, remains relatively low (~0.1–0.2% per year)

Summary

Quiz: Endometrial Thickness, Postmenopausal Bleeding & Tamoxifen

Section 1: Postmenopausal Bleeding — Basics

• A) 3 months
• B) 6 months
• C) 9 months
• D) 12 months
• E) 18 months

Answer: D — Menopause is defined as 12 months without a menstrual period; any bleeding after that point is abnormal and requires investigation. — Textbook of Family Medicine

• A) Endometrial carcinoma
• B) Hormone replacement therapy
• C) Endometrial atrophy
• D) Endometrial polyp
• E) Cervical carcinoma

Answer: C — The most common cause of PMB is endometrial and vaginal atrophy (thinning of the endometrial lining and vaginal tissue due to estrogen deficiency). — Sabiston Textbook of Surgery

• A) 50%
• B) 65%
• C) 75%
• D) 90%
• E) 99%

Answer: D — 90% of patients diagnosed with endometrial cancer experience postmenopausal bleeding, making PMB the cardinal symptom requiring urgent evaluation. — Sabiston Textbook of Surgery

• A) 1–2%
• B) 5–10%
• C) 10–20%
• D) 25–30%
• E) 40–50%

Answer: C — Between 10% and 20% of all postmenopausal bleeding is caused by malignancy. — Textbook of Family Medicine

• A) Uterine polyps and fibroids only
• B) Polyps, fibroids, adenomyosis, and medications (HRT, anticoagulants)
• C) Cervical cancer and ovarian cancer only
• D) Atrophy and Lynch syndrome only
• E) Tamoxifen use and BRCA mutation only

Answer: B — Other causes include uterine polyps, fibroids, adenomyosis, and medications — most commonly hormone replacement therapies and anticoagulants. — Sabiston Textbook of Surgery

Section 2: Endometrial Thickness — Thresholds & Interpretation

• A) < 8 mm
• B) < 6 mm
• C) < 4–5 mm
• D) < 3 mm
• E) < 2 mm

Answer: C — An endometrium measuring < 4–5 mm on TVUS reliably excludes endometrial cancer in postmenopausal women with bleeding. A meta-analysis confirmed 96% of endometrial cancers had a stripe > 5 mm. — Rosen's Emergency Medicine; Swanson's Family Medicine Review

• A) Low NPV — biopsy is still required regardless
• B) High NPV — endometrial biopsy can be safely avoided in most cases
• C) Only valid in women under age 60
• D) Only valid if the woman has never used HRT
• E) Equivalent to a normal endometrial biopsy result

Answer: B — An endometrial stripe < 5 mm has a high negative predictive value in postmenopausal women with bleeding; biopsy can be avoided in most cases with this finding. — Swanson's Family Medicine Review

• A) > 4 mm
• B) > 5 mm
• C) > 8 mm
• D) ≥ 11 mm
• E) ≥ 15 mm

Answer: D — The conventional threshold in asymptomatic postmenopausal women is ≥ 11 mm, reflecting the substantially lower pre-test probability of cancer in the absence of bleeding compared to symptomatic women. — SGO/IETA consensus

• A) RR 1.5 (95% CI 1.1–2.0)
• B) RR 2.5 (95% CI 1.5–4.0)
• C) RR 3.77 (95% CI 2.26–6.32)
• D) RR 6.5 (95% CI 4.0–10.0)
• E) RR 10.0 (95% CI 6.0–16.0)

Answer: C — At a threshold of ≥ 3 mm, the risk of AEH or carcinoma was increased 3.77-fold (95% CI 2.26–6.32). The same meta-analysis found no statistically significant difference in RR across subgroups (3–5.9 mm, 6–9.9 mm, 10–13.9 mm, ≥ 14 mm), highlighting that no single "safe" cutoff exists. — Vitale SG et al., Am J Obstet Gynecol 2023 [PMID 35932873]

• A) Both sensitivity and specificity increase
• B) Sensitivity increases, specificity decreases
• C) Sensitivity decreases, specificity increases
• D) Both sensitivity and specificity decrease
• E) No change in either parameter

Answer: C — Pooled sensitivity decreased from 0.81 (at 3–5.9 mm) to 0.28 (at ≥ 14 mm), while specificity increased from 0.70 to 0.86 — the classic sensitivity-specificity trade-off. Lower cutoffs catch more cancers but generate more false positives. — Vitale SG et al., Am J Obstet Gynecol 2023 [PMID 35932873]

• A) Immediate endometrial biopsy — the 5 mm threshold is exceeded
• B) Reassure and discharge — the 11 mm threshold is not exceeded
• C) Clinical assessment integrating morphology, additional risk factors, and shared decision-making; biopsy considered if risk factors are present
• D) Repeat ultrasound in 3 months
• E) MRI pelvis as first line

Answer: C — There is no universal consensus on a single cutoff in asymptomatic women. At 6 mm, the situation is in a grey zone below the ≥ 11 mm conventional threshold. Clinical context, morphology (uniform vs. irregular), and additional risk factors (obesity, diabetes, Lynch syndrome, HRT use) should guide the decision. — Vitale SG et al., J Gynecol Obstet Hum Reprod 2023 [PMID 37061093]

Section 3: Tamoxifen & Endometrial Risk

• A) Endometrial atrophy and amenorrhoea
• B) Endometrial polyps, hyperplasia, and carcinoma
• C) Endometrial sarcoma exclusively
• D) Asherman syndrome
• E) Endometrial calcification only

Answer: B — Tamoxifen's endometrial agonist activity leads to polyps, hyperplasia, and carcinoma. Vaginal bleeding and discharge are also direct consequences of its endometrial stimulation. — Berek & Novak's Gynecology; Lippincott Pharmacology

• A) > 8 mm
• B) > 6 mm
• C) ≥ 5 mm
• D) > 4 mm
• E) > 11 mm

Answer: D — The 2023 evidence-based practice guideline (Vitale SG et al.) states: "Women with sonographic endometrial thickness > 4 mm using tamoxifen should undergo hysteroscopic endometrial biopsy" — a lower threshold than the ≥ 11 mm used in asymptomatic non-tamoxifen users, reflecting the elevated oncological risk in this group. — Vitale SG et al., J Gynecol Obstet Hum Reprod 2023 [PMID 37061093]

• A) Tamoxifen users are always older and therefore at higher absolute risk
• B) Tamoxifen causes subendometrial cystic changes that falsely increase the apparent stripe thickness on TVUS, and the underlying endometrial cancer risk is elevated 2–3 fold
• C) TVUS overestimates thickness in tamoxifen users, so a lower cutoff compensates
• D) Tamoxifen suppresses progesterone receptors, making biopsy technically easier
• E) Guidelines require biopsy at any thickness in tamoxifen users

Answer: B — Two key reasons: (1) tamoxifen's endometrial agonism elevates cancer risk (RR 2–3×); (2) tamoxifen induces subendometrial cystic changes and stromal oedema that falsely exaggerate the apparent endometrial stripe on TVUS, making the 4 mm threshold a more appropriate trigger. — Berek & Novak's Gynecology; Current Surgical Therapy 14e

• A) Blind Pipelle (suction curette) — fast, office-based, adequate sampling
• B) Dilatation and curettage under general anaesthesia — gold standard
• C) Hysteroscopy with targeted/directed biopsy — because tamoxifen-associated pathology is often focal and blind sampling misses focal lesions
• D) Random four-quadrant cervical biopsy
• E) MRI-guided biopsy

Answer: C — Hysteroscopy with targeted biopsy is recommended because tamoxifen-associated pathology (polyps, focal hyperplasia) is frequently focal; blind sampling techniques miss focal lesions in up to 25–40% of cases. — Vitale SG et al., J Gynecol Obstet Hum Reprod 2023 [PMID 37061093]

• A) Yes — annual TVUS is mandatory for all tamoxifen users
• B) Yes — TVUS every 6 months is the standard of care
• C) No — routine TVUS surveillance is NOT recommended because tamoxifen-related subendometrial changes reduce its specificity, generating high false-positive rates
• D) No — only MRI surveillance is recommended
• E) Yes — but only after 5 years of tamoxifen use

Answer: C — Major guidelines (ACOG, ASCO, RCOG) do not recommend routine TVUS surveillance in asymptomatic tamoxifen users. The poor specificity due to the "tamoxifen effect" on the endometrium leads to excess false positives and unnecessary invasive procedures. The strategy is symptom-triggered investigation. — Berek & Novak's Gynecology

• A) Reassure — vaginal discharge is a known and expected side effect, requires no investigation
• B) Switch to an aromatase inhibitor without investigation
• C) Perform TVUS; proceed to biopsy only if stripe > 11 mm
• D) Promptly investigate regardless of TVUS findings — vaginal bleeding/discharge in a tamoxifen user is always an indication for endometrial biopsy
• E) Repeat examination in 3 months if bleeding is light

Answer: D — Any vaginal bleeding or discharge in a tamoxifen user warrants immediate investigation regardless of ultrasound thickness. The threshold for symptomatic women remains > 4 mm on TVUS, but clinical symptoms override the requirement for imaging before proceeding to biopsy. — Current Surgical Therapy 14e; Berek & Novak's Gynecology

• A) Tamoxifen
• B) Toremifene
• C) Ospemifene
• D) Raloxifene
• E) Clomiphene

Answer: D — Raloxifene acts as an estrogen antagonist in endometrial tissue (no agonism), so it does not increase the risk of endometrial cancer, polyps, or hyperplasia. In the STAR trial, raloxifene achieved a 45% reduction in endometrial cancer risk compared to tamoxifen. — Lippincott Illustrated Reviews: Pharmacology; Sabiston Textbook of Surgery

Section 4: Integrated Clinical Scenarios

• A) Reassure — 5 mm is below the 11 mm threshold for asymptomatic women
• B) Repeat TVUS in 6 months
• C) Refer for hysteroscopy and targeted endometrial biopsy — stripe > 4 mm in a tamoxifen user mandates biopsy
• D) Start progestin to oppose tamoxifen's endometrial effect
• E) No action required until symptoms develop

Answer: C — In a tamoxifen user, the threshold is > 4 mm, not > 11 mm. An endometrial stripe of 5 mm in this patient exceeds the tamoxifen-specific cutoff and mandates hysteroscopy with targeted biopsy. — Vitale SG et al., J Gynecol Obstet Hum Reprod 2023 [PMID 37061093]

• A) Immediate inpatient D&C
• B) Endometrial biopsy — any bleeding requires biopsy regardless of stripe thickness
• C) Endometrial biopsy can be deferred; the < 4–5 mm stripe reliably excludes endometrial cancer; clinical follow-up with instructions to return if bleeding recurs
• D) MRI pelvis urgently
• E) Serum CA-125 and refer to oncology

Answer: C — A stripe of < 4–5 mm has a high NPV for excluding endometrial cancer in postmenopausal women with bleeding. Biopsy can be deferred with appropriate follow-up instructions. — Rosen's Emergency Medicine; Washington Manual of Medical Therapeutics

• A) No action — 9 mm is below the 11 mm conventional threshold
• B) Endometrial biopsy is strongly recommended despite being below 11 mm, because Lynch syndrome carries a 40–60% lifetime risk of endometrial cancer — additional risk factors lower the threshold
• C) Repeat TVUS in 12 months
• D) Refer for prophylactic hysterectomy immediately
• E) CA-125 measurement as a first step

Answer: B — While the conventional threshold in asymptomatic women is ≥ 11 mm, this is a population average. Lynch syndrome confers a 40–60% lifetime risk of endometrial cancer (RR ~20 vs. general population) — a compelling additional risk factor that justifies biopsy at a lower thickness. Shared decision-making with biopsy is the appropriate approach. — Berek & Novak's Gynecology

Summary Reference Table

Quiz: Risk of Malignancy Index (RMI)

Section 1: Formula & Components

• A) Uterine size score, Morphology score, CA125 in ng/mL
• B) Ultrasound score, Menopausal status score, CA125 in kU/L
• C) Ultrasound score, Metastasis score, CA125 in ng/mL
• D) Unilocular cyst score, Menopausal score, CA125 in IU/mL
• E) Ultrasound score, Morphology score, CA125 in pmol/L

Answer: B — RMI = U (ultrasound score) × M (menopausal status score) × CA125 concentration in kU/L (or U/mL). — Tietz Textbook of Laboratory Medicine, 7th ed.

• A) Size > 5 cm, simple cyst, unilateral, mobile, no ascites
• B) Multilocular cyst, solid areas, evidence of metastases, ascites, bilateral lesions
• C) Papillary projections only
• D) Colour Doppler flow, calcification, wall thickness, size, septa
• E) Fixed mass, pelvic adhesions, acoustic shadowing, nodularity, echogenicity

Answer: B — The five ultrasound features each scoring one point are: multilocular/nodular cyst, solid areas, evidence of metastases, ascites, bilateral lesions. — Tietz Textbook of Laboratory Medicine, 7th ed.

• A) U = ultrasound score directly (0–5)
• B) U = 0 if score 0; U = 1 if score 1; U = 3 if score 2–5
• C) U = 0 if score 0–1; U = 2 if score 2–3; U = 4 if score 4–5
• D) U = 1 always if any feature is present; U = 0 if none
• E) U = the square of the raw ultrasound score

Answer: B — U = 0 (score 0); U = 1 (score 1); U = 3 (score 2–5). The non-linear weighting amplifies the score when multiple suspicious features are present. — Tietz Textbook of Laboratory Medicine, 7th ed.

• A) M = 1 if postmenopausal; M = 3 if premenopausal
• B) M = 0 if premenopausal; M = 1 if postmenopausal
• C) M = 1 if premenopausal; M = 3 if postmenopausal
• D) M = 2 if premenopausal; M = 4 if postmenopausal
• E) M = 1 regardless of menopausal status

Answer: C — M = 1 (premenopausal); M = 3 (postmenopausal) — reflecting the higher background risk of malignancy in postmenopausal women. — Tietz Textbook of Laboratory Medicine, 7th ed.

• A) RMI = 80
• B) RMI = 240
• C) RMI = 480
• D) RMI = 720
• E) RMI = 960

Answer: D — Ultrasound score = 3 features → U = 3; postmenopausal → M = 3; CA125 = 80 kU/L.
RMI = 3 × 3 × 80 = 720 — Tietz Textbook of Laboratory Medicine, 7th ed.

• A) RMI = 40
• B) RMI = 120
• C) RMI = 40
• D) RMI = 0
• E) RMI = 80

Answer: C — Ultrasound score = 1 feature → U = 1; premenopausal → M = 1; CA125 = 40 kU/L.
RMI = 1 × 1 × 40 = 40 — Tietz Textbook of Laboratory Medicine, 7th ed.

Section 2: Interpretation & Clinical Thresholds

• A) ~40%
• B) ~60%
• C) ~80%
• D) ~95%
• E) ~100%

Answer: C — Using an RMI cutoff of 200, the PPV for malignancy is approximately 80%. — Tietz Textbook of Laboratory Medicine, 7th ed.

• A) General gynaecologist in a district general hospital
• B) General surgeon with gynaecological experience
• C) Lead clinician in a cancer centre
• D) Gynaecologic oncologist in a cancer centre
• E) Any surgeon experienced in laparoscopy

Answer: D — High RMI (> 250): Operation by a gynaecologic oncologist in a cancer centre. Moderate RMI (25–250): Lead clinician in a cancer centre. Low RMI (< 25): General gynaecologist. — Tietz Textbook of Laboratory Medicine, 7th ed.

• A) A general gynaecologist — the RMI is not high enough for specialist care
• B) Emergency surgical referral regardless of symptoms
• C) A lead clinician in a cancer centre
• D) Conservative management with repeat imaging only
• E) Referral to a general surgeon for laparoscopic cystectomy

Answer: C — Moderate RMI (25–250): Operation by a lead clinician in a cancer centre. — Tietz Textbook of Laboratory Medicine, 7th ed.

• A) Gynaecologic oncologist in a cancer centre
• B) General gynaecologist, if conservative management is not appropriate
• C) General surgeon
• D) No surgery — RMI < 25 means the mass is always benign
• E) Referral deferred until RMI rises above 25

Answer: B — Low RMI (< 25): Operation by a general gynaecologist if conservative management is not appropriate. A low RMI does not guarantee benignity — it guides triage, not absolute exclusion of malignancy. — Tietz Textbook of Laboratory Medicine, 7th ed.

Section 3: RMI vs. Other Algorithms

• A) Uses ultrasound, CA125, and age
• B) Uses HE4, CA125, and menopausal status — but does NOT include ultrasound
• C) Uses ultrasound, HE4, and menopausal status only
• D) Uses CA125 alone with a menopausal multiplier
• E) Uses ultrasound and age without any serum biomarker

Answer: B — ROMA combines HE4 + CA125 + menopausal status and generates a probability score. It is independent of ultrasound, in contrast to RMI. — Tietz Textbook of Laboratory Medicine, 7th ed.

• A) ROMA had significantly higher specificity than RMI-I in premenopausal women
• B) RMI-I had significantly higher specificity than ROMA in premenopausal women (89% vs. 78%)
• C) Both had equal sensitivity and specificity in premenopausal women
• D) Neither test was reliable in premenopausal women
• E) ROMA had higher sensitivity AND specificity in all groups

Answer: B — RMI-I specificity was 89% vs. ROMA 78% (p = 0.022) in premenopausal women, with similar sensitivity (~73–80%) in both groups. — Chacón E et al., Gynecol Obstet Invest 2019 [PMID 31311023]

• A) CA125 (specificity 0.73)
• B) ROMA postmenopausal (specificity 0.83)
• C) HE4 (specificity 0.90)
• D) ROMA premenopausal (specificity 0.80)
• E) All were equivalent

Answer: C — Pooled specificity: HE4 (0.90) > ROMA postmenopausal (0.83) > ROMA premenopausal (0.80) > CA125 (0.73). HE4 is the most specific single marker. — Suri A et al., Sci Rep 2021 [PMID 34453074]

• A) CA125 alone (AUC 0.86)
• B) HE4 alone (AUC 0.91)
• C) ROMA in postmenopausal women (AUC 0.94)
• D) ROMA in premenopausal women (AUC 0.88)
• E) RMI (AUC 0.92)

Answer: C — ROMA in postmenopausal women had the highest AUC of 0.94, making it the best overall discriminator of EOC from benign masses in this group. — Suri A et al., Sci Rep 2021 [PMID 34453074]

• A) It includes ultrasound findings but excludes CA125
• B) It includes HE4, CA125, and age — replacing menopausal status with a continuous age variable
• C) It uses HE4 only with a menopausal multiplier
• D) It was developed for premenopausal women only
• E) It requires MRI and serum HE4

Answer: B — CPH-I includes serum HE4, serum CA125, and age — age as a continuous variable instead of binary menopausal status, and no ultrasound component. — Tietz Textbook of Laboratory Medicine, 7th ed.

Section 4: Limitations & Clinical Caveats

• A) High-grade serous carcinoma
• B) Clear cell and endometrioid carcinomas, particularly stage I disease
• C) Undifferentiated carcinoma
• D) Dysgerminoma
• E) Granulosa cell tumours

Answer: B — RMI and related algorithms "perform best in patients with high-grade serous histology and less well in patients with stage I disease where clear cell and endometrioid histologies predominate." — Tietz Textbook of Laboratory Medicine, 7th ed.

• A) Cervical ectropion
• B) Atrophic vaginitis
• C) Endometriosis, fibroids, pelvic inflammatory disease, pregnancy, menstruation
• D) Polycystic ovary syndrome only
• E) Hypothyroidism only

Answer: C — CA125 is elevated in many benign conditions in premenopausal women: endometriosis, fibroids, PID, pregnancy, and menstruation — explaining why CA125 alone has low specificity in this group, and why the menopausal multiplier in RMI (M = 1 vs. 3) partially corrects for this. — Tietz Textbook of Laboratory Medicine, 7th ed.

• A) Recommended annually from age 50 by all major guidelines
• B) Recommended biennially by ACOG
• C) Not recommended — large trials (UKCTOCS, PLCO) showed no significant reduction in ovarian cancer mortality, and false positives lead to unnecessary surgery with significant complication rates
• D) Recommended only if combined with HE4
• E) Recommended from age 40 if there is a family history of any cancer

Answer: C — The UKCTOCS and PLCO trials showed no significant mortality benefit from screening; 11 operations were performed per ovarian cancer detected in UKCTOCS, with 3.5% of women having "unnecessary" operations experiencing major surgical complications. "The literature does not support routine screening for ovarian cancer in the general population." — Tietz Textbook of Laboratory Medicine, 7th ed.

• A) Uses only serum biomarkers without imaging
• B) Provides a probability estimate for five distinct diagnoses (benign, borderline, stage I, stage II–IV, secondary metastatic) rather than a single malignancy score
• C) Was developed exclusively for postmenopausal women
• D) Replaces CA125 with HE4 as the sole tumour marker
• E) Requires MRI rather than TVUS

Answer: B — ADNEX provides probability estimates for five categories (benign, borderline, stage I OC, stage II–IV OC, secondary metastatic), giving more granular pre-operative risk stratification compared to RMI's single continuous score. — Tietz Textbook of Laboratory Medicine, 7th ed.; Davenport C et al., Cochrane 2022 [PMID 35879201]

• A) RMI at threshold 200
• B) CA125 alone
• C) HE4 alone
• D) ROMA (threshold 13.1), IOTA LR2, and ADNEX — all demonstrated higher sensitivity than RMI in premenopausal women
• E) TVUS morphology alone

Answer: D — In premenopausal women, ROMA (threshold ~13.1), IOTA LR2, and ADNEX demonstrated higher sensitivity than RMI at a post-test probability threshold of 10%, suggesting these newer models outperform RMI in premenopausal women. — Davenport C et al., Cochrane Database Syst Rev 2022 [PMID 35879201]

Quick Reference Summary

Quiz: Ovarian Cyst Size Cut-offs & Surgical Management

Section 1: Functional Cysts — Natural History

• A) 1–2 cm
• B) 3–8 cm
• C) 8–12 cm
• D) > 12 cm
• E) Always < 1 cm

Answer: B — Follicular cysts typically vary from 3 to 8 cm in diameter, are thin-walled, hypoechoic, and unilocular on ultrasound. — Grainger & Allison's Diagnostic Radiology

• A) Surgical removal within 4 weeks — risk of torsion is high
• B) No treatment required in most cases; cysts usually regress spontaneously within 2 months
• C) Oral contraceptive pills to accelerate regression over 6 months
• D) Aspiration under ultrasound guidance within 6 weeks
• E) Watchful waiting for 12 months before any action

Answer: B — Follicular cysts are often asymptomatic and usually regress spontaneously in 2 months; no treatment is required in the majority of cases. — Grainger & Allison's Diagnostic Radiology

• A) Immediate laparoscopy
• B) Repeat ultrasound after 6–12 weeks to confirm regression
• C) Serum CA125 and tumour marker panel immediately
• D) MRI pelvis within 1 week
• E) Diagnostic laparoscopy at 4 weeks

Answer: B — Corpus luteal cysts commonly resolve spontaneously; a repeat ultrasound after 6–12 weeks will usually demonstrate regression. — Grainger & Allison's Diagnostic Radiology

Section 2: Premenopausal Women — Size Thresholds

• A) Up to 3 cm
• B) Up to 5 cm
• C) Up to 5–7 cm (ACOG PB 174 threshold)
• D) Up to 10 cm
• E) Any size, provided CA125 is normal

Answer: C — ACOG Practice Bulletin 174 recommends that in premenopausal women, simple cysts ≤ 5 cm are almost certainly benign and require no follow-up imaging; 5–7 cm simple cysts can be followed with annual imaging. Surgical intervention is recommended for cysts > 7 cm due to the technical limitations of serial imaging for larger masses and increased torsion risk.

• A) Urgent surgical referral
• B) Repeat TVUS in 6 weeks
• C) Annual imaging surveillance
• D) No follow-up imaging is required — these are almost certainly benign
• E) CA125 + repeat TVUS in 3 months

Answer: D — ACOG Practice Bulletin 174: simple cysts ≤ 5 cm in premenopausal women are almost certainly benign and no follow-up imaging is needed.

• A) Immediate laparoscopic cystectomy
• B) Repeat TVUS in 2 weeks
• C) Annual ultrasound surveillance — 5–7 cm simple cysts can be followed with annual imaging
• D) Serum HE4 and ROMA score calculation
• E) OCP suppression for 3 cycles then reassess

Answer: C — Simple cysts measuring 5–7 cm in premenopausal women warrant annual imaging surveillance; the risk of malignancy remains very low in this group. — ACOG Practice Bulletin 174

• A) > 3 cm
• B) > 5 cm
• C) > 7 cm
• D) > 10 cm
• E) > 12 cm

Answer: C — Cysts > 7 cm in premenopausal women are generally considered for surgical evaluation because they cannot be reliably assessed by ultrasound imaging alone and carry increased risk of torsion. — ACOG Practice Bulletin 174

Section 3: Postmenopausal Women — Size Thresholds

• A) ≤ 3 cm
• B) ≤ 5 cm (SRU/ACR and ACOG consensus)
• C) ≤ 7 cm
• D) ≤ 10 cm
• E) Any simple cyst is surgical regardless of size

Answer: B — The SRU/ACR consensus and ACOG Practice Bulletin 174 recommend that in postmenopausal women, simple unilocular cysts ≤ 5 cm with normal CA125 and no symptoms can be followed conservatively with annual ultrasound surveillance — the risk of malignancy is very low (< 1%).

• A) 5–10%
• B) 3–5%
• C) 1–3%
• D) < 1%
• E) 15–20%

Answer: D — The risk of malignancy in a simple unilocular cyst ≤ 5 cm in postmenopausal women is < 1%, supporting a conservative management approach. — ACOG Practice Bulletin 174; SRU/ACR Consensus

• A) Immediate laparoscopic salpingo-oophorectomy
• B) Calculate RMI — if > 200, proceed to surgery
• C) Annual ultrasound surveillance — meets criteria for conservative management
• D) Transvaginal ultrasound every 3 months for 1 year
• E) Prophylactic bilateral salpingo-oophorectomy

Answer: C — A simple, unilocular cyst ≤ 5 cm with normal CA125 in an asymptomatic postmenopausal woman meets criteria for annual ultrasound surveillance rather than surgical intervention. — ACOG Practice Bulletin 174

• A) > 5 cm
• B) > 7 cm
• C) > 7–10 cm (surgical evaluation recommended)
• D) > 12 cm
• E) Size is irrelevant — only morphology and CA125 matter

Answer: C — Cysts > 7–10 cm in postmenopausal women are generally recommended for surgical evaluation, as larger cysts have higher rates of malignancy and technical surveillance limitations. ACOG PB 174 specifically recommends surgical evaluation for simple cysts > 10 cm in postmenopausal women.

Section 4: Features Warranting Surgery Regardless of Size

• A) Thin wall, unilocular, anechoic appearance
• B) Solid components or papillary projections, multilocularity, thick septae (> 3 mm), bilateral lesions, associated ascites, colour Doppler flow within solid areas
• C) Any cyst persisting beyond 8 weeks
• D) Cyst with a single thin septum and no solid component
• E) Cyst with high T2 signal on MRI

Answer: B — Morphological features mandating surgical evaluation include solid components, papillary projections, thick septae (> 3 mm), multilocularity, bilaterality, ascites, and internal Doppler flow in solid areas — regardless of size. — ACOG Practice Bulletin 174; RMI ultrasound scoring criteria

• A) Thin wall with posterior acoustic enhancement
• B) Unilocular cyst with high T2 MRI signal
• C) Papillary projections or solid nodules within the cyst wall with colour Doppler flow
• D) Ground-glass echogenicity suggesting endometrioma
• E) Dependent echoes suggesting haemorrhage

Answer: C — Papillary projections or solid components with internal vascularity on colour Doppler are the most worrying features indicating possible malignancy, warranting urgent surgical referral at any cyst size. — Grainger & Allison's Diagnostic Radiology; ACOG

• A) Cyst size > 7 cm alone
• B) CA125 elevation
• C) Suspected ovarian torsion — absent Doppler flow with acute pain and enlarged ovary requires emergency surgical intervention
• D) Multilocularity
• E) Bilateral cysts

Answer: C — Ovarian torsion is an absolute surgical emergency. Absent Doppler flow in the context of acute pelvic pain and an enlarged ovary warrants immediate laparoscopic intervention regardless of cyst size or morphology. — ACOG Practice Bulletin 174

• A) Simple follicular cyst
• B) Corpus luteum cyst
• C) Mature cystic teratoma (dermoid cyst)
• D) Endometrioma < 4 cm
• E) Para-ovarian cyst

Answer: C — Dermoid cysts (mature cystic teratomas) have a long pedicle and carry a higher risk of torsion. They are generally managed surgically at ≥ 5 cm in reproductive-age women. Their sebaceous/fat content also gives characteristic ultrasound appearances.

Section 5: Special Scenarios

• A) Dermoid cyst — surgical if > 7 cm
• B) Endometrioma — surgical management is recommended for endometriomas ≥ 4 cm, particularly if symptomatic or affecting fertility
• C) Corpus luteum cyst — follow for 12 weeks
• D) Serous cystadenoma — surgical if > 10 cm
• E) Follicular cyst — no treatment needed

Answer: B — The "ground-glass" appearance is characteristic of an endometrioma. ESHRE guidelines recommend surgery for endometriomas ≥ 4 cm when symptomatic (pain, subfertility) or prior to assisted reproduction. — ESHRE Endometriosis Guidelines

• A) > 3 cm
• B) > 5 cm
• C) > 5–6 cm persisting into the second trimester with complex features
• D) > 10 cm
• E) Any cyst in pregnancy requires immediate surgery

Answer: C — In pregnancy, simple cysts ≤ 5 cm are almost always managed conservatively. Cysts > 5–6 cm with complex or suspicious features persisting into the second trimester (14–20 weeks) are considered for surgery due to torsion risk as the uterus grows and to avoid obstruction of labour. — Cagino K et al., J Minim Invasive Gynecol 2021 [PMID 33515746]

• A) Any cyst in a postmenopausal woman regardless of features
• B) Cyst > 5 cm alone
• C) RMI > 250; or any cyst with solid areas, bilaterality, ascites, or metastatic features
• D) CA125 > 35 kU/L alone
• E) Any persistent cyst after 3 months

Answer: C — RCOG GTG 62 states that women with an RMI > 250, or with cysts demonstrating high-risk morphological features (solid areas, bilaterality, ascites, metastases), should be referred to a gynaecologic oncologist. — RCOG Green-top Guideline 62

• A) Surgical excision — all cysts > 5 cm in postmenopausal women require surgery
• B) Immediate referral to gynaecologic oncology
• C) Conservative management with annual ultrasound — simple cysts 5–7 cm with normal CA125 in postmenopausal women may be surveilled
• D) Combined OCP to suppress the cyst
• E) MRI pelvis within 1 month

Answer: C — Per ACOG PB 174, simple cysts 5–7 cm in postmenopausal women with normal CA125 can be managed with annual ultrasound surveillance. Surgery is indicated when size exceeds this range, CA125 is elevated, or morphological complexity develops.

• A) Rupture has no clinical significance for benign-appearing cysts
• B) Spillage always requires conversion to open laparotomy
• C) Efforts should be made to remove the cyst intact (in a bag); if rupture occurs, thorough peritoneal washings and cytology are essential; upstaging of early ovarian cancer (from stage IA to stage IC) can occur with rupture
• D) Rupture automatically upgrades surgical management to full staging
• E) Cyst content can be aspirated first to reduce size before removal

Answer: C — Intraoperative cyst spillage of a malignant or borderline tumour can upgrade disease from FIGO stage IA to stage IC1, altering adjuvant treatment decisions. Intact removal using an endobag is the recommended technique. — ACOG Practice Bulletin 174; Berek & Novak's Gynecology

Summary Table: Size Cut-offs at a Glance