Treatment of Ovarian Cysts

Types of Ovarian Cysts (Affects Treatment Choice)

1. Expectant (Watchful Waiting) - First-Line for Most Cysts

• Functional cysts (follicular and corpus luteum) are the most common and almost always resolve spontaneously within 1-3 menstrual cycles - Harrison's Principles of Internal Medicine, 22E
• Small, simple, unilocular cysts in premenopausal women under 5 cm typically just need ultrasound follow-up in 6-12 weeks
• RCOG 2025 update: postmenopausal women with simple cysts ≤3 cm do not require routine follow-up

2. Medical (Drug) Treatment

A. Pain Relief

• NSAIDs (ibuprofen, naproxen): first-line for pain from uncomplicated cysts. Harrison's specifically recommends NSAIDs for pain related to degenerating or inflamed pelvic masses
• Paracetamol (acetaminophen): mild analgesic alternative

B. Combined Oral Contraceptive Pill (COCP)

• Not effective for shrinking existing cysts, but strongly recommended for women with recurrent functional cyst formation to suppress ovulation and prevent new cysts - Harrison's Principles, 22E
• Examples: ethinylestradiol + levonorgestrel, ethinylestradiol + norethisterone
• Also helps manage dysmenorrhea and pelvic pain associated with cysts

C. Hormonal Therapy for Endometriomas (Endometriotic Cysts)

• GnRH agonists (e.g., leuprolide, nafarelin, goserelin): suppress estrogen, reduce endometrioma size, reduce pain. Used before or after surgery. Given as injection or nasal spray; add-back HRT often co-prescribed to prevent bone loss with long-term use
• Progestins (e.g., dienogest 2 mg/day, norethisterone acetate, medroxyprogesterone acetate): reduce estrogen effect on endometrial tissue, suppress endometrioma growth, control pain. Dienogest is widely used and well-tolerated
• Combined OCP: reduces recurrence of endometriomas post-surgery
• Aromatase inhibitors (letrozole): used in refractory cases, typically with a progestin or OCP to prevent ovarian stimulation
• Three-step procedure for large endometriomas: marsupialization → GnRH analog for 3 months → then laser/electrocoagulation of cyst wall - Berek & Novak's Gynecology

3. Surgical Treatment

• Cyst is symptomatic, persistent, or enlarging
• Size >5-10 cm (simple) or any size (complex/suspicious features)
• Signs of torsion, rupture, or hemorrhage
• Suspected malignancy

• Laparoscopic cystectomy (preferred): removes cyst wall while preserving normal ovarian tissue - recommended over drainage/ablation, especially for endometriomas, as it gives lower recurrence rates (OR 0.41 for endometrioma recurrence; OR 0.15 for dysmenorrhea recurrence) - Berek & Novak's Gynecology, citing ESHRE guidelines
• Laparotomy: for large, complex, or potentially malignant cysts
• Ultrasound-guided aspiration: a 2023 meta-analysis (PMID: 36912183) supports ultrasound-guided interventional therapy for benign cysts as an effective minimally invasive option with less blood loss vs open surgery
• Salpingo-oophorectomy: for postmenopausal women or when malignancy is strongly suspected

Special Situations

Summary of Medicines Used

Important note: Most simple ovarian cysts in reproductive-age women resolve on their own and do not require medication. A gynaecologist should be consulted before starting any hormonal therapy, as the appropriate treatment depends on cyst type, size, symptoms, and the patient's age and reproductive goals.