Menopause Live (21 May, 2012) from IMS

The prevalence of simple ovarian cysts in postmenopausal women may range from 3% to 15%. Simple cysts are usually followed conservatively, but concern about progression to malignancy may lead to surgical exploration, which in most cases would likely be for benign conditions. A recent retrospective study from the USA [1] evaluated 619 patients with 743 simple ovarian cysts; 305 patients (49.27%) were lost in follow-up. Therefore, 314 patients (50.73%) with 378 cysts were followed further by ultrasound study. In all, 175 (46.30%) of the 378 cysts that could be followed further had spontaneous resolution and 166 cysts (43.91%) persisted unchanged over the follow-up period. Thirty cysts (7.94%) turned into complex cysts and four cysts (1.06%) significantly increased in size. One cyst significantly decreased in size, although it did not resolve. Only one patient developed papillary serous carcinoma (high grade) of the ovary. This occurred 3 years after her last ultrasound for simple cyst surveillance. Thus, simple ovarian cysts during the menopause can be followed conservatively because their risk for malignant transformation is low. The majority of these cysts either resolve spontaneously or persist unaltered on follow-up.

Comment
The diagnosis of simple ovarian cysts among postmenopausal women is being made more commonly in recent years due to the increased use of transvaginal ultrasound for screening. Aggressive surgical management, which was the norm a decade ago, has now changed to a more conservative approach. Close monitoring is advocated by most authors, while some have raised the question of whether simple cysts need to be monitored at all [2].

Women in the study by Sarkar and Wolf were followed up every 4 months in the first year and then annually thereafter. Their findings support recent recommendations to follow unilocular simple cysts in postmenopausal women without intervention. Although almost 50% of women in the study were lost to follow-up, there was only one malignancy detected in the remaining 314 patients. In fact, a much larger study from Kentucky, where 2763 women (18%) were diagnosed with 3259 unilocular ovarian cysts, concluded that the risk of malignancy in unilocular ovarian cystic tumors less than 10 cm in diameter in women 50 years old or older is extremely low [3]. Results from a large cohort in the Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial also suggested that simple cysts were not associated with development of ovarian cancer, an outcome actively ascertained in the PLCO trial [4].

Jyothi Unni
Jehangir Hospital, Pune, India

References
1. Sarkar M, Wolf MG. Simple ovarian cysts in postmenopausal women: scope of conservative management. Eur J Obstet Gynecol 2012 February 14. Epub ahead of print.
http://www.ncbi.nlm.nih.gov/pubmed/22340986
2. Valentin L, Akrawi D. The natural history of adnexal cysts incidentally detected at transvaginal ultrasound examination in postmenopausal women. Ultrasound Obstet Gynecol 2002;20:174–80.
http://www.ncbi.nlm.nih.gov/pubmed/12153669
3. Modesitt SC, Pavlik EJ, Ueland FR, DePriest PD, Kryscio RJ, van Nagell JR Jr. Risk of malignancy in unilocular ovarian cystic tumors less than 10 centimeters in diameter. Obstet Gynecol 2003;102:594–9.
http://www.ncbi.nlm.nih.gov/pubmed/12962948
4. Greenlee RT, Kessel B Williams CR, et al. 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.e1–9.
http://www.ncbi.nlm.nih.gov/pubmed/20096820