Image: National Institutes of Health.

 

Ovarian cysts in post-menopausal women are now known to be very common and most are not cancerous.  However, because the greatest risk factor for ovarian cancer is age, any cysts in a postmenopausal woman should be taken seriously. Before ultrasound was readily available for physicians to use as a tool to evaluate the ovaries, any ovary which a physician was able to palpate (feel) on a physical examination in a post menopausal woman was recommended to be removed. After the advent of the use of ultrasound in pelvic imagining, any cysts noted in post-menopausal women were generally removed. Now, after years of widespread use and experience in ultrasound imaging, the criteria for how to manage an ovarian cyst has radically changed, and generally cysts that do not demonstrate well-defined malignant characteristics  and do not grow may simply be observed for change.

In one study of 7,700 healthy women, 450 were found to have ovarian cysts, and many of these resolved with time. Ovarian cysts may be detected on physical examination by your healthcare provider, because your physician has performed or ordered a pelvic ultrasound, or they may be found when imaging studies such as a CT scan, MRI, or ultrasound have been performed for another reason. Cysts may be associated with pelvic pressure or pain. When they twist, they may be associated with severe pain.

In general, all post-menopausal women with ovarian cysts should be evaluated by a physician and an expert in pelvic sonography.  A CA125 blood test should also be performed. Simple cysts (those which only contain liquid) are generally benign and may be followed through serial ultrasounds for a period of time. Cysts should be considered for removal if they are associated with pain or an elevated CA125. Complex cysts (those which have potentially malignant characteristics) should thoroughly be evaluated by an expert sonographer in pelvic imaging, and careful consideration about their removal should be made.

Removal of an ovarian cyst can many times be performed with minimally invasive surgery, such as laparoscopy (referred to as belly button or keyhole surgery). However, occasionally an open procedure (referred to as a laparotomy) will be required. It is important that the gynecologist, if not a gynecologic oncologist, have a gynecologic oncologist on standby if the cyst has potential malignant characteristics or if the CA125 is elevated. Your gynecologist may also pre-operatively order a new blood test called OVA1 to help determine if the cyst is malignant.

Important questions to consider when surgery is recommended are: Do I remove just the cyst, or the entire ovary? Do I remove both ovaries? These points should be thoroughly reviewed pre-operatively with your physician. If you have an elevated risk of ovarian or breast cancer, then careful consideration about removal of both ovaries should be made. If you are not at elevated risk for ovarian cancer, then you should discuss with your healthcare provider the fact that the ovaries, even after menopause, help protect women against cardiac disease, which remains the leading cause of death in women.

The take-home message:

  • Benign cysts are common in post-menopausal women.
  • If a woman has a small, simple ovarian cyst with a normal CA125 and no symptoms, she may be followed closely by a physician with serial ultrasound imaging, CA125 testing, and physical examinations.
  • Cysts which are growing significantly, have potentially malignant characteristics, are associated with an elevated CA125, or associated with symptoms should be removed.
  • Careful consideration should be given to surgical approach with minimally invasive surgery, and to whether the cyst, one, or both ovaries should be removed. A gynecologic oncologist should be on standby or perform the operation if there is a significant chance that the cyst could be malignant.

Current models suggest that there is a potential 5-year pre-clinical phase (a time where a cancer is developing and is not detectable or associated with symptoms) to ovarian cancer. So no cyst or ovarian abnormality should be ignored and forgotten about. All need some form of follow-up.