Ovarian Cysts

Author: C William Helm, MB, BCh, MA, FRCS(Edin), FRCSE, Associate Professor, Division of Gynecologic Oncology, James Graham Brown Cancer Center, University of Louisville

Introduction

Background

An ovarian cyst is a sac filled with liquid or semi-liquid material arising in an ovary. The number of diagnoses of ovarian cysts has increased with the widespread implementation of regular physical examinations and ultrasound technology. The finding of an ovarian cyst causes considerable anxiety for women because of the fear of malignancy, but the vast majority of ovarian cysts are benign.

Pathophysiology

Each month, normally functioning ovaries develop small cysts called Graafian follicles.1 At mid cycle, a single dominant follicle up to about 2.8 cm in diameter releases a mature oocyte.

The ruptured follicle becomes the corpus luteum, which, at maturity, is a 1.5- to 2-cm structure with a cystic center. In the absence of fertilization of the oocyte, it undergoes progressive fibrosis and shrinkage. If fertilization occurs, the corpus luteum initially enlarges and then gradually decreases in size during pregnancy.

Ovarian cysts arising in the normal process of ovulation are called functional cysts and are always benign. They may be follicular and luteal, sometimes called theca-lutein cysts. These cysts can be stimulated by gonadotropins, including follicle-stimulating hormone (FSH) and human chorionic gonadotropin (hCG). A theca-lutein cyst is shown in the sonogram below.

Theca-lutein cysts replacing an ovary in a patien...

Theca-lutein cysts replacing an ovary in a patient with a molar pregnancy. Despite their size these cysts are benign and usually resolve after treatment of the underlying disease.


Multiple functional cysts can occur as a result of excessive gonadotropin stimulation or sensitivity. In gestational trophoblastic neoplasia (hydatidiform mole and choriocarcinoma) and rarely in multiple and diabetic pregnancy, hCG causes a condition called hyperreactio luteinalis. In patients being treated for infertility, ovulation induction with gonadotropins (FSH and luteinizing hormone [LH]), and rarely clomiphene citrate, may lead to ovarian hyperstimulation syndrome, especially if accompanied by hCG administration.

Neoplastic cysts arise by inappropriate overgrowth of cells within the ovary and may be malignant or benign. Malignant neoplasms may arise from all ovarian cell types and tissues. By far, the most frequent are those arising from the surface epithelium (mesothelium), and most of these are partially cystic lesions. The benign counterparts of these cancers are serous and mucinous cystadenomas. Other malignant ovarian tumors may contain cystic areas, and these include granulosa cell tumors from sex cord stromal cells and germ cell tumors from primordial germ cells. A clear cell carcinoma is shown in the image below.

Cross-section of a clear cell carcinoma of the ov...

Cross-section of a clear cell carcinoma of the ovary. Note the cystic spaces intermingled with solid areas.

 

Teratomas are a form of germ cell tumor2 containing elements from all 3 embryonic germ layers, ie, ectoderm, endoderm, and mesoderm. A mature cystic teratoma is shown in the image below.

A dermoid cyst (mature cystic teratoma) after op...

A dermoid cyst (mature cystic teratoma) after opening the abdomen. Note the yellowish color of the contents seen through the wall.

 

Endometriomas are cysts filled with blood arising from the ectopic endometrium. In polycystic ovary syndrome, the ovary often contains multiple cystic follicles 2-5 mm in diameter as viewed on sonograms. The cysts themselves are never the main problem, and discussion of this disease is beyond the scope of this article.

Frequency

United States

Ovarian cysts are found on transvaginal sonograms in nearly all premenopausal women and in up to 18% of postmenopausal women.3 Most of these cysts are functional in nature and benign. Mature cystic teratomas or dermoids represent more than 10% of all ovarian neoplasms. The incidence of ovarian carcinoma is approximately 15 cases per 100,000 women per year. Annually in the United States, ovarian carcinomas are diagnosed in more than 21,000 women, causing an estimated 14,600 deaths.4 Most malignant ovarian tumors are epithelial ovarian cystadenocarcinomas. Tumors of low malignant potential comprise approximately 20% of malignant ovarian tumors, whereas fewer than 5% are malignant germ cell tumors, and approximately 2% granulosa cell tumors.

Mortality/Morbidity

  • Benign cysts can cause pain and discomfort related to pressure on adjacent structures, torsion, rupture, hemorrhage (both within and outside of the cyst), and abnormal uterine bleeding. They rarely cause death. Mucinous cystadenomas may cause a relentless collection of mucinous fluid within the abdomen, known as pseudomyxoma peritonei, which may be fatal without extensive treatment.
  • Mortality associated with malignant ovarian carcinoma is related to the stage at the time of diagnosis, and patients with ovarian carcinoma generally present late in the course of disease. The 5-year survival rate overall is 41.6%, varying between 86.9% for International Federation of Gynecology and Obstetrics (FIGO) stage Ia and 11.1% for stage IV.5 Granulosa cell tumors are associated with an 82% survival rate, whereas squamous cell carcinomas arising in a dermoid cyst have a very poor outcome. Most germ cell tumors are diagnosed at an early stage and have an excellent outcome. Advanced-stage dysgerminomas are associated with a better outcome compared to nondysgerminomatous germ cell tumors. A distinct group of less aggressive tumors of low malignant potential has a more benign course but is still associated with mortality.6 The overall survival rate is 86.2% at 5 years.
  • Malignant ovarian cystic tumors can cause severe morbidity, including pain, abdominal distension, bowel obstruction, nausea, vomiting, early satiety, wasting, cachexia, indigestion, heartburn, abnormal uterine bleeding, deep venous thrombosis, and dyspnea. Cystic granulosa cell tumors may secrete estrogen, which leads to postmenopausal bleeding and precocious puberty in elderly patients and young patients, respectively.

Race

Malignant epithelial ovarian cystadenocarcinomas are the only ovarian cysts associated with racial differences.

  • Women from northern and western Europe and North America are affected most frequently, whereas women from Asia, Africa, and Latin America are affected least frequently.
  • Within the United States, age-adjusted incidence rates in surveillance areas are highest among American Indian women, followed by white, Vietnamese, Hispanic, and Hawaiian women. Incidence is lowest among Korean and Chinese women.7
  • Among women for whom sufficient numbers of cases are available to calculate rates based on age, incidence in those aged 30-54 years is highest in white women, followed by Japanese, Hispanic, and Filipino women. For those aged 55-69 years, the highest rates occur in white women, followed by Hispanic and Japanese women. Among women aged 70 years or older, the highest rate occurs among white women, followed by those of African descent and Hispanic women.

Age

  • Functional ovarian cysts occur at any age (including in utero), but are much more common in reproductive-aged women. They are rare after menopause. Luteal cysts occur after ovulation in reproductive-aged women. Most benign neoplastic cysts occur during the reproductive years, but the age range is wide and they may occur in persons of any age.
  • The incidence of epithelial ovarian cystadenocarcinomas, sex cord stromal tumors, and mesenchymal tumors rises exponentially with age until the sixth decade of life, at which point the incidence plateaus. Tumors of low malignant potential occur at a mean age of 44 years, with a span from adolescence to senescence. The average age is more than a decade less than that for invasive cystadenocarcinoma. Germ cell tumors are most common in adolescence and rarely occur in those older than 30 years.

Clinical

History

  • Most patients with ovarian cysts are asymptomatic but some cysts may be associated with a range of symptoms, sometimes severe.8 Even malignant ovarian cysts commonly do not cause symptoms until they reach an advanced stage.
  • Pain or discomfort may occur in the lower abdomen. Torsion (twisting) or rupture may lead to more severe pain. An ovarian cyst that has undergone torsion is shown in the image below.

    • An ovarian cyst that has undergone torsion (twist...

      An ovarian cyst that has undergone torsion (twisting of the vascular pedicle). The patient presented with a short history of severe lower abdominal pain. The twisted pedicle can be seen attached to the cyst, which has turned dusky due to ischemia. No viable epithelial lining was available for histologic diagnosis.

  • Patients may experience discomfort with intercourse, particularly deep penetration.
  • Having bowel movements may be difficult, or pressure may develop, leading to a desire to defecate.
  • Micturition may occur frequently and is due to pressure on the bladder.
  • Irregularity of the menstrual cycle and abnormal vaginal bleeding may occur. Young children may present with precocious puberty and early onset of menarche.
  • Patients may experience abdominal fullness and bloating.
  • Patients may experience indigestion, heartburn, or early satiety.
  • Endometriomas are associated with endometriosis, which causes a classic triad of painful and heavy periods and dyspareunia.
  • Polycystic ovaries may be part of the polycystic ovary syndrome , which includes hirsutism, infertility, oligomenorrhea, obesity, and acne.

Physical

  • Advanced malignant disease may be associated with cachexia and weight loss, lymphadenopathy in the neck, shortness of breath, and signs of pleural effusion.
  • A large cyst may be palpable on abdominal examination. Gross ascites may interfere with palpation of an intra-abdominal mass.
  • Although normal ovaries may be palpable during the pelvic examination in thin premenopausal patients, a palpable ovary should be considered abnormal in a postmenopausal woman. If a patient is obese, palpating cysts of any size may prove difficult.
  • Sometimes, discerning the cystic nature of an ovarian cyst may be possible, and it may be tender to palpation. The cervix and uterus may be pushed to one side.
  • Other masses may be palpable, including fibroids and nodules in the uterosacral ligament consistent with malignancy or endometriosis.

Causes

  • Multiple functional cysts can occur as a result of excessive gonadotropin stimulation or sensitivity.
    • In gestational trophoblastic neoplasia (hydatidiform mole and choriocarcinoma) and rarely in multiple or diabetic pregnancy, hCG is the stimulating gonadotropin. The condition is called hyperreactio luteinalis.
    • Patients being treated for infertility by ovulation induction with gonadotropins or other agents, such as clomiphene citrate or letrozole, may develop cysts as part of ovarian hyperstimulation syndrome.
  • Tamoxifen can cause benign functional ovarian cysts that usually resolve following discontinuation of treatment.
  • Risk factors for ovarian cystadenocarcinoma include strong family history, advancing age, white race, infertility, nulliparity, a history of breast cancer , and BRCA gene mutations.

Differential Diagnoses

Abdominal Abscess
Ectopic Pregnancy

Other Problems to Be Considered

Diverticular disease
Hydronephrosis
Hydrosalpinx
Paraovarian cyst
Pedunculated leiomyoma
Pelvic kidney
Pelvic lymphocele
Peritoneal cyst
Tubo-ovarian abscess

Workup

Laboratory Studies

  • No laboratory tests are diagnostic for ovarian cysts.
  • Cancer antigen 125 (CA125) is a protein expressed on the cell membrane of normal ovarian tissue and ovarian carcinomas.
    • A serum level of less than 35 U/mL is considered normal. In some laboratories, the upper limit of normal may be lower than this.
    • While CA125 values are elevated in 85% of patients with epithelial ovarian carcinomas, overall, the value is elevated in only 50% of patients with stage I cancers confined to the ovary.9 CA125 levels are also elevated in patients with some benign conditions or other malignancies and in 6% of healthy patients.
    • The finding of an elevated CA125 level is most useful when combined with an ultrasonographic investigation while assessing a postmenopausal woman with an ovarian cyst.
  • Extensive research is ongoing to find an accurate blood test for the detection of early ovarian cancer or precancer. Approaches that have been reported and received some publicity include the use of proteomic patterns in serum10 and more recently estimation of a panel of blood markers (leptin, prolactin, osteopontin, insulinlike growth factor, macrophage inhibitory factor, and CA125) included in an immunoassay marketed with the name Ovasure.11 ,12 ,13 However, no test with widely accepted proven accuracy has yet been defined.
  • Other tumor marker values may be elevated in patients with neoplastic ovarian cysts. These markers include serum inhibin in granulosa cell tumors, alpha-fetoprotein in endodermal sinus tumors, lactic dehydrogenase in dysgerminomas, and alpha-fetoprotein and beta-hCG in embryonal carcinomas.

Imaging Studies

  • Ultrasonography
    • This is the primary imaging tool for a patient considered to have an ovarian cyst.8 ,14 ,15 Findings can help define morphologic characteristics of ovarian cysts.
    • Simple cysts are unilocular and have a uniformly thin wall surrounding a single cavity that contains no internal echoes. These cysts are unlikely to be cancerous. Most commonly, they are functional follicular or luteal cysts or, less commonly, serous cystadenomas or inclusion cysts.
    • Complex cysts may have more than one compartment (multilocular), thickening of the wall, projections (papulations) sticking into the lumen or on the surface, or abnormalities within the cyst contents. Malignant cysts usually fall within this category, as do many benign neoplastic cysts.
    • Hemorrhagic cysts, endometriomas, and dermoids tend to have characteristic features on sonograms that may help to differentiate them from malignant complex cysts. A dermoid cyst is shown in the sonogram below.

      • Endovaginal sonogram shows a striking echogenic m...

        Endovaginal sonogram shows a striking echogenic mass lateral to the uterus, with posterior acoustic shadowing giving a "tip-of-the-iceberg" appearance. This is pathognomonic for dermoid cyst. Occasionally, this appearance may be mistaken for gas-filled bowel. Courtesy of Patrick O'Kane,

    • Sonograms may not be helpful for differentiating hydrosalpinx, paraovarian, and tubal cysts from ovarian cysts.
    • Endovaginal ultrasonography can help in a detailed morphologic examination of pelvic structures. This requires a handheld probe to be inserted into the vagina. It is relatively noninvasive and is well tolerated in reproductive-aged women and post–reproductive-aged women who are still engaging in intercourse. It does not require a full bladder.
    • Transabdominal ultrasonography is better than endovaginal ultrasonography for evaluating large masses and allows assessment of other intra-abdominal structures such as the kidneys, liver, and ascites. It requires a full bladder. Transabdominal sonogram is shown in the image below.

      • Transabdominal sonogram of a 24-cm diameter multi...

        Transabdominal sonogram of a 24-cm diameter multilocular right ovarian cyst with adjacent Fallopian tube and uterus. The infundibulo-pelvic ligament carrying the ovarian artery and vein has been divided. This sonogram demonstrates a large, complex, cystic mass with vascularity within the septations. Red and blue colors show blood flow towards and away from the transducer. The resistive index was low. Histology reported a mucinous cystadenocarcinoma of low malignant potential. Courtesy Patrick O'Kane, MD.

    • 3-dimensional ultrasonography may have advantages in the evaluation of ovarian cysts.16 ,17 Doppler flow studies
    • These studies can help identify blood flow within a cyst wall and adjacent areas, including tumor surface, septa, solid parts within the tumor, and peritumorous ovarian stroma. The principle is that new vessels within tumors have lower resistance to blood flow because they lack developed smooth muscle in the walls. This can be quantitated into a resistive or pulsatility index.
    • Estimation of the resistive index has limited clinical value in premenopausal women because of the great overlap of low-resistance flow characteristics in functional tumors and early cancers.
    • Determination of the presence or absence of any blood flow within certain cysts may be helpful in diagnosis. For instance, hemorrhagic cysts may contain fine internal septations that characteristically do not demonstrate blood flow on Doppler images.
  • MRI
    • MRI with gadolinium allows clearer evaluation of lesions deemed indeterminate after performing ultrasonography.
    • MRI images have better soft tissue contrast compared to CT scan images, particularly for identifying fat and blood products, and can give a better idea of the organ of origin of gynecologic masses.
    • MRI is not necessary in most cases.
  • CT scan
    • CT scanning is inferior to ultrasonography and MRI for helping define ovarian cysts and pelvic masses.
    • CT scan allows examination of the abdominal contents and retroperitoneum in cases of malignant ovarian disease.

Procedures

  • Using needle aspiration to obtain fluid for cytologic examination provides inaccurate cytology results, and needle aspiration is an inappropriate method for cyst drainage in most cases.18 ,19 ,20
  • Performing diagnostic laparoscopy may sometimes be necessary to inspect a suggestive adnexal cystic mass, but an intraovarian malignancy may be missed.

Histologic Findings

The definitive diagnosis of all ovarian cysts is made based on histological analysis. Each type has characteristic findings.

Treatment

Medical Care

  • Many patients with simple ovarian cysts based on ultrasonographic findings do not require treatment.
  • In a postmenopausal patient, a persistent simple cyst smaller than 5 cm in dimension in the presence of a normal CA125 value may be monitored with serial ultrasonography examinations.21 ,22 Some evidence suggests that cysts up to 10 cm can be safely followed in this way.
  • Premenopausal women with asymptomatic simple cysts smaller than 8 cm on sonograms in whom the CA125 value is within the reference range may be monitored with a repeat ultrasonographic examination in 8-12 weeks. Hormone therapy, including the use of the oral contraceptive pill, is not helpful in causing resolution.23

Surgical Care

  • Persistent simple ovarian cysts larger than 5-10 cm, especially if symptomatic, and complex ovarian cysts should be considered for surgical removal.
  • The surgical approaches include an open incisional technique (laparotomy) and a minimally invasive technique (laparoscopy) with very small incisions. Whichever route is used, the goals remain the same and include the following: 
    • To confirm the diagnosis of an ovarian cyst
    • To assess whether the cyst appears to be malignant
    • To obtain fluid from peritoneal washings for cytologic assessment
    • To remove the entire cyst intact for pathologic analysis (This may mean removing the entire ovary.)
    • To assess the opposite ovary and other abdominal organs
    • To perform additional surgery as indicated
  • The use of laparoscopic techniques is becoming widespread and the indications are extending. Laparoscopy is preferred to laparotomy when indicated because it has less adverse effects for the patient and leads to faster recovery.24 However, it is essential that the disease outcome for the patient is not inferior to that achieved with laparotomy.25
  • Some patients, including those with chronic lung disease who are unable to tolerate a high intra-abdominal pressure or a steep head-down position, are unsuitable for laparoscopy. Others are unsuitable because of previous surgeries causing severe adhesions. For many situations the most important factor is the skill and experience of the surgeon.
  • With benign cysts there is no absolute contraindication to the use of laparoscopy. Such patients include those considered to have a dermoid cyst or endometrioma, those with functional or simple cysts that are causing symptoms and have not resolved with conservative management, and those presenting with acute symptoms. Although the aim should be to remove all cysts intact26 ,27 , if this is not possible the cyst and/or affected ovary may be placed in a protective bag that allows the cyst to be ruptured and drained without contamination prior to removal.
  • Malignant ovarian cysts associated with widespread disease are usually managed by laparotomy.
  • Some controversy surrounds the surgical approach for very large benign-appearing ovarian cysts. The traditional approach for both was a long, midline incision. Some now promote the laparoscopic drainage of the former allowing the ovary to be removed through a small incision.28 The down side to this is the potential for the cyst to spill cancer cells into the abdominal cavity. Laparoscopy is now used to remove small to medium-sized cancerous ovarian cysts (up to about 12 cm) and to stage ovarian cancer.
  • Excision of a benign cyst alone, with conservation of the ovary, may be performed in patients who desire retention of their ovaries for future fertility or other reasons. Included are endometrioma, dermoid, and functional cysts.
  • If the ovarian cyst is benign, removal of the opposite ovary should be considered in postmenopausal, perimenopausal, and premenopausal women older than 35 years who have completed their family and are considered at increased genetic risk for subsequent development of ovarian carcinoma. These indications are all relative and the issues should be discussed with the patient prior to any surgery.
  • A gynecologic cancer specialist should be available to help with any patient who undergoes surgery for a potentially malignant ovarian cyst. This allows the appropriate surgery to be performed on patients found to have cancer. Whenever possible, the patient should have consulted with the specialist prior to the surgery to allow all issues to be addressed.

Consultations

  • Infertility and reproductive endocrinologist for endometrioma and polycystic ovary syndrome
  • Gynecologic oncologist for any complex ovarian cyst or adnexal mass, especially if the serum CA125 level is elevated above 35 U/mL and for a patient with a strong family history of ovarian carcinoma

Diet

Normal healthy diet

Follow-up

Deterrence/Prevention

  • Current use of oral contraceptive pills protects against the development of functional ovarian cysts. Current and previous use within 15 years reduces the risk of epithelial ovarian cystadenocarcinoma.
  • All women should undergo an annual gynecologic examination. No generalized screening test is available for ovarian cystadenocarcinoma, but women at high risk based on family history or previous history of breast cancer should undergo an annual ultrasonographic examination and CA125 test. Referral for genetic counseling should be considered.
  • Women at high risk for ovarian cystadenocarcinoma may be offered prophylactic oophorectomy, which will prevent the development of ovarian cancer but not peritoneal carcinoma.

Complications

  • Torsion
  • Rupture
  • Hemorrhage
  • Malignant change: The potential of benign ovarian cystadenomas to become malignant has been postulated but, to date, remains unproven. Malignant change can occur in a small percentage of dermoid cysts and endometriomas.

Prognosis

  • The prognosis for benign cysts is excellent. All such cysts may occur in residual ovarian tissue or in the contralateral ovary.
  • Mortality associated with malignant ovarian carcinoma is related to the stage at the time of diagnosis, and patients with this carcinoma tend to present late in the course of the disease. The 5-year survival rate overall is 41.6%, varying between 86.9% for FIGO stage Ia and 11.1% for stage IV.
  • Granulosa cell tumors are associated with an 82% survival rate, whereas squamous cell carcinomas arising in a dermoid cyst are associated with a very poor outcome.
  • Most germ cell tumors are diagnosed at an early stage and are associated with an excellent outcome. Advanced-stage dysgerminoma are associated with a better outcome compared to nondysgerminomatous germ cell tumors.
  • A distinct group of less aggressive tumors of low malignant potential runs a more benign course but still is associated with definite mortality. The overall survival rate is 86.2% at 5 years.

Miscellaneous

Medicolegal Pitfalls

  • Any pelvic mass should be assumed to be a cancer until proven otherwise, particularly in a patient with a prior history of breast cancer or a family history of breast/ovarian cancer.
  • An ultrasonographic examination of the pelvis should always be obtained if a patient is thought to have a pelvic mass on clinical examination.
  • If a patient has large fibroids, missing concomitant ovarian pathology, both clinically and on ultrasonographic examination, is possible.
  • Always be vigilant about patients with an increased risk of ovarian cancer, and arrange appropriate counseling.

Special Concerns

  • Ovarian cysts in pregnancy
    • Because of the routine use of ultrasonography, ovarian cysts are commonly diagnosed in pregnancy.29 Cysts should be evaluated in pregnant patients the same way as in nonpregnant patients, with ultrasonographic examinations and CA125 testing. MRI is preferable to CT scanning, but both modalities should be avoided in the first trimester.
    • In addition to the normal complications of cysts, they may cause obstructed labor in pregnancy.
    • Benign simple cysts can be monitored, and most resolve spontaneously.
    • Persistent cysts larger than 5-10 cm or those that are symptomatic or have features suggestive of malignancy may be removed surgically, preferably in the second trimester.
  • Ovarian cysts occurring in children
    • In a child found to have a symptomatic abdominopelvic mass, the ovary is the most common site of origin.
    • Although such masses are infrequent occurrences, the percentage due to malignant tumors is thought to be higher than for older age groups. The most common are germ cell tumors, followed by epithelial and granulosa cell tumors. Such tumors may be partially cystic.

References

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  2. Caruso PA, Marsh MR, Minkowitz S, Karten G. An intense clinicopathologic study of 305 teratomas of the ovary. Cancer . Feb 1971;27(2):343-8. [Medline] .

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  7. Miller BA, Kolonel LN, Bernstein L, et al. Racial/Ethnic Patterns of Cancer in the United States 1988-1992 . Bethesda, Md: National Cancer Institute; 1996.

  8. Bottomley C, Bourne T. Diagnosis and management of ovarian cyst accidents. Best Pract Res Clin Obstet Gynaecol . Oct 2009;23(5):711-24. [Medline] .

  9. Jacobs I, Bast RC Jr. The CA 125 tumour-associated antigen: a review of the literature. Hum Reprod . Jan 1989;4(1):1-12. [Medline] .

  10. Petricoin EF, Ardekani AM, Hitt BA, Levine PJ, Fusaro VA, Steinberg SM, et al. Use of proteomic patterns in serum to identify ovarian cancer. Lancet . Feb 16 2002;359(9306):572-7. [Medline] .

  11. Visintin I, Feng Z, Longton G, Ward DC, Alvero AB, Lai Y. Diagnostic markers for early detection of ovarian cancer. Clin Cancer Res . Feb 15 2008;14(4):1065-72. [Medline] .

  12. McIntosh M, Anderson G, Drescher C, Hanash S, Urban N, Brown P. Ovarian cancer early detection claims are biased. Clin Cancer Res . Nov 15 2008;14(22):7574; author reply 7577-9. [Medline] .

  13. Greene MH, Feng Z, Gail MH. The importance of test positive predictive value in ovarian cancer screening. Clin Cancer Res . Nov 15 2008;14(22):7574; author reply 7577-9. [Medline] .

  14. Osmers R. Sonographic evaluation of ovarian masses and its therapeutical implications [editorial]. Ultrasound Obstet Gynecol . Oct 1996;8(4):217-22. [Medline] .

  15. Loyer EM, Whitman GJ, Fenstermacher MJ. Imaging of ovarian carcinoma. Int J Gynecol Cancer . Sep 1999;9(5):351-361. [Medline] .

  16. Chan L, Lin WM, Uerpairojkit B, Hartman D, Reece EA, Helm W. Evaluation of adnexal masses using three-dimensional ultrasonographic technology: preliminary report. J Ultrasound Med . May 1997;16(5):349-54. [Medline] .

  17. Kupesic S, Plavsic BM. Early ovarian cancer: 3-D power Doppler. Abdom Imaging . Sep-Oct 2006;31(5):613-9. [Medline] .

  18. Higgins RV, Matkins JF, Marroum MC. Comparison of fine-needle aspiration cytologic findings of ovarian cysts with ovarian histologic findings. Am J Obstet Gynecol . Mar 1999;180(3 Pt 1):550-3. [Medline] .

  19. Moran O, Menczer J, Ben-Baruch G, et al. Cytologic examination of ovarian cyst fluid for the distinction between benign and malignant tumors. Obstet Gynecol . Sep 1993;82(3):444-6. [Medline] .

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  21. Roman LD. Small cystic pelvic masses in older women: is surgical removal necessary?. Gynecol Oncol . Apr 1998;69(1):1-2. [Medline] .

  22. Bailey CL, Ueland FR, Land GL, DePriest PD, Gallion HH, Kryscio RJ, et al. The malignant potential of small cystic ovarian tumors in women over 50 years of age. Gynecol Oncol . Apr 1998;69(1):3-7. [Medline] .

  23. [Best Evidence] Grimes DA, Jones LB, Lopez LM, Schulz KF. Oral contraceptives for functional ovarian cysts. Cochrane Database Syst Rev . Apr 15 2009;CD006134. [Medline] .

  24. Medeiros LR, Rosa DD, Bozzetti MC, Fachel JM, Furness S, Garry R, et al. Laparoscopy versus laparotomy for benign ovarian tumour. Cochrane Database Syst Rev . Apr 15 2009;CD004751. [Medline] .

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