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A woman's lifetime risk for ovarian cancer is between 1% and 2%. It is the leading cause of death from gynaecologic cancer and is the fourth most common cause of cancer death in women. Early-stage disease is often asymptomatic, and by the time the diagnosis is made, the disease has often progressed and is at an advanced stage (III or IV). Bloating and change in bowel function are common symptoms of early-stage disease but are often ignored by both patients and the providers. Early menarche, late menopause, nulliparity, lack of oral contraceptive use, older age, and a family history are all known risk factors.

Ovarian cancer screening

Unfortunately, effective screening tools for ovarian cancer do not exist. Transvaginal ultrasonography to look for ovarian abnormalities and routine measurement of tumor markers are associated with low positive predictive value. This study assessed the incidence and natural history of simple ovarian cysts detected on routine vaginal ultrasonography during menopause.

Study results

Patients in this study participated in a large cancer screening trial (Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial). As part of the screeningsimple ovarian cyst, patients received annual transvaginal ultrasonography and CA-125 measurement. Women aged 55 to 74 years were eligible. Cysts larger than 10 cm3 and those that were complex in appearance were considered suspicious for ovarian cancer. Cysts without papillary projections or septations (simple cysts) were followed conservatively. Progression from baseline (increase in CA-125 level or more complex appearance) was considered a positive finding during follow-up.

More than 15,000 women were included in this analysis. Simple ovarian cysts were detected in 14% of women at the baseline scan. Simple cysts were most common in women aged 55 to 59 years. In 6% of the cases, progression of the cysts to a more complex appearance was noted during follow-up. Cysts persisted in 54% of cases and disappeared in 32%. CA-125 levels were not associated with progression to a more complex appearance. The presence of simple ovarian cysts on the initial scan was not linked to a later increased risk for ovarian cancer. Current smokers and women with a younger age at first birth were at lower risk for ovarian cancer. Women with higher level of education or a past history of gynecologic surgery were at a slightly increased risk for cancer. Premature menopause was associated with an increased risk for simple cysts.

The investigators concluded that simple ovarian cysts are rather common during menopause and most either remain stable or resolve during follow-up.

Ovarian cancer risk

Ovarian cancer is the leading cause of cancer death from the organs of the female genital tract. Survival is around 90% when the disease is diagnosed at an early stage but is only 20-25% when it is diagnosed at an advanced stage. However, some improvement in the survival rate was observed in recent years.

Because early disease is not associated with any specific symptoms, the diagnosis is often made at an advanced stage, when survival is poor despite treatment. The lack of good screening tools makes it difficult to identify early-stage disease and makes management of incidental findings challenging. Certain ultrasonographic features of cysts, such as septation, papillary projections, and abnormal Doppler flow, are suspicious for cancer and usually lead to surgical exploration.

Managing simple ovarian cysts

The ideal management of simple cysts is less obvious. Concern about progression can lead to a recommendation for surgery, but in most cases, this would be for benign findings. Measurement of tumor markers can aid in decision-making, although the markers are not necessarily specific for ovarian cancer.

Simple ovarian cysts progression

This study adds to the existing literature by showing that simple ovarian cysts rarely progress to cancer and therefore may be followed conservatively among menopausal women. Obviously, each case has to be assessed individually. The patient's reproductive history, family background, and genetic predisposition need to be taken into consideration. Women at low risk with a simple cyst and low tumor marker levels may be followed by repeating these tests at 3- to 6-month intervals. Patients at high risk on the basis of risk factors or elevated levels of tumor markers are probably better off having surgery. Overall, the study supports the American Congress of Obstetricians and Gynecologists (ACOG) recommendation that simple cysts found incidentally during menopause can be followed because their risk for malignant transformation is low.

The original, on which this article is based first appeared on Medscape on the 9th of August, 2010.

Simple ovarian cysts after the menopause

By Dr Joe Kabyemela, MD