Ovarian Cyst and Ovarian Mass Surgery: Symptoms, Diagnosis, Treatment and Follow-Up
Ovarian cysts and ovarian masses are common findings in gynecological practice. Most ovarian cysts are benign and may resolve without treatment, especially in women of reproductive age. However, some cysts or masses can cause pain, menstrual changes, abdominal bloating, pressure symptoms, or, rarely, urgent complications.
For this reason, every ovarian cyst should not be managed in the same way. The patient’s age, menopausal status, symptoms, ultrasound findings, cyst size, laboratory results and fertility wishes should all be considered together.
What is an ovarian cyst?
An ovarian cyst is a fluid-filled sac that develops inside or on the surface of the ovary. In women who have menstrual cycles, many ovarian cysts are functional cysts related to ovulation. These cysts often disappear spontaneously within a few menstrual cycles.
However, not every ovarian mass is a simple functional cyst. Dermoid cysts, endometriomas, cystadenomas and, rarely, malignant tumors can also appear as ovarian masses. Therefore, the key question is not only “Is there a cyst?” but also “What type of cyst is it, and does it require observation, medical treatment or surgery?”
Does every ovarian cyst require surgery?
No. Many ovarian cysts do not require surgery. Small, simple-looking cysts that do not cause symptoms can often be monitored with ultrasound, particularly in premenopausal women.
Surgery may be considered when:
The cyst is large
The cyst persists or grows over time
The cyst causes pain, pressure or bloating
Ultrasound shows suspicious features
There are solid areas, papillary projections, thick septations or irregular borders
There is concern for ovarian torsion, rupture or bleeding
The cyst appears after menopause and has concerning features
Blood tests and imaging suggest a possible malignancy
What symptoms can ovarian cysts cause?
Many ovarian cysts cause no symptoms and are found incidentally during a routine examination or ultrasound. When symptoms occur, they may include:
Pelvic or lower abdominal pain
One-sided pelvic pain
Abdominal bloating or fullness
Menstrual irregularities
Pain during intercourse
Frequent urination or bladder pressure
Constipation or bowel pressure
Sudden severe pelvic pain
Why is sudden severe pain important?
Sudden and severe pelvic or abdominal pain may indicate cyst rupture, bleeding into the cyst, or ovarian torsion. Ovarian torsion means that the ovary twists around its supporting structures, which may reduce or block its blood supply.
If severe pain is accompanied by nausea, vomiting, faintness, fever or general deterioration, urgent medical evaluation is necessary. These symptoms should not be ignored or simply observed at home.
How is an ovarian cyst or mass diagnosed?
The first step is a detailed medical history, gynecological examination and ultrasound. Ultrasound helps assess the size, structure and appearance of the cyst. It can show whether the cyst is simple or complex, whether it contains solid components, and whether there are features that require closer evaluation.
Depending on the clinical situation, further tests may include:
Transvaginal or abdominal ultrasound
Doppler ultrasound
Pregnancy test
Complete blood count and inflammatory markers
Tumor markers such as CA-125
HE4 or ROMA score in selected patients
Magnetic resonance imaging, also known as MRI
Computed tomography, especially if spread of disease is suspected
Risk assessment tools based on menopausal status and imaging findings
Does a high CA-125 always mean cancer?
No. CA-125 can be elevated in some ovarian cancers, but it is not a cancer diagnosis by itself. It can also be elevated in benign conditions such as endometriosis, fibroids, pelvic infection, menstruation and pregnancy.
Therefore, CA-125 should always be interpreted together with the patient’s age, menopausal status, ultrasound findings and clinical picture. In postmenopausal women, CA-125 and ultrasound findings are usually assessed more carefully, and referral to a gynecologic oncologist may be needed if the risk is significant.
What are the treatment options?
Treatment is individualized. Two cysts of the same size may require different management in different patients. Treatment options can generally be grouped into observation, medical treatment and surgery.
1. Observation and follow-up
Small, simple and asymptomatic cysts can often be monitored. Many functional cysts in reproductive-age women disappear without intervention. Follow-up intervals depend on the size and appearance of the cyst, the patient’s age and symptoms.
The aim of follow-up is to check whether the cyst disappears, decreases in size, remains stable or develops concerning features.
2. Medical treatment
Pain relief medication may be used when appropriate. Hormonal treatments may help reduce the formation of new functional cysts in selected patients, but they do not reliably shrink an existing cyst.
For endometriomas, also known as chocolate cysts, treatment decisions should take into account pain, fertility plans, cyst size, ovarian reserve and previous surgeries.
3. Surgical treatment
Surgery may involve removing only the cyst or, in some cases, removing the ovary together with the mass. The extent of surgery depends on the patient’s age, fertility wishes, cyst characteristics, suspicion of malignancy and findings during the operation.
The main surgical approaches are:
Laparoscopic ovarian cyst surgery
Laparoscopy, also known as keyhole surgery, is performed through small incisions using a camera and special surgical instruments. In suitable patients, it may offer less postoperative pain, smaller scars, shorter hospital stay and faster recovery.
The goal is often to remove the cyst while preserving as much healthy ovarian tissue as possible. This procedure is called ovarian cystectomy.
Laparotomy, or open surgery
Open surgery may be preferred when the cyst is very large, when there are extensive adhesions, when malignancy is suspected, or when a wider surgical field is needed for safety.
Cystectomy or removal of the ovary?
In reproductive-age patients and those who wish to preserve fertility, the aim is usually to protect ovarian tissue whenever possible. However, removing only the cyst may not always be safe or feasible.
Removal of the ovary may be necessary if the ovary is severely damaged, if the blood supply is compromised, if the mass cannot be separated safely from the ovary, or if malignancy is suspected.
This decision should be made by considering preoperative findings, the patient’s preferences and intraoperative safety.
What is evaluated before surgery?
Before deciding on surgery, the following questions are important:
How old is the patient?
Is the patient premenopausal or postmenopausal?
Does the patient wish to preserve fertility?
Are there symptoms such as pain or pressure?
What is the size of the cyst?
Is the ultrasound appearance simple or complex?
Are there solid areas or suspicious features?
Are CA-125 or other markers significantly elevated?
Has the patient had previous abdominal or pelvic surgery?
Is endometriosis or adhesion disease suspected?
Is there any concern for malignancy?
These questions help determine whether surgery should be laparoscopic or open, whether only the cyst or the ovary should be removed, and whether a gynecologic oncology team should be involved.
Why are ovarian cysts after menopause evaluated more carefully?
Ovarian cysts detected after menopause require more careful assessment because the risk of malignancy is higher in this age group compared with younger women. However, not every postmenopausal cyst is cancer.
Small, simple, one-sided cysts without symptoms may be suitable for follow-up in selected patients. The decision depends on ultrasound findings, CA-125 level, cyst size, overall health and risk assessment.
What is recovery like after surgery?
Recovery depends on whether the operation is laparoscopic or open, the size and type of the cyst, whether additional procedures were required, and the patient’s general health.
After laparoscopic surgery, patients often return to daily activities sooner. Recovery after open surgery usually takes longer. Mild pelvic pain, shoulder pain, fatigue and tenderness around the incision sites may occur after surgery.
Patients may be advised to avoid heavy lifting, intense exercise and sexual intercourse for a certain period. Medical attention should be sought if there is fever, worsening pain, heavy bleeding, foul-smelling discharge, redness or swelling around the incision, or general deterioration.
Why is the pathology report important?
Any cyst or mass removed during surgery is sent for pathological examination. Pathology provides the final diagnosis and determines whether the mass is benign, borderline or malignant.
Even if a mass appears benign during surgery, the final conclusion is made by pathology. Therefore, reviewing the pathology report at the postoperative visit is one of the most important steps in care.
How is follow-up planned?
Follow-up depends on the cyst type, surgical findings, pathology result, patient age and symptoms.
Follow-up may include:
Gynecological examination
Ultrasound monitoring
Blood tests when needed
Long-term follow-up for conditions with recurrence risk, such as endometrioma
Assessment of ovarian reserve in patients who desire fertility
Gynecologic oncology follow-up for borderline or malignant tumors
Can ovarian cysts recur?
Yes, some types of ovarian cysts can recur. Functional cysts may form again. Endometriomas also carry a risk of recurrence. In selected patients, hormonal treatment or regular follow-up may be recommended to reduce recurrence risk or detect recurrence early.
The best strategy depends on the type of cyst and the patient’s individual needs.
When should you see a doctor?
A gynecological evaluation is recommended if you experience:
Persistent or recurrent pelvic pain
Abdominal bloating or pressure
Menstrual irregularities
Pain during intercourse
Pelvic pain or bleeding after menopause
Sudden severe pelvic or abdominal pain
Pain with nausea, vomiting, fever or faintness
A known ovarian cyst that grows or does not disappear during follow-up
Conclusion
Ovarian cysts are common, and most are benign. However, every cyst is different. The correct management depends on the patient’s age, menopausal status, symptoms, ultrasound findings and laboratory results.
The goal is not only to treat the cyst, but also to avoid unnecessary surgery, preserve ovarian tissue when possible, detect malignancy risk early and create a safe follow-up plan.
For this reason, ovarian cysts and ovarian masses should be evaluated individually and managed with a patient-centered approach.
