RCOG | Ovarian cysts in postmenopausal women

This is an updated guideline from RCOG on investigating and managing ovarian cysts in post-menopausal women.

I have previously summarised a guideline from NICE on ovarian cancer and from the RCOG on managing cysts in premenopausal women.

As both these came out some time ago, I will do a general overview, as I'd forgotten quite a bit of this. I've concentrated on the elements I think are useful to us. At the bottom I've done a section on what counts as a 'significant family history' as this comes up quite a lot.

What history and examination should you do?

In a woman with symptoms of a possible ovarian cyst, check for a significant family history of cancer or familial genetic mutations.

Beware a woman over 50 presenting with IBS type symptoms. Consider ovarian masses.

Post-menopausal women can present acutely with abdominal pain from a cyst (eg due to torsion, rupture or haemorrhage).

Examination:

  • BMI
  • Abdo exam
  • Vaginal exam

What further assessment should you do?

1. CA125 - if there are concerning symptoms, or if a cyst is otherwise found. NB - this guideline looks at ovarian cysts, but the NICE ovarian cancer guideline advises that if you are investigating due to symptoms, if the CA125 is less than 35 then the woman can be reassured that there is a low risk of malignancy.

2. USS - this should be transvaginal (not just abdominal)

3. RMI - I (Risk of Malignancy Index). This score gives an idea of the risk of malignancy. It takes into account the CA125, the ultrasound findings and the woman's menopausal status. A score of < 25 gives a low risk of malignancy (3%). Over 200 gives a risk of 75%. Between 25 - 200 gives a risk of 20%.

RMI I = U x M x CA125

U is based on the 'ultrasound score'. In the 'ultrasound score', you score 1 for each of: multilocular, solid areas, mets, ascites or bilateral lesions.

  • U = 0 (for ultrasound score of 0)
  • U = 1 (for ultrasound score of 1)
  • U = 3 (for ultrasound score of 2 - 5)

M is based on the menopausal status

  • M = 1 (for premenopausal)
  • M = 2 (for postmenopausal)

CA125 is the CA125 level in iu/ml

What is the management of these women?

This guideline doesn't really advise which women need referral onto gynaecology. They do advise that women with an RMI I > 200 should be managed in a centre that deals with ovarian malignancy.

Simple Cysts

These have a very low risk of malignancy (< 1%) and a high rate of spontaneous resolution (up to 50% in 3m). Therefore they advise conservative management in a woman with a normal CA125 if a cyst is: asymptomatic, simple, unilateral, unilocular and less than 5cm in diameter. Evaluation should be repeated in 4-6m. If the cyst remains the same, or shrinks after 12m and if the CA125 remains normal, then the woman can be discharged.

Surgery should be considered if:

  • Symptomatic
  • Non-simple (ie complete septation or multilocular, solid nodules or papillary projections)
  • Bilateral
  • Multilocular
  • More than 5cm

What constitutes a 'significant family history'?

Familial genetic mutations:

  • Known carrier of a familial mutation (eg BRCA1, BRCA2 or mismatch repair genes).
  • Untested first-degree relative of an individual with a relevant mutation.
  • Untested second-degree relative, through an unaffected male, of an individual with a relevant mutation.

Other family members with cancer.

This is a bit long-winded, but useful.

There should be one first-degree relative with either ovarian, breast or bowel cancer AND:

  • 2 or more individuals with ovarian CA who are first-degree relatives of each other
  • 1 individual with ovarian CA AND one with breast CA, diagnosed under 50 who are first degree relatives of each other
  • 1 relative with ovarian CA at any age AND 2 with breast CA diagnosed under age 60 who are first degree relatives
  • 3 or more family members with colon CA in 2 generations with 1 diagnosed under age 50 and affected relatives should be first degree relatives.
  • 2 family members with colon CA and 1 with stomach, ovarian, endometrial, urinary tract or small bowel CA in 2 generations with 1 diagnosed under age 50 and affected relatives should be first degree relatives.
  • 1 individual with both ovarian and breast CA

 

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