Ovarian Cysts and Masses

ED Priorities

Overview

        Key concept: Most ovarian cysts in premenopausal women are benign and can be managed conservatively.
        In the ED, focus on identifying complications (rupture, torsion, haemorrhage) and red flags for malignancy,
        especially in post-menopausal patients.
      

Always treat pelvic pain as ectopic pregnancy until proven otherwise in reproductive-age women.
Assess haemodynamic stability and degree of pain.
Use ultrasound and clinical features to separate benign, complicated, and suspicious masses.

ED Algorithm

Flow

Assess ABC and vitals. Look for shock (tachycardia, hypotension, pallor) → resuscitate if unstable.
Pregnancy test (urine or serum β-hCG) in all reproductive-age patients with pelvic pain.
Focused history: onset/character of pain, cyclical pattern, known cysts, previous torsion, fertility treatment, family history of ovarian/breast cancer.
Examination: abdominal tenderness, guarding, peritonism; pelvic exam if appropriate – adnexal mass, cervical motion tenderness, discharge.
Baseline bloods: FBC, U&E, CRP, ± coagulation; consider group & save if bleeding/rupture suspected.
Arrange pelvic or transvaginal ultrasound (as available) to characterise the mass and assess for free fluid.
Stratify:
- Complication suspected (torsion, rupture, haemorrhage) → urgent gynae consult, likely admission.
- Simple-appearing cyst, stable, low risk → analgesia, safety-netting, outpatient follow-up.
- Suspicious/complex mass (esp. post-menopausal) → urgent gynae referral; admission if unstable or unable to arrange follow-up.

Types of Ovarian Cysts & Masses

Essentials

Common categories you’ll see in ED reports:

Type	Typical Features / Notes
Simple follicular cyst	Thin-walled, anechoic, unilocular; usually < 5 cm; often incidental and resolve spontaneously.
Corpus luteum / haemorrhagic cyst	Thicker wall, internal echoes or clot; may present with acute pain if ruptured; free fluid may be present.
Endometrioma	“Ground glass” homogeneous internal echoes; associated with dysmenorrhoea, dyspareunia, chronic pelvic pain.
Benign cystic teratoma (dermoid)	Complex with fat, calcifications, hyperechoic components; torsion risk due to weight and size.
Cystadenoma / other benign tumours	Often large, can be simple or complex; usually require gynae follow-up or surgical removal.
Suspicious / malignant mass	Solid elements, papillary projections, thick septations, bilateral masses, ascites, nodes – especially in post-menopausal women.

Tip: mention size, complexity (simple vs complex), solid elements, septations, and presence of free fluid when documenting.

Clinical Presentation & Complications

Presentation

Typical Presentations

Incidental finding on ultrasound or CT done for another reason.
Dull, unilateral pelvic discomfort or pressure.
Cyclical pain related to ovulation or menstruation.
Dyspareunia (especially endometrioma).
Urinary or bowel symptoms from mass effect with large cysts.

Acute Complications

Rupture: sudden unilateral pain, often after exertion or intercourse; localised tenderness ± free fluid; if significant bleeding → tachycardia, hypotension, peritonism.
Torsion: severe unilateral pain, nausea/vomiting, adnexal tenderness; surgical emergency (see Adnexal Torsion page).
Haemorrhage into cyst: acute or subacute pain, drop in Hb if significant.
Infection: fever, discharge, pelvic inflammatory disease picture if associated with tubo-ovarian abscess.

        Red flags: severe acute pain, peritonism, fever, haemodynamic instability, or a rapidly enlarging mass
        → think rupture, torsion, haemorrhage, or malignancy and escalate early.
      

Differential Diagnosis

Don’t Miss

Ectopic pregnancy (especially with free fluid or adnexal mass).
Pelvic inflammatory disease / tubo-ovarian abscess.
Appendicitis (right iliac fossa pain).
Urinary tract infection or renal colic.
Endometriosis without large cysts.
Uterine fibroids, especially subserosal masses.
Gastrointestinal pathology (diverticulitis, bowel obstruction, colitis).

Diagnostic Evaluation

Workup

β-hCG: must be done in all reproductive-age women with pelvic pain or mass.
Ultrasound (transvaginal or transabdominal):
- Primary imaging modality – defines size, morphology, complexity, and free fluid.
- Look for features of torsion (enlarged ovary, peripheral follicles, reduced/absent flow) or rupture (free fluid, echogenic material).
FBC: anaemia (rupture/bleeding) or leucocytosis (infection/inflammation).
CRP / ESR: if infection or inflammatory process suspected.
Hematocrit/Hb trend: useful in suspected haemorrhagic cyst rupture.
CT/MRI: usually not first-line for gynae pathology but may be available if CT done for “acute abdomen” – review reports carefully.
Tumour markers (e.g. CA-125) are not ED tests but may be arranged by gynae, especially in post-menopausal patients.

Risk Stratification

Red Flags

Features that increase concern for malignancy (especially in post-menopausal women):

Solid components within the mass.
Thick septations or papillary projections.
Bilateral masses.
Ascites or evidence of peritoneal disease.
Large size (e.g. > 8–10 cm) and complex morphology.
Unexplained weight loss, early satiety, or systemic symptoms.

Simple, small, premenopausal → usually benign Complex, solid, post-menopausal → high risk Acute pain + mass → rule out torsion/rupture

Management & Disposition

ED Plan

Analgesia & Supportive Care

Paracetamol and NSAIDs as first-line (if no contraindications).
Short course of oral opioids for severe pain if needed.
Anti-emetics for nausea; IV fluids if vomiting or dehydrated.

When to Admit / Urgent Gynae Review

Haemodynamic instability or significant anaemia from suspected rupture/haemorrhage.
Clinical suspicion of torsion (acute severe unilateral pain, nausea/vomiting, adnexal mass).
Large or complex cysts with concerning features, especially in post-menopausal women.
Associated sepsis or suspected tubo-ovarian abscess.
Inability to provide safe outpatient follow-up.

Safe Outpatient Management (Typical Scenario)

Premenopausal woman with:
- Simple cyst (e.g. ≤ 5 cm) on ultrasound.
- Stable vitals, controlled pain, normal Hb.
- No red flags for torsion, rupture, or malignancy.
Provide:
- Analgesia plan and written safety-net advice.
- Referral for follow-up ultrasound or gynae review as per local protocol.

Patient Counselling & Follow-Up

Communication

Explain that most ovarian cysts are benign and may resolve spontaneously, especially in younger women.
Clarify what was seen on the scan (size, side, simple vs complex) in simple language.
Advise urgent return if:
- Sudden severe worsening of pain.
- Faintness, dizziness, palpitations, or breathlessness.
- Fever, rigors, or feeling very unwell.
Stress the importance of attending follow-up appointments for repeat imaging or specialist review.

Teamwork: clear documentation and communication with gynae/primary care make it easier for juniors to hand over these patients safely.