2d:I[856015,["/_next/static/immutable/chunks/1xzisbplk9czp.js","/_next/static/immutable/chunks/3j2i1faptc_-9.js","/_next/static/immutable/chunks/0fma7nlq6immz.js","/_next/static/immutable/chunks/08tq8rmv423j5.js","/_next/static/immutable/chunks/1chr5wkk3j58k.js","/_next/static/immutable/chunks/37kmmh_zm4dov.js","/_next/static/immutable/chunks/311zvdjfxff-f.js","/_next/static/immutable/chunks/1a_hqhrsle_n_.js"],"default"] 2e:T60f7,

Summary Table

Feature	Detail
Risk Factors	Reproductive-age women, ovulatory cycles, use of fertility drugs (clomiphene), endometriosis, history of prior ovarian cysts
Etiology	Most arise from normal follicular development (functional cysts); others from aberrant tissue differentiation (dermoid) or endometrial implantation (endometrioma)
Patient Presentation	Often asymptomatic and found incidentally on imaging; may present with dull pelvic pain, bloating, menstrual irregularity, or acute pain if ruptured or torsed
Classic Physical Exam	Unilateral, smooth, mobile adnexal mass; non-tender unless complicated; no ascites, no fixed nodularity
Key Diagnostic Results	Pelvic ultrasound showing a simple, thin-walled, anechoic cyst; normal CA-125; normal tumor markers
Management	Observation with repeat ultrasound for simple cysts under 5 cm in premenopausal women; oral contraceptive pills (OCPs) to prevent new cyst formation; surgical intervention (cystectomy or oophorectomy) for persistent, large, or symptomatic cysts
Keywords	"Simple cyst," "thin-walled, anechoic," "premenopausal," "resolved on follow-up ultrasound," "adnexal mass with regular borders"

1. Pathophysiology

Benign ovarian cysts are broadly divided into functional cysts and non-functional (neoplastic) cysts, and understanding this distinction is central to exam reasoning.

Functional cysts arise directly from the normal ovulatory cycle. A follicular cyst forms when a dominant follicle fails to rupture and continues to enlarge, accumulating follicular fluid. Because ovulation does not occur, the patient may present with a missed or delayed period followed by irregular bleeding, which can mimic ectopic pregnancy on a vignette. A corpus luteum cyst forms after ovulation when the corpus luteum fails to regress and instead fills with blood or fluid. The corpus luteum is a progesterone-secreting structure, so these cysts can sustain early pregnancy-like hormonal changes and are associated with delayed menses and a positive pregnancy test, again making the differential with ectopic pregnancy clinically important. Rupture of a corpus luteum cyst causes sudden, sharp unilateral pain and may produce hemoperitoneum, presenting similarly to a ruptured ectopic.

A theca-lutein cyst is a bilateral, multicystic enlargement of the ovaries caused by excessive stimulation by human chorionic gonadotropin (hCG). This is classically seen in the setting of gestational trophoblastic disease (hydatidiform mole), multiple gestations, or ovarian hyperstimulation syndrome from fertility treatments. The key pathophysiologic link is that markedly elevated hCG drives excessive theca cell luteinization. These cysts regress once the hCG stimulus is removed (e.g., after molar evacuation).

Among non-functional benign neoplasms, the most tested is the mature cystic teratoma (dermoid cyst). This is a germ cell tumor that contains tissue from all three embryologic layers (ectoderm, mesoderm, endoderm), which is why imaging may show fat, hair, teeth, or calcifications. It is the most common ovarian neoplasm in women under 30. Despite containing differentiated tissue, it is benign in the overwhelming majority of cases, though it carries a risk of ovarian torsion due to its weight and pedunculated nature.

Endometriomas (chocolate cysts) arise from ectopic endometrial tissue implanting on the ovary. Repeated cyclic bleeding within the cyst produces a thick, dark, hemolyzed fluid giving the characteristic "chocolate" appearance. These are strongly associated with endometriosis and present with chronic pelvic pain, dysmenorrhea, and dyspareunia.

Serous cystadenomas are the most common benign epithelial ovarian neoplasm overall. They are thin-walled, fluid-filled, and lined by tubal-type epithelium. Mucinous cystadenomas are lined by mucin-secreting epithelium and can grow extremely large, sometimes exceeding 20 cm. The feared complication of a mucinous tumor is pseudomyxoma peritonei if it ruptures, flooding the peritoneum with mucinous material (though this is more associated with appendiceal mucinous tumors).

2. Classification and Clinical Manifestation

Type	Origin	Key Features	Age	Clinical Manifestation
Follicular cyst	Functional (unruptured follicle)	Simple, thin-walled, anechoic, usually under 3 cm	Reproductive age	Asymptomatic or mild pelvic pressure; menstrual irregularity; resolves spontaneously in 4 to 8 weeks
Corpus luteum cyst	Functional (persistent corpus luteum)	Thick-walled, internal echoes (hemorrhagic), "ring of fire" on Doppler	Reproductive age	Delayed menses, unilateral pain; if ruptured, acute abdomen with hemoperitoneum
Theca-lutein cyst	Functional (hCG-driven)	Bilateral, multiloculated, large	Any age with elevated hCG	Associated with molar pregnancy, hyperemesis; resolves after hCG normalization
Mature cystic teratoma (Dermoid)	Germ cell neoplasm	Fat, hair, teeth, calcification on imaging; "tip of the iceberg" sign on ultrasound	20 to 30 years	Often asymptomatic; risk of torsion; rarely undergoes malignant transformation (squamous cell carcinoma, under 2%)
Endometrioma	Ectopic endometrial tissue	Homogeneous low-level echoes ("ground glass"), thick wall	25 to 40 years	Chronic pelvic pain, dysmenorrhea, dyspareunia, subfertility
Serous cystadenoma	Epithelial neoplasm	Thin-walled, unilocular, filled with clear serous fluid	30 to 50 years	Usually asymptomatic; pelvic pressure if large
Mucinous cystadenoma	Epithelial neoplasm	Multiloculated, can grow very large (over 20 cm), filled with mucin	30 to 50 years	Abdominal distension, pressure symptoms; risk of pseudomyxoma peritonei if ruptured
Fibroma	Sex cord-stromal	Solid, well-circumscribed	Middle-aged	Meigs syndrome: ovarian fibroma + ascites + right-sided pleural effusion; resolves after tumor removal

3. Diagnostic Workup

Test	Role	Key Findings
Pelvic ultrasound (transvaginal)	Best initial test	Simple cyst: anechoic, thin-walled, no septations, no solid components, no internal flow
Serum beta-hCG	Rule out pregnancy and ectopic	Must be obtained in any reproductive-age woman with pelvic pain or adnexal mass
CA-125	Adjunct in postmenopausal women	Elevated in ovarian malignancy; also elevated in endometriosis, PID, pregnancy, liver disease (low accuracy in premenopausal women)
CT or MRI pelvis	Second-line imaging	MRI is superior for tissue characterization; CT detects fat and calcification in dermoids
Doppler ultrasound	Evaluate blood flow	"Ring of fire" in corpus luteum cyst; absent flow raises concern for torsion
Surgical pathology (after excision)	Gold standard / confirmatory	Histologic examination confirms benign vs. malignant

Transvaginal pelvic ultrasound is the best initial test for any adnexal mass. The goal is to characterize the cyst and stratify malignancy risk. Features that favor a benign process include: a simple unilocular structure, thin smooth walls (under 3 mm), no solid components, no internal septations, and absence of internal vascularity. Features that raise concern for malignancy include: thick septations, solid components with internal blood flow, papillary excrescences, and associated ascites.

Serum beta-hCG is mandatory in any woman of childbearing age presenting with pelvic pain or an adnexal mass. This is a non-negotiable first step to rule out ectopic pregnancy and gestational trophoblastic disease. If hCG is markedly elevated and bilateral multiloculated cysts are present, think theca-lutein cysts secondary to a molar pregnancy.

CA-125 has limited utility in premenopausal women because it is elevated in many benign conditions (endometriosis, fibroids, pelvic inflammatory disease, even menstruation). In postmenopausal women, however, an elevated CA-125 combined with a complex-appearing cyst on ultrasound significantly raises the probability of epithelial ovarian cancer and warrants surgical evaluation. CA-125 is most useful as part of a risk stratification algorithm (such as the Risk of Malignancy Index) rather than as a standalone test.

MRI of the pelvis is reserved for indeterminate cysts on ultrasound. It provides excellent soft tissue characterization: fat within a dermoid shows high signal on T1-weighted images, and endometriomas show characteristic T1 hyperintensity (blood products) with T2 "shading." MRI does not use ionizing radiation, making it preferable in younger patients.

A definitive diagnosis, when needed, requires surgical excision and histopathologic examination. This remains the gold standard to confirm benign versus malignant pathology but is only pursued when clinical and imaging features are concerning or when the cyst is persistent, symptomatic, or meets surgical criteria.

4. Management and Treatment

Scenario	Management	Details
Simple cyst under 5 cm, premenopausal	Observation	Repeat ultrasound in 8 to 12 weeks; most resolve spontaneously
Simple cyst 5 to 7 cm, premenopausal	Close follow-up	Repeat ultrasound in 6 to 12 weeks; consider OCP to suppress new cyst formation
Simple cyst over 7 cm or persistent beyond 2 to 3 cycles	Surgical evaluation	Laparoscopic cystectomy (ovary-sparing) preferred
Complex cyst with concerning features	Surgical evaluation	Laparoscopic or open approach based on malignancy risk; intraoperative frozen section
Postmenopausal simple cyst under 5 cm, normal CA-125	Serial ultrasound surveillance	Repeat imaging at 6 to 12 months; many of these are benign serous cysts
Postmenopausal complex cyst or elevated CA-125	Surgical excision	Refer to gynecologic oncology
Ruptured cyst, hemodynamically stable	Supportive care	Analgesics (NSAIDs, acetaminophen), IV fluids, observation
Ruptured cyst, hemodynamically unstable	Emergency surgery	Exploratory laparotomy or laparoscopy for hemorrhage control
Ovarian torsion	Emergency surgery	Laparoscopic detorsion (preferred in reproductive-age women) with or without cystectomy
Dermoid cyst	Elective cystectomy	Recommended regardless of size due to torsion risk and potential for slow growth

Observation is the cornerstone of management for functional cysts. The majority of follicular and corpus luteum cysts resolve within one to three menstrual cycles without any intervention. The critical exam principle is: a simple, small, asymptomatic cyst in a premenopausal woman does not require surgery. Repeat transvaginal ultrasound in 8 to 12 weeks is the next best step.

Oral contraceptive pills do not treat an existing cyst (this is a commonly tested misconception). OCPs suppress gonadotropin release, thereby preventing the development of new functional cysts in subsequent cycles. They are indicated for recurrent functional cysts. Combined OCPs are typically prescribed as a monophasic formulation (e.g., ethinyl estradiol 30 to 35 mcg with levonorgestrel or norethindrone) taken continuously.

Surgical intervention is indicated when a cyst is large (over 7 to 10 cm), persistent beyond 2 to 3 menstrual cycles, symptomatic, or has features suspicious for malignancy. Laparoscopic ovarian cystectomy is the preferred approach in reproductive-age women because it preserves ovarian tissue and future fertility. Oophorectomy is considered when malignancy cannot be excluded, the ovary is unsalvageable, or the patient is postmenopausal.

For a ruptured hemorrhagic cyst in a hemodynamically stable patient, management is conservative: pain control with NSAIDs (ibuprofen 400 to 600 mg every 6 to 8 hours) or acetaminophen, IV fluid resuscitation if needed, and serial hemoglobin monitoring. Hemodynamic instability (tachycardia, hypotension, dropping hemoglobin, significant free fluid on ultrasound) mandates emergent surgical intervention.

Ovarian torsion is a surgical emergency. The classic presentation is sudden, severe, unilateral pelvic pain with nausea and vomiting, often in the setting of a known adnexal mass (dermoids and large cysts are the most common precipitants). Doppler ultrasound may show absent or decreased ovarian blood flow, but a normal Doppler does not rule out torsion because of dual blood supply (ovarian artery and uterine artery branch). The next best step in a suspected torsion is emergent laparoscopy with detorsion. Do not delay surgery for additional imaging.

5. Differential Diagnosis and Distractors

Differential Diagnosis	Why It Is Similar	Key Discriminator
Ectopic pregnancy	Unilateral pelvic pain, adnexal mass, delayed menses	Positive beta-hCG with no intrauterine pregnancy on ultrasound; hCG levels that plateau or rise abnormally
Ovarian malignancy	Adnexal mass, may have similar pain or pressure symptoms	Complex cyst with solid components, thick septations, papillary projections, ascites; elevated CA-125 in postmenopausal women
Tubo-ovarian abscess (TOA)	Adnexal mass with pain	Fever, cervical motion tenderness, purulent vaginal discharge, elevated WBC/ESR/CRP; history of PID
Appendicitis	Right lower quadrant pain, nausea, vomiting	Pain at McBurney point, migration from periumbilical area, elevated WBC, CT showing appendiceal inflammation
Pedunculated uterine fibroid	Adnexal mass on exam, can undergo torsion	Arises from the uterus; on ultrasound, the mass is connected to the myometrium by a stalk; whorled appearance
Hydrosalpinx	Tubular adnexal mass on imaging	Elongated, tubular shape with incomplete septations ("cogwheel sign" on cross-section); history of PID or tubal surgery
Paraovarian cyst	Simple-appearing cyst adjacent to the ovary	Normal ipsilateral ovary is visible separately from the cyst on ultrasound ("split sign")
Meigs syndrome vs. ovarian cancer with ascites	Both present with an ovarian mass plus ascites and pleural effusion	Meigs syndrome is associated with benign fibroma/thecoma; ascites and effusion resolve completely after tumor removal; cytology of fluid is negative for malignant cells

6. Traps and High-Yield Pearls

The single most common trap with benign ovarian cysts involves overtreatment of a simple functional cyst in a premenopausal woman. Exam writers will present a young, asymptomatic woman with an incidentally found simple anechoic cyst under 5 cm and include surgery among the answer choices. The correct answer is always observation with repeat ultrasound. Operating on a simple functional cyst is never the right answer unless it is large, persistent, symptomatic, or complicated.

A second major trap is the belief that OCPs will shrink an existing cyst. They will not. OCPs suppress new cyst formation by inhibiting ovulation. If the vignette asks about managing a currently present functional cyst, the answer is observation, not OCPs.

Another classic pitfall involves the ruptured corpus luteum cyst mimicking ectopic pregnancy. Both present with acute unilateral pelvic pain, free fluid in the cul-de-sac, and possibly a positive pregnancy test (the corpus luteum supports early pregnancy). The discriminating factor is ultrasound: if an intrauterine pregnancy is confirmed and the patient is stable, the diagnosis is a ruptured corpus luteum cyst, not an ectopic. Always check beta-hCG before attributing pelvic pain to a cyst.

For ovarian torsion, the trap is relying on Doppler ultrasound to rule it out. A normal Doppler study does not exclude torsion because of intermittent torsion and dual arterial supply. If clinical suspicion is high (acute onset pain, nausea, known ovarian mass, whirlpool sign), the next step is emergent laparoscopy regardless of Doppler findings.

In postmenopausal women, the rules change entirely. Any new ovarian cyst in a postmenopausal patient must be evaluated more aggressively because functional cysts should not form in the absence of ovulation. Even a simple-appearing cyst in this population requires CA-125 and close surveillance, and any complexity on imaging warrants surgical referral to gynecologic oncology.

Finally, remember that a dermoid cyst (mature teratoma) is the most common ovarian tumor in young women and the most common cause of ovarian torsion. Exam vignettes often describe a young woman with sudden pelvic pain and an adnexal mass containing calcifications or a fat-fluid level on imaging. The combination of young age, torsion, and fat/teeth on imaging is virtually diagnostic.

1e:["$","$L2d",null,{"article":{"id":"a95659f9-d5b6-4f29-879a-54ec46b58162","title":"Kista Ovarium","content":"$2e","category":"Reproduksi","created_at":"2026-05-16T18:33:07.621369+00:00","status":"published","subcategory":null},"questionCount":0,"sections":[{"id":"section-pathophysiology","num":"01","title":"Pathophysiology"},{"id":"section-classification-and-clinical-manifestation","num":"02","title":"Classification and Clinical Manifestation"},{"id":"section-diagnostic-workup","num":"03","title":"Diagnostic Workup"},{"id":"section-management-and-treatment","num":"04","title":"Management and Treatment"},{"id":"section-differential-diagnosis-and-distractors","num":"05","title":"Differential Diagnosis and Distractors"},{"id":"section-traps-and-high-yield-pearls","num":"06","title":"Traps and High-Yield Pearls"}],"hasSummaryTable":true}]