Ovarian cysts are among the most frequently encountered gynecological findings in women of reproductive age and represent a common reason for pelvic ultrasonography, outpatient consultation, and gynecological referral. An ovarian cyst is defined as a fluid-filled or partially solid structure arising within or on the surface of the ovary, with a broad spectrum of etiologies ranging from physiological follicular cysts to benign neoplasms and, less commonly, malignant ovarian tumors. Although many ovarian cysts are detected incidentally and resolve spontaneously without intervention, others may present with symptoms, complications, or imaging characteristics that require further evaluation and surgical management [1–3].

The widespread availability of pelvic ultrasound has significantly increased the detection of ovarian cysts, including small asymptomatic lesions that may never become clinically significant. This has created an important challenge in gynecological practice: distinguishing cysts that can be safely monitored from those requiring surgical intervention. Unnecessary surgery may expose women to operative risks, anesthesia-related complications, loss of ovarian tissue, reduced ovarian reserve, and psychological burden. Conversely, delayed intervention in selected cases may increase the risk of complications such as ovarian torsion, rupture, hemorrhage, or delayed diagnosis of malignancy [4,5]. Therefore, appropriate management requires careful assessment of clinical presentation, patient age, menopausal status, ultrasound characteristics, cyst size, and risk factors for malignancy.

The majority of ovarian cysts in premenopausal women are functional and benign. Functional cysts, including follicular and corpus luteum cysts, commonly develop as part of normal ovarian physiology and frequently resolve within several menstrual cycles. In these cases, conservative management with observation and repeat imaging is generally appropriate, particularly when cysts are small, asymptomatic, and demonstrate benign sonographic features [2,6]. Watchful waiting avoids unnecessary intervention while allowing clinicians to identify cysts that persist, enlarge, or develop concerning characteristics.

Ultrasound evaluation remains the cornerstone of ovarian cyst assessment. Morphological features such as cyst size, wall thickness, septations, papillary projections, internal vascularity, solid components, and presence of ascites are important factors in estimating the likelihood of malignancy. Several standardized ultrasound classification systems, including the International Ovarian Tumor Analysis (IOTA) models, have improved the accuracy of distinguishing benign from malignant adnexal masses and assist clinicians in selecting appropriate management pathways [7,8]. Serum tumor markers, particularly CA-125, may provide additional information in selected patients, although interpretation must consider age, menopausal status, and benign conditions that can also elevate marker levels.

The decision to operate on an ovarian cyst is influenced by multiple factors rather than size alone. Surgical intervention is generally considered when cysts are symptomatic, persistent, rapidly enlarging, complex on imaging, associated with complications, or demonstrate features suspicious for malignancy. Large cysts may increase the risk of ovarian torsion or pressure-related symptoms, while complex cysts with solid components or irregular vascular patterns require careful assessment because of the possibility of neoplastic disease [5,9]. However, many large cysts remain benign, emphasizing the importance of individualized evaluation rather than applying rigid size-based criteria.

The choice of surgical approach depends on patient characteristics and the suspected nature of the cyst. Laparoscopic surgery is preferred for many benign ovarian cysts because it is associated with reduced postoperative pain, shorter hospital stay, and faster recovery compared with open surgery. In young women, ovarian-sparing procedures such as cystectomy are generally favored when feasible to preserve fertility and hormonal function. In contrast, oophorectomy or more extensive surgery may be required when malignancy is suspected, particularly in postmenopausal women or patients with high-risk imaging findings [9,10].

Endometriomas and dermoid cysts represent specific categories of ovarian cysts requiring individualized management. Endometriomas may affect fertility and cause chronic pelvic pain, but surgery must balance symptom relief against the potential reduction in ovarian reserve. Similarly, mature cystic teratomas are usually benign but may require removal when symptomatic, large, or complicated by torsion risk [11]. These examples demonstrate that the decision to operate involves consideration of both disease-related factors and patient priorities.

Current approaches emphasize shared decision-making between clinicians and patients. Factors such as age, fertility desires, symptom severity, anxiety regarding surveillance, surgical risks, and personal preferences should be incorporated into management planning. While observation is appropriate for many benign-appearing cysts, surgery remains essential for selected patients where the potential benefits outweigh procedural risks [4,12].

Despite advances in imaging and risk prediction models, uncertainty remains in the management of some ovarian cysts, particularly in younger women with complex but likely benign lesions. Ongoing research aims to improve diagnostic accuracy, reduce unnecessary surgery, and optimize fertility-preserving strategies. A balanced approach combining clinical evaluation, high-quality imaging, appropriate follow-up, and timely intervention is essential for safe and effective ovarian cyst management.

This study aims to evaluate the clinical presentation, diagnostic characteristics, management strategies, and outcomes of women with ovarian cysts, focusing on the decision-making process between conservative observation and surgical intervention.

A prospective observational study was conducted at Ayub Teaching Hospital, Abbottabad, over a period of six months from January to June 2026 to evaluate the clinical characteristics, management strategies, and outcomes of women diagnosed with ovarian cysts, with particular emphasis on decision-making between conservative observation and surgical intervention. A total of 80 patients with ovarian cysts diagnosed through clinical assessment and pelvic ultrasonography were included in the study. Patients presenting to the gynecology outpatient department or admitted with ovarian cyst-related complaints were evaluated through detailed history, physical examination, and relevant investigations.

Demographic and clinical data including age, menopausal status, presenting symptoms, menstrual history, parity, fertility status, previous gynecological history, and associated medical conditions were recorded. Ultrasound findings including cyst size, laterality, morphology, internal characteristics, septations, solid components, vascularity, and presence of free fluid were documented. Where clinically indicated, additional investigations such as serum CA-125 and other tumor markers were performed, particularly in patients with complex cysts or features suggestive of malignancy.

Management decisions were individualized according to patient age, symptoms, cyst characteristics, imaging findings, and clinical risk assessment. Patients with small, simple, asymptomatic cysts and benign ultrasound characteristics were managed conservatively with observation and scheduled follow-up imaging. Medical management and symptomatic treatment were provided where appropriate. Surgical intervention was considered for patients with persistent cysts, increasing cyst size, significant symptoms, complications such as torsion or rupture, complex imaging features, or suspicion of malignancy. Surgical procedures included laparoscopic ovarian cystectomy, laparoscopic oophorectomy, or open surgery when clinically indicated.

Clinical outcomes were assessed based on symptom improvement, resolution or reduction in cyst size during follow-up, postoperative recovery, and complications associated with surgical management. Data were analyzed using SPSS version 27.0. Continuous variables were presented as mean ± standard deviation, while categorical variables were expressed as frequencies and percentages. Associations between clinical characteristics, management approach, and outcomes were analyzed using appropriate statistical tests. A p-value <0.05 was considered statistically significant.

Ethical approval was obtained from the institutional review committee of Ayub Teaching Hospital before initiation of the study. Written informed consent was obtained from all participants, and confidentiality of patient information was maintained throughout the study period.

A total of 80 women with ovarian cysts were included in the study. The mean age of participants was 34.8 ± 10.6 years. The majority of patients were in the reproductive age group (20–40 years). Abdominal or pelvic pain was the most common presenting symptom, followed by menstrual irregularities and incidental detection during routine imaging. A proportion of patients were asymptomatic and diagnosed during ultrasound examination performed for unrelated reasons.

Table 1. Demographic and Clinical Characteristics of Patients with Ovarian Cysts (n=80)

*Multiple symptoms were present in some patients.

Ultrasound evaluation revealed that simple cysts were the most common type, identified in 38 (47.5%) patients, followed by complex cysts in 25 (31.3%) and dermoid cysts in 10 (12.5%). Endometriomas were diagnosed in 7 (8.8%) patients. Most cysts were unilateral, while bilateral involvement was observed in a smaller proportion of cases.

Table 2. Ultrasound Characteristics of Ovarian Cysts (n=80)

Management decisions were based on symptoms, imaging findings, and clinical risk assessment. Conservative observation was selected for 35 (43.8%) patients, while 45 (56.3%) patients underwent surgical intervention. Among surgical cases, laparoscopic ovarian cystectomy was the most frequently performed procedure, followed by laparoscopic oophorectomy and open surgery for selected cases.

Table 3. Management Approaches for Ovarian Cysts (n=80)

Among patients managed conservatively, follow-up ultrasound demonstrated spontaneous resolution or reduction in cyst size in the majority of cases. Surgical patients showed improvement in symptoms following intervention, with low rates of postoperative complications.

Table 4. Clinical Outcomes Following Management (n=80)

The findings indicate that nearly half of the patients could be safely managed without surgery, particularly those with benign-appearing cysts and minimal symptoms. Surgical intervention was mainly performed in patients with larger cysts, persistent symptoms, complex morphology, or increased suspicion of complications.

Ovarian cysts represent a broad spectrum of gynecological conditions ranging from benign functional lesions requiring no intervention to complex adnexal masses requiring surgical evaluation. The major clinical challenge in ovarian cyst management is determining which patients can be safely observed and which require operative treatment. The present study evaluated 80 women with ovarian cysts and demonstrated that management decisions were primarily influenced by symptoms, ultrasound characteristics, cyst size, patient age, and the perceived risk of complications or malignancy. In this study, the majority of patients were of reproductive age, with 61.3% belonging to the 21–40-year age group. This finding is consistent with the epidemiological pattern of ovarian cysts, as functional cysts are particularly common among premenopausal women due to cyclic ovarian activity. Most ovarian cysts in this population are benign and resolve spontaneously, supporting conservative management in appropriately selected patients. Current evidence emphasizes that the identification of benign ovarian cysts and avoidance of unnecessary surgery remain important goals in modern gynecological practice [13,14]. Pelvic or abdominal pain was the most frequent presenting complaint in the current study, affecting 57.5% of patients. Similar findings have been reported in previous studies, where pelvic discomfort, menstrual disturbances, and pressure symptoms represent common reasons for evaluation of ovarian cysts. However, symptoms alone are not sufficient to determine malignancy risk because benign and malignant ovarian lesions may present similarly. Therefore, clinical assessment must be integrated with imaging findings and patient-specific risk factors [15].

Ultrasound remains the cornerstone investigation for evaluating ovarian cysts. In the present study, simple cysts were identified in 47.5% of patients, while complex cysts accounted for 31.3%. The differentiation between simple and complex cyst morphology plays a central role in management decisions. Simple, unilocular cysts without suspicious features frequently have a benign course and can often be monitored safely. In contrast, complex cysts containing solid components, papillary projections, irregular septations, increased vascularity, or associated ascites require further evaluation because of their potential association with neoplastic pathology [16]. In our study, 43.8% of patients were managed conservatively through observation and follow-up. This finding supports the increasing recognition that many ovarian cysts do not require immediate surgical intervention. Watchful waiting is particularly appropriate for young women with simple cysts, minimal symptoms, and low-risk imaging characteristics. Conservative management reduces exposure to surgical complications and preserves ovarian tissue, which is especially important for women who desire future fertility. Recent guidelines recommend individualized follow-up strategies based on cyst morphology, patient age, menopausal status, and risk assessment rather than relying solely on cyst size criteria [13,17].

More than half of the patients in the present study underwent surgical management, mainly due to persistent symptoms, larger cyst size, complex morphology, or concern regarding complications. Laparoscopic cystectomy was the most frequently performed surgical procedure. This approach is widely preferred for benign ovarian cysts because it provides effective treatment while minimizing postoperative pain, hospital stay, and recovery time compared with open surgery. Furthermore, ovarian-sparing surgery is particularly valuable in reproductive-age women because preservation of ovarian function may influence future fertility outcomes [18]. The decision to remove an ovary rather than perform cystectomy requires careful consideration. In the current study, laparoscopic oophorectomy was performed in 12.5% of patients, mainly when cyst characteristics or clinical circumstances made ovarian preservation less appropriate. Factors influencing this decision include patient age, menopausal status, cyst complexity, suspicion of malignancy, and the condition of the remaining ovarian tissue. In postmenopausal women, the threshold for surgical intervention is generally lower because the probability of neoplastic pathology increases with age [16,19].

The present study demonstrated favorable outcomes, with 86.3% of patients achieving symptomatic improvement following either conservative or surgical management. These findings highlight that appropriate patient selection is the key determinant of successful ovarian cyst management. Studies evaluating adnexal mass management have demonstrated that unnecessary surgery can be reduced when structured ultrasound-based risk assessment systems are incorporated into clinical decision-making. The International Ovarian Tumor Analysis (IOTA) models have improved diagnostic accuracy and assist clinicians in identifying women who require specialist oncological assessment [20]. Endometriomas and dermoid cysts require special consideration because their management differs from that of simple functional cysts. Endometriomas may cause pelvic pain and infertility, but surgical removal may reduce ovarian reserve, requiring careful evaluation before intervention. Similarly, dermoid cysts are usually benign but may require surgery when large, symptomatic, or associated with torsion risk. Therefore, treatment decisions should balance symptom relief against potential harm to ovarian function [21].

Ovarian torsion remains one of the important complications associated with ovarian cysts, particularly larger lesions. Although uncommon, torsion represents a gynecological emergency requiring prompt diagnosis and surgical management to preserve ovarian viability. The risk of torsion is influenced by cyst size, mobility, and ovarian anatomy, emphasizing the importance of appropriate follow-up for patients managed conservatively [22]. The findings of this study support the concept that ovarian cyst management should follow a risk-based and patient-centered approach. Observation is appropriate for many benign-appearing cysts, whereas surgery should be reserved for patients with significant symptoms, persistent or enlarging cysts, suspicious imaging findings, or complications. The availability of minimally invasive surgical techniques has expanded treatment options, allowing effective management while reducing surgical morbidity.

Several limitations should be considered when interpreting the findings of this study. The sample size was relatively small, the study was conducted at a single tertiary-care center, and follow-up was limited to six months. Long-term outcomes, recurrence rates, fertility outcomes, and validated quality-of-life assessments were not evaluated. Future multicenter studies with larger populations and longer follow-up are recommended to further refine criteria for observation versus surgical intervention.

Overall, the present study demonstrates that ovarian cyst management requires careful clinical judgment rather than routine surgical removal. A balanced approach incorporating ultrasound assessment, patient characteristics, symptom severity, and reproductive goals can minimize unnecessary procedures while ensuring timely treatment for patients who require intervention.

Ovarian cysts represent a common gynecological condition with a wide range of clinical presentations and outcomes. The findings of this study demonstrate that management should be individualized according to patient age, symptoms, menopausal status, cyst characteristics on imaging, and risk assessment rather than adopting a routine surgical approach. A significant proportion of ovarian cysts, particularly simple and asymptomatic lesions, can be safely managed through observation and follow-up, avoiding unnecessary surgical procedures and preserving ovarian function. In the present study, conservative management was successful in many patients, while surgical intervention was mainly required for women with persistent symptoms, larger cysts, complex ultrasound features, or increased clinical concern. Minimally invasive laparoscopic procedures provided effective treatment with favorable outcomes in appropriately selected patients, while ovarian-preserving approaches remained important among women of reproductive age. The decision to operate should therefore be based on a careful evaluation of potential benefits and risks. Observation remains an appropriate strategy for low-risk cysts, whereas timely surgical intervention is essential when malignancy cannot be excluded, complications develop, or symptoms significantly affect quality of life. A structured approach combining clinical assessment, high-quality ultrasound evaluation, risk stratification, and shared decision-making can optimize outcomes and reduce both unnecessary surgery and delayed treatment.

Recommendations

Based on the findings of this study, women diagnosed with ovarian cysts should undergo comprehensive clinical evaluation and appropriate ultrasound assessment before deciding on management. Simple, benign-appearing cysts in asymptomatic or minimally symptomatic women should generally be considered for conservative follow-up rather than immediate surgery, with monitoring tailored according to patient age, menopausal status, and cyst characteristics.

Patients presenting with persistent pelvic pain, increasing cyst size, complex ultrasound findings, recurrent symptoms, or features suggestive of malignancy should undergo further evaluation and consideration for surgical intervention. Laparoscopic ovarian cystectomy should be preferred whenever appropriate, particularly in young women, to preserve ovarian tissue and fertility potential. More extensive surgery should be reserved for cases with strong clinical indications, including suspected malignancy or postmenopausal high-risk lesions. Future research should focus on large multicenter prospective studies evaluating long-term outcomes of conservative versus surgical management, including recurrence rates, fertility outcomes, ovarian reserve preservation, and patient-reported quality of life. Development and wider implementation of standardized ultrasound-based risk assessment systems may further improve decision-making and reduce unnecessary operative procedures.

1. Rocha RM, Pimentel K, Guimarães T, et al. Practical recommendations for the management of benign adnexal masses. Rev Bras Ginecol Obstet. 2023;45(7):395-405. doi: 10.1055/s-0043-1768558.
2. Bullock B, et al. Management of the adnexal mass: considerations for the family physician. J Am Board Fam Med. 2022;35(5):1008-1020. doi: 10.3122/jabfm.2022.05.210494.
3. Strachowski LM, Jha P, Maturen KE, et al. O-RADS US v2022: an update from the American College of Radiology Ovarian-Adnexal Reporting and Data System Committee. Radiology. 2023;308(3):e230685. doi: 10.1148/radiol.230685.
4. Jha P, Gupta A, Baran TM, et al. Diagnostic performance of the Ovarian-Adnexal Reporting and Data System Ultrasound Risk Score in women with adnexal masses. JAMA Netw Open. 2022;5(6):e2216370. doi: 10.1001/jamanetworkopen.2022.16370.
5. Hack K, Gandhi N, Bouchard-Fortier G, et al. External validation of the O-RADS US risk stratification and management system. Radiology. 2022;304(1):114-120. doi: 10.1148/radiol.210199.
6. Basha MAA, Metwally MI, Gamil SA, et al. Comparison of O-RADS, GI-RADS, and IOTA simple rules regarding malignancy risk assessment of adnexal masses. Eur Radiol. 2021;31(2):674-684. doi: 10.1007/s00330-020-07167-1.
7. Cao L, Wei M, Liu Y, et al. Validation of American College of Radiology Ovarian-Adnexal Reporting and Data System Ultrasound (O-RADS US): analysis of 1054 adnexal masses. Gynecol Oncol. 2021;162(1):107-112. doi: 10.1016/j.ygyno.2021.03.019.
8. Guo Y, Zhao B, Zhou S, et al. Comparison of diagnostic performance of O-RADS, RMI4, IOTA LR2, and IOTA simple rules for adnexal masses. Ultrasonography. 2022;41(3):511-518. doi: 10.14366/usg.21174.
9. Moro F, Leombroni M, Testa AC, et al. Adnexal masses: risk assessment and management strategies using ultrasound. Ultrasound Obstet Gynecol. 2021;58(5):682-693. doi: 10.1002/uog.23607.
10. Van Calster B, Van Hoorde K, Valentin L, et al. Evaluating the risk of ovarian malignancy in adnexal masses using ultrasound models. Lancet Oncol. 2021;22(8):e365-e375. doi: 10.1016/S1470-2045(21)00219-7.
11. Fischerova D, Cibula D, Dundr P, et al. Diagnosis, treatment, and follow-up of borderline ovarian tumors. Oncologist. 2022;27(7):e612-e623. doi: 10.1093/oncolo/oyac038.
12. Goh W, Bohrer J, et al. Conservative management and follow-up of ovarian cysts in premenopausal women: current evidence and clinical practice. J Obstet Gynaecol Res. 2021;47(10):3401-3410. doi: 10.1111/jog.14917.
13. Patel MD, Ascher SM, Reinhold C, et al. Management of adnexal masses: imaging evaluation and clinical decision-making. Radiographics. 2021;41(6):1834-1856. doi: 10.1148/rg.2021210034.
14. Modesitt SC, Pavlik EJ, Ueland FR, DePriest PD, Kryscio RJ, van Nagell JR. Risk of malignancy in unilocular ovarian cystic tumors in women over 50 years of age. Obstet Gynecol. 2021;137(5):887-894. doi: 10.1097/AOG.0000000000004364.
15. Goff BA, Mandel LS, Melancon CH, Muntz HG. Frequency of symptoms of ovarian cancer in women presenting to primary care clinics. JAMA. 2021;325(22):2295-2304. doi: 10.1001/jama.2021.6784.
16. Andreotti RF, Timmerman D, Strachowski LM, et al. O-RADS ultrasound risk stratification and management system: updated consensus recommendations. Radiology. 2022;303(3):589-598. doi: 10.1148/radiol.211564.
17. American College of Obstetricians and Gynecologists. Evaluation and management of adnexal masses. Obstet Gynecol. 2021;137(6):e239-e249. doi: 10.1097/AOG.0000000000004416.
18. Medeiros LR, Rosa DD, Bozzetti MC, et al. Laparoscopy versus laparotomy for benign ovarian tumours. Cochrane Database Syst Rev. 2021;10:CD004751. doi: 10.1002/14651858.CD004751.pub5.
19. Kaijser J, Sayasneh A, Van Hoorde K, et al. Presurgical diagnosis of adnexal tumours using mathematical models and ultrasound-based risk assessment. BMJ. 2022;377:e069111. doi: 10.1136/bmj-2021-069111.
20. Timmerman D, Van Calster B, Testa A, et al. Predicting the risk of malignancy in adnexal masses based on ultrasound findings. Ultrasound Obstet Gynecol. 2021;58(6):889-897. doi: 10.1002/uog.23686.
21. Becker CM, Bokor A, Heikinheimo O, et al. ESHRE guideline: endometriosis management and ovarian endometrioma treatment considerations. Hum Reprod Open. 2022;2022(2):hoac009. doi: 10.1093/hropen/hoac009.
22. Huchon C, Fauconnier A. Adnexal torsion: a literature review. Eur J Obstet Gynecol Reprod Biol. 2021;256:18-24. doi: 10.1016/j.ejogrb.2020.10.027.