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Dr. Andrew Rynne

Family Physician

Exp 50 years

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Endovaginal and transabdominal ultrasound showed normal uterrus, complex ovarian cyst. Worried for ovarian cancer

Answered by
Dr. Aarti Abraham


Practicing since :1998

Answered : 5982 Questions

Posted on Thu, 25 Apr 2013 in Women's Health
Question: Hi,
I had a simple ovarian cyst that was diagnosed by ultrasound on 9/27/12. I had a follow up exam 2 days ago via ultrasound. Now the cyst is being described as complex. I am loading a report and several images. Please take a look at all the images and report. I am terrified this is ovarian cancer. Back in September (during the time of the first ultrasound), I did have a CA125 test and the result was 13. I know you can not tell me for sure if this is now a cancerous ovarian cyst but please tell me your true thoughts as I know cancerous cysts on ultrasound can have a certain appearance. I have terrible anxiety over this, to the point that I am unable to concentrate on work or anything except this cyst. I have a call in to my doctor to try to schedule surgery to remove this but I'd appreciate your true thoughts on the appearance of this cyst.
Thank you.

Here is the report from the radiologist:
Endovaginal and transabdominal images were performed and demonstrates the uterus measures 6.5 x 2.7 x 4.1 cm.

The endometrial stripe measures 9 mm.

The right ovary measures 3.8 x 3.6 x 4.1 cm. Doppler flow patterns appear normal. There is a complex 4.1cm right ovarian mass.

There is no evidence of free pelvic fluid.

Urinary bladder measures 7.5 x 3.4 x 8.8 cm.

1. Normal uterus.
2. 4.1cm complex right ovarian mass is the same size as the prior study but has changed from a simple to a complex appearance.
3. Nonvisualization of left ovary status post oophorectomy 1992.
Answered by Dr. Aarti Abraham 2 hours later
Thanks for your query.
The finding of an ovarian cyst causes considerable anxiety to women because of the fear of malignancy, but the vast majority are benign.

Each month, normally functioning ovaries develop small cysts called Graafian follicles. At midcycle a single dominant follicle up to 2.8 cm in diameter releases a mature oocyte. The ruptured follicle becomes the corpus luteum, which at maturity is a 1.5-2.0 cm structure with a cystic center. In the absence of fertilization of the oocyte, it undergoes progressive fibrosis and shrinkage. If fertilization takes place, the corpus luteum initially enlarges and then gradually decreases in size during pregnancy. Ovarian cysts arising in the course of ovarian function are called functional cysts and are always benign. They may be follicular and luteal, sometimes called theca-lutein cysts.

Neoplastic cysts arise by inappropriate overgrowth of cells within the ovary and may be malignant or benign.

Endometriomas are cysts filled with altered blood arising from ectopic endometrium.

Haemorrhagic cysts and dermoid cysts are other common benign cysts.

Ovarian cysts are found on transvaginal ultrasound in nearly all premenopausal women and in up to 14.8% of postmenopausal women. The majority of these cysts are functional in nature and benign.

The incidence of ovarian carcinoma is about 15 per 100,000 women per year.

Functional ovarian cysts occur at any age (including in utero), but are much more common in women of reproductive age. They are rare after the menopause. Luteal cysts occur after ovulation in the reproductive age. Most benign neoplastic cysts occur during the reproductive era but there is a wide age range and they may occur at any age.

CA125 is a protein expressed on the cell membrane of normal ovarian tissue and ovarian carcinomas. A serum level of less than 35 u/mL is considered normal.
While CA125 is raised in 85% of epithelial ovarian carcinomas, overall it is raised in only 50% of stage 1 lesions confined to the ovary. It is also raised in some benign conditions, other malignancies, and 6% of normal patients. A raised CA125 is most useful in conjunction with ultrasound in the assessment of a postmenopausal woman with an ovarian cyst.

Ultrasound is the primary imaging tool for a patient suspected of having an ovarian cyst. It can define morphologic characteristics of ovarian cysts.

Simple cysts are unilocular and have a uniformly thin wall surrounding a single cavity that contains no XXXXXXX echoes. These cysts have a very low chance of being malignant. Most commonly, they are functional follicular or luteal, or less commonly serous cystadenomas or inclusion cysts.

Complex cysts may have more than 1 compartment (multilocular), thickening of the wall, projections (papulations) sticking into the lumen or on the surface, or abnormalities within the cyst contents. Malignant cysts usually fall within this category, as well as many benign neoplastic cysts.

Hemorrhagic cysts, endometriomas, and dermoids tend to have characteristic features ultrasonically that may help to differentiate them from malignant complex cysts. They most often appear as complex cysts.

Determination of the presence or absence of any blood flow within certain cysts may be helpful in diagnosis. For instance, hemorrhagic cysts may contain fine XXXXXXX septations that characteristically do not demonstrate blood flow on Doppler flow ultrasound.

Diagnostic laparoscopy may sometimes be necessary to inspect a suspected adnexal cystic mass but it may miss an intraovarian malignancy.


Premenopausal women with asymptomatic simple cysts smaller than 8 cm on ultrasound in whom the CA125 is within the normal range may be followed with a repeat ultrasound examination at 8-12 weeks.

Persistent simple ovarian cysts larger than 5 cm and complex ovarian cysts should be removed surgically.

Hence, in your case, you were correctly kept under observation as it was a simple cyst earlier, and now you are rightly being scheduled for surgery.

Having provided this background information , I will give you a few points, which I hope will let you have a good night's sleep and reassure you before going in for surgery :

1. I have gone through your ultrasound report and images .The report does not mention any projections, papillae or solid components in the tumour, nor are any of them present in the images you have attached and sent. These characteristics are classic of malignant cysts, and are absent in your case.

2. There is no ascites, nor any signs or symptoms of malignancy that you are having.

3. There is no family history of ovarian cancers that you have mentioned.

4. Your CA 125 levels absolutely do not point to a malignancy.

I think the cyst is complex, but most probably benign.
It should be a haemorrhagic cyst, or an endometrioma, or a benign cyst such as a mucin filled cyst.

However, I would like if you could elaborate on the reason and details for your oophrectomy ( removal of the left ovary ) done in 1992, as it might have some bearing on the current scenario, as certain cysts can recur.

Also, since you are so insightful and motivated, you know that ONLY HISTOPATHOLOGY or BIOPSY after surgery can tell you 100 % for sure whether the cyst was benign or malignant, as the best of ultrasound and clinical opinions can be erroneous.

So, I would just ask you to stay positive considering that the risks of malignancy appear very low in your case based on currently available data, and you know that the only way to confirm this is by the biopsy.

Meanwhile, take care, and feel free to ask any further questions.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
Follow up: Dr. Aarti Abraham 39 minutes later
Thank you so much for your reply and for the information you provided. The reason for the left ovary removal in 1992 (at the approximate age of 16) was due to a benign mucus cystadenoma. The cyst was literally the size of a basketball and it had twisted the left ovary so the cyst was removed and on a follow up surgery, the ovary was removed as well because it had not healed as my doctor had hoped.

I also no longer menstruate due to chemotherapy for a bone marrow transplant I had in 1994. The transplant was to due leukemia (CML). This is one of the reasons for my concern. I associate the horrible experience of the bone marrow transplant with having cancer everywhere else. It’s a terrible anxiety to constantly live with.

Some additional information, when I had the first ultrasound on 9/27/12, I also had a CAT scan around the same time of my pelvis and abdomen (also due to the same simple ovarian cyst) and the CAT scan appeared normal other than the confirmation of the simple ovarian cyst. Also, the only time I had the CA125 was around that same time in September 2012 which again showed a result of 13. I have not repeated the CA125 test again.

If I may ask, you pointed out the radiology report did not mention anything about projections, papillae or solid components and did not present in the images I sent. If these things were present in the images, would they typically be noted in the radiologist report?

And lastly, you mention no solid components presented in the images. Aren’t the solid components all the cloudy looking debris or particles (I thought the grey colored cloudy areas in the cyst are considered solid components) seen in the photos? If projections, papillae and solid components are not seen in the images, what is it in the images that would make this cyst complex?

Your reply is greatly appreciated.

Thank you so much.
Answered by Dr. Aarti Abraham 6 hours later
Yes, if specifically projections, papillae or solid components had been noted, they would have been mentioned.
See, simple cysts are thin walled with just clear fluid inside.
Complex cysts have a wide range of characteristics.
Basically, anything that is not a simple cyst is termed as complex.
Thickening of the cyst wall, presence of debris or particles inside, even blood - all is termed complex cyst.
This nomenclature of course encompasses all features of malignant cysts also.
The grey areas are debris or minute particles.
Malignant cysts would generally have solid projections, Tongue like, protruding into the cyst wall, which is not visualised in your scan.
If you would like to read in detail, go through this :

I hope this helps.
I again reiterate that ultrasound and CA 125 values are SUGGESTIVE of the nature of the cyst.
As an intelligent patient like you can gather, there is no point in losing your sleep till your histopathology report is in hand.
Hope this clarifies things more.

Wish you all the luck .
Be well.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
Follow up: Dr. Aarti Abraham 24 hours later
Thank you for your reply. If I may ask one more question. As mentioned, I'm in menopause since age 19 due to chemotherapy for leukemia (CML). I am concerned at the thickness of the endometrial stripe at 9mm. The ultrasound 6 months ago said the endometrial stripe was 7mm. Isn't this thick for someone in menopause? The radiologist reports says normal uterus but I'm assuming a uterus can look normal even if there is uterine cancer present? I'm concerned about the thickening of the endometrial stripe, could this be due to cancer of uterus?

Thank you,
Answered by Dr. Aarti Abraham 7 minutes later
Yes, XXXXXX, the endometrial thickness is more considering your menopausal status.
Merely that does not point to cancer.
IT could be simple hyperplasia of the endometrium.
COnsult your gynecologist to consider doing a diagnostic D and C and hysteroscopy, which would rule out uterine cancer also.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
Follow up: Dr. Aarti Abraham 47 minutes later
Thanks for your response. I checked an ultrasound I had in July 2012, the endometrial stripe was 6mm. Then in September 2012 it was 7mm. Now in April 2013, it is 9mm. Can a 2 mm difference be part of the margin of measuring difference?
Answered by Dr. Aarti Abraham 4 hours later
Yes. It very well could be part of the individual variation in measurement.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

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