Most Ultrasound Cysts in Menopausal Women Are Not Cancerous: News from the North American Menopause Society Meeting

Steven Goldstein, MD Gyncecologist at NYU Medical School addressed the opening session of the 2012 North American Menopause Society Meeting and addressed what should happen when a gyno sees a small ovarian cyst in a menopausal aged woman or older. Ultrasound technology has become vastly improved and it helps us find anatomy that wasn't seen in the past. Most of these cysts can be watched, but gynos didn't always think so.

Dr. Goldstein asked the question can seeing too much be a bad thing for your provider? Are these ultrasounds too good!?! He points out that in the past we used the very low risk and non-invasive techniques of inspection, palpation (feeling) and auscultation(hearing heartbeat means the lump in this woman is not a cyst but a baby!). And old school gynos were trained to talk to the patient for the history, did the exam by looking, touching and listening, and then we ordered some blood tests. Now we have very sophisticated technologies that give us things we couldn’t see before. The term “sonomicroscopy” meaning that we see things that aren’t visible to the naked eye, like when we see a 2 mm embryo with a visible heart rate. So we are discovering things that are normal and so called “incidental” such as small endometriomas (a cyst of endometriosis) and small dermoids (this is a cyst that can have any of the components of the human egg that are within the ovary and is asymptomatic).
Back in 1971 Dr. Hugh Barber published the PPMO standing for the "Palpable Post Menopausal Ovary" it was not normal and cancerous, he was still saying this in 1984, and thus if a gyno felt the ovary on pelvic exam  then the gyno should recommend that the ovary should be removed, and for many years this was the standard practice. Dr. Goldstein has been pointing out that you have to take what you see with one eye to the fact that it might not be abnormal.  Ultrasounds have helped us peer within abdomens and into the pelvis like we never have before.  And ultrasound has helped us see that in fact not every ovary in a menopausal woman is just small and quiet.  By the late 1990s we began to change how gynos made recommendations to women. So back in the year 1999 Dr. Goldstein was saying if the cyst in a post menopausal woman was 5 cm you could watch.  And around that same time an article by a Dr. Baily found that about 17% of menopausal women will have a simple cyst. The key is for your gyno to try to figure out if your cyst has features that would make her believe that it is cancerous. If a cyst is not cancerous there is still no evidence that a non-cancerous benign cyst just by being left in your body could become cancerous.

So if you aren’t in pain, and you do not have any symptoms, there’s no reason not to just let your gyno carefully watch. We’ve also now got good information as to how long to watch. Greenless PLCO cancer screening, showed that of the cysts that develop a full third go away in a year.  And if you have been told you may have an ovarian cyst remember that the cysts you may have been told you have on ultrasound or CT scan may not be in your ovary at all. Women wonder if not all pelvic cysts are ovarian in origin, what are they: often they are paratubal (attached or around the fallopian tube) non-cancerous cysts or other structures. Dr. Goldstein now suggests if the cysts of the ovary seen on ultrasound are that tiny there is virtually no chance they are cancerous. Because of the slim chance of cancer are under 1 cm he suggests that gynos not even say they are there (not really my bent), a recommendation that probably is still going to take awhile for gynos to adopt.  And Dr. Goldstein also has reviewed the research and cysts that are between1 to and 7 cm that are just simple cysts can be described by statement that they are most certainly not cancerous, but benign. This is a complex topic that is really best handled by your own gyno. But the important thing to remember, that much of what is found on ultrasound can be managed safely, at least for several months, without being invasive.

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