Premenopausal ovarian cysts: a practical evidence-based approach to risk assessment, tumor markers, surveillance and surgical management

Abstract

Ovarian cysts are common in premenopausal women, and most are physiological or benign. Assessment aims to identify lesions that require further investigation or treatment while avoiding unnecessary surgery and loss of ovarian tissue. This narrative review examines ultrasound characterization, malignancy risk assessment, tumor markers, surveillance, surgical management, and fertility considerations. Transvaginal ultrasonography (TVUS) is the first-line investigation, and lesion morphology should be interpreted alongside symptoms, age, and clinical history. The International Ovarian Tumor Analysis Simple Rules and ADNEX model, together with the Ovarian-Adnexal Reporting and Data System, provide structured approaches to risk assessment. Tumor-marker testing should follow the differential diagnosis. CA125 has limited specificity in premenopausal women, whereas suspected germ-cell or sex-cord stromal tumors may require other markers. Many confidently characterized simple cysts can be managed without intervention. Follow-up depends on lesion type, size, symptoms, and the imaging framework used; persistence alone does not establish malignancy. Indeterminate masses may require expert ultrasound or magnetic resonance imaging, and suspicious lesions warrant gynecological oncology assessment. Acute presentations require urgent evaluation outside elective surveillance pathways. When surgery is appropriate for benign disease, the approach should minimize morbidity and preserve ovarian tissue where feasible. Management therefore requires integration of imaging findings, clinical risk, reproductive priorities, and patient preferences.