Guideline No. 404: Initial Investigation and Management of Benign Ovarian Masses

To provide recommendations for a systematic approach to the initial investigation and management of a benign ovarian mass and facilitate patient referral to a gynaecologic oncologist for management. Obstetricians, gynaecologists, family physicians, internists, nurse practitioners, radiologists, general surgeons, medical students, medical residents, fellows, and other health care providers. Women ≥18 years of age presenting for evaluation of an ovarian mass (including simple and unilocular cystic masses, endometriomas, dermoids, fibromas, and hemorrhagic cysts) who are not acutely symptomatic and without known genetic predisposition to ovarian cancer. This guideline aims to encourage conservative management and help reduce unnecessary surgery and long-term health complications, maintain fertility, and decrease operative costs and improve overall patient care and outcomes by providing criteria for referral of patients with ultrasound imaging findings suggestive of a malignant mass to a gynaecologic oncologist. Databases searched: Medline, Cochrane, and PubMed. Medical terms used: benign asymptomatic and symptomatic ovarian cysts, adnexal masses, oophorectomy, ultrasound diagnosis of cysts, simple ultrasound rules, surgical and medical therapies for cysts, screening for ovarian cancer, ovarian torsion, and menopause. Initial search was completed by 2017 and updated in 2018. Exclusion criteria were malignant ovarian cystic masses, endometriosis therapies, and other adnexal pathologies unrelated to the ovary. The content and recommendations were drafted and agreed upon by the authors. The Society of Obstetricians and Gynaecologists of Canada's Board of Directors approved the final draft for publication. The quality of evidence was rated using the criteria described in the Grading of Recommendations Assessment, Development and Evaluation methodology framework. Implementation of the recommendations could reduce costs due to unnecessary surgeries and hospitalizations and reduce lost work days and the risk of loss of fertility, early menopause, and surgical complications. 1The following ovarian masses typically demonstrate classic benign features on ultrasound: simple or unilocular cystic mass, hemorrhagic cyst, endometrioma, mature cystic teratoma (dermoid), and fibroma (high).2The risk of malignancy for simple ovarian cystic masses is low (