If an ovarian cyst grows, measures several centimetres, causes pain, or shows suspicious features on ultrasound (O-RADS 3-4), Dr Jérémie Zeitoun reviews the ultrasound and MRI to clarify whether an operation is warranted, and by which route. He does not manage endometriomas or pelvic endometriosis, which are handled by dedicated specialist teams.
An ovarian cyst is a fluid-filled sac that develops on the ovary. It is extremely common and most often harmless: many cysts are functional cysts, linked to the menstrual cycle, which appear and then disappear spontaneously within one to three cycles.
Other cysts are described as organic: they do not resolve on their own. This is the case for the dermoid cyst, the endometrioma (a cyst related to endometriosis) and the cystadenoma. These are the ones that may require surgery — not as a matter of principle, but because they persist, grow, become painful, or show features that call for analysis.
This article explains how these cysts are distinguished, how their reassuring or suspicious nature is assessed (IOTA and O-RADS classifications), when surgery is justified, and how laparoscopic surgery is performed while preserving the ovary and fertility as much as possible. It draws on guidance from the CNGOF, ESHRE and the RCOG.
Is your cyst growing, painful or suspicious? Dr Zeitoun goes over the ultrasound and MRI to see if surgery is warranted.
Dr Zeitoun does not manage endometriomas or pelvic endometriosis, which are handled by dedicated specialist teams.
Understanding the ovarian cyst
Before talking about surgery, a few key points: what an ovarian cyst is, why most are harmless, and what distinguishes a cyst to be monitored from one to be operated on.
Functional or organic: that is the whole decision
A functional cyst arises from the normal working of the ovary during the cycle (follicle or corpus luteum). It is common, simple on ultrasound, and resolves spontaneously: it is monitored, not operated on.
An organic cyst, by contrast, is a true lesion that does not disappear on its own. It is then its size, symptoms, change over time or appearance on imaging that may point towards surgery — persistence alone is not enough. Telling functional and organic apart is the first goal of the consultation.
Remember: an ovarian cyst is not synonymous with cancer. In younger women, the vast majority are benign. Caution increases after menopause, when the ovary no longer produces functional cysts.
What are the types of ovarian cyst?
Not all cysts are alike, and it is precisely their nature that guides management. Here are the main types, from the most ordinary to those most likely to require surgery.
Functional cyst
A follicular or corpus luteum cyst, linked to the cycle. Simple, often painless, it disappears on its own within one to three cycles. No surgery: a follow-up ultrasound is usually enough.
Dermoid cyst
The mature teratoma contains various tissues (sebum, hair, sometimes a little calcium). Benign, but it does not resolve and carries a torsion risk as it grows. Laparoscopic removal, with an extraction bag, is usually recommended.
Endometrioma
The "chocolate cyst" contains old blood and signals ovarian endometriosis. It may be painful and affect fertility. Its management is handled by dedicated endometriosis teams — Dr Zeitoun does not manage it.
Cystadenoma
A benign epithelial tumour, serous or mucinous. It can reach a significant size. When it persists or becomes large, removal with pathological analysis is recommended.
How is a cyst assessed as reassuring — or suspicious?
Pelvic ultrasound is the reference examination. Standardised tools assess the cyst objectively to avoid both over-treatment and delayed care.
| Tool | What it assesses | What it is for |
|---|---|---|
| Ultrasound + IOTA | Cyst features: walls, septa, solid components, papillary projections, vascularity (Simple Rules, ADNEX model) | Classifying benign / suspicious at the first scan |
| O-RADS | A risk score from 1 (normal) to 5 (highly suggestive of malignancy) | Standardising management |
| Pelvic MRI | Fine characterisation when in doubt (dermoid, endometrioma, complex mass) | Resolving indeterminate cases |
| Tumour markers | CA-125 and HE4 (combined in the ROMA score); in younger women with a solid mass, germ-cell markers: AFP, β-hCG, LDH; CA 19-9 for mucinous cysts | Complementing imaging, never deciding alone |
Important: an elevated CA-125 is not synonymous with cancer. Before menopause it can rise with endometriosis, a functional cyst, menstruation or infection. It is always interpreted together with imaging and the clinical context.
The dermoid cyst in detail
The dermoid cyst deserves special attention: it is one of the most common organic cysts in younger women, and its management follows specific rules.
A benign tumour of varied tissues
The dermoid cyst, or mature cystic teratoma, is a benign tumour arising from the germ cells of the ovary. It can contain very diverse tissues: sebum, hair, skin, sometimes cartilage or a small tooth. This gives it a very characteristic signature on ultrasound and MRI.
It never resolves spontaneously and grows slowly over time.
Torsion
It is the cyst most prone to ovarian torsion, especially above 5-6 cm. Sudden severe pelvic pain, often with nausea, calls for emergency assessment.
Removal, to prevent
Because it does not resolve and carries a torsion risk, laparoscopic removal is usually recommended, especially if it is large, symptomatic or growing. In younger women, the cyst is removed while preserving the ovary.
The extraction bag
The contents of a dermoid irritate the peritoneum. It is therefore removed inside a sealed bag to prevent any spillage and the risk of chemical peritonitis.
Sometimes bilateral
The dermoid cyst is bilateral in about 1 in 10 cases. Both ovaries are therefore carefully examined during surgery. In younger women with a solid mass, specific markers (AFP, β-hCG, LDH) may be measured.
When should an ovarian cyst be operated on?
A cyst is never operated on "as a matter of principle". Surgery answers specific situations. If one of them applies to you, a surgical opinion is justified.
Evolving character
A cyst that grows or changes across follow-up scans is more concerning than a stable one — even if persistent.
Suspicious features
Solid components, thick septa, papillary projections, vascularity, O-RADS 3-4: removal with analysis is required.
Size & symptoms
A large cyst, heaviness, pelvic pain, compression of the bladder or rectum.
Torsion risk
A large dermoid cyst carries a torsion risk. Sudden severe pain is a surgical emergency.
Large mass
A very large mass is generally removed, for comfort and because it makes monitoring unreliable.
After menopause
The ovary no longer makes functional cysts: any persistent cyst is assessed with a lower surgical threshold.
Persistence alone is not a surgical indication. A small purely cystic (anechoic) cyst, stable for months or even years, can simply be monitored. It is the combination of several elements — appearance, size, symptoms, change over time — that leads to surgery, never a single criterion.
Neither rushing nor delay
Many cysts are operated on unnecessarily when they would have resolved on their own; others are monitored for too long. The right decision rests on imaging, context and follow-up, not on the anxiety of the moment.
When surgery is decided, every specimen is sent for pathological analysis, without exception: that is the guarantee that nothing is missed.
For a dermoid cyst, Dr Zeitoun usually suggests removal by laparoscopy, using an extraction bag.
Surgery by laparoscopy
Laparoscopy (keyhole surgery, under general anaesthesia) is the reference approach for ovarian cysts. It allows rapid recovery and small scars. In women of childbearing age, the goal is to remove the cyst while preserving the ovary. In cases suspected of malignancy, the surgical approach may be adapted (see below).
Cystectomy
Only the cyst is removed, preserving healthy ovarian tissue. It is the procedure of choice in younger women, preserving the ovary's function and fertility.
Adnexectomy
Removal of the ovary and tube is proposed only in certain cases: an ovary that cannot be preserved, suspected malignancy, or after menopause. The remaining ovary compensates hormonally in non-menopausal women.
Extraction bag
The cyst is removed inside a sealed bag to avoid spilling its contents into the abdomen. This is essential for the dermoid cyst and any potentially suspicious lesion.
Laparotomy
In certain cases — a mass suspected of malignancy or very large — surgery may be performed by laparotomy: a Pfannenstiel incision (low transverse, like a caesarean) or a midline incision, to remove the mass en bloc, without rupturing it.
And if the lesion turns out to be more complex? If a borderline tumour or a malignant lesion is found, the case is reviewed at a multidisciplinary team meeting (MDT) and management follows the principles of ovarian cancer surgery.
Preserving the ovary and fertility
This is a major concern, and rightly so. Careful ovarian surgery aims to preserve the ovarian reserve as much as possible — while being honest about what it involves.
A reality to understand, a technique designed to limit it
Let us be transparent: every cystectomy causes some reduction in ovarian reserve. In removing the cyst wall, a thin layer of healthy ovarian tissue is inevitably taken with it. This reduction is greater for endometriomas.
Conversely, the cyst itself — especially an endometrioma — has often already damaged part of the ovary before surgery: some of the loss therefore pre-exists the operation. The goal is to limit this loss: maximal preservation of the parenchyma, minimal targeted coagulation, careful haemostasis.
What is AMH? Anti-Müllerian hormone (AMH) is a blood marker of ovarian reserve: its level reflects the remaining follicle pool. Measuring it before (and sometimes after) surgery — especially for bilateral cysts, repeat surgery or pregnancy plans — helps assess the ovarian capital, choose the strategy and, if needed, discuss oocyte preservation.
Scope of care: Dr Zeitoun manages ovarian cysts (functional, dermoid, cystadenoma…). However, he does not manage endometriomas or pelvic endometriosis, which are handled by dedicated endometriosis teams.
Recovery
Laparoscopy for an ovarian cyst is surgery with a recovery that is most often simple and quick.
Day surgery or one night
Depending on the procedure and your situation, you go home the same day or after one night at Clinique Hartmann. Pain is moderate and well controlled by painkillers.
Return to activities
Return to everyday activities usually within one to two weeks. Time off work is tailored to your job. A few weeks for intense exertion.
Pathology
The specimen is systematically analysed. The result confirms the benign nature and is explained at the follow-up consultation.
Follow-up consultation
A follow-up appointment checks proper healing, reviews the pathology and organises follow-up (a control ultrasound if needed).
Your pathway, step by step
From the first consultation to follow-up, a clear pathway without rushing.
Consultation & review
Clinical examination, review of your ultrasound and MRI, analysis of the context (age, symptoms, pregnancy plans).
Work-up & decision
Additional imaging or blood tests if needed, then a shared decision: surveillance or surgery, and which one.
Surgery
Scheduled laparoscopy at Clinique Hartmann, with a prior anaesthetic consultation and a quote provided in advance.
Follow-up
Follow-up consultation, pathology result explained, and organisation of follow-up tailored to your situation.
Frequently asked questions
Is an ovarian cyst serious?
In the vast majority of cases, no. Most ovarian cysts are benign, and many are functional cysts that disappear on their own within one to three cycles. The purpose of the consultation is to distinguish cysts that need surveillance from those that justify surgery.
Do all ovarian cysts need surgery?
No. A simple, asymptomatic functional cyst is monitored with ultrasound and usually resolves spontaneously. Surgery is reserved for organic cysts that persist, are large, painful, suspicious on imaging (O-RADS 3-4) or at risk of torsion.
How do you know if a cyst is suspicious?
Pelvic ultrasound is the reference examination. The IOTA classifications (Simple Rules, ADNEX model) and O-RADS assess solid components, thick septa, papillary projections and vascularity. When in doubt, a pelvic MRI and sometimes a CA-125 test complete the work-up.
What is a dermoid cyst and should it be removed?
A dermoid cyst (mature teratoma) is a benign tumour containing various tissues. Because it does not resolve and carries a torsion risk as it grows, laparoscopic removal using an extraction bag to prevent any spillage is usually recommended, preserving the ovary in younger women.
I have an endometrioma: should it be operated on?
Surgery for an endometrioma is discussed based on pain, pregnancy plans and ovarian reserve, and it always reduces that reserve somewhat. Important: Dr Zeitoun does not manage endometriomas or endometriosis — this condition is handled by dedicated specialist teams, to whom he can refer you.
Will I lose my ovary during surgery?
In women of childbearing age, the goal is to remove the cyst while preserving the ovary (cystectomy). Removal of the ovary and tube (adnexectomy) is only proposed in specific situations: an ovary that cannot be preserved, suspected malignancy, or after menopause.
Will surgery reduce my fertility?
To be transparent: every cystectomy causes some reduction in ovarian reserve, because a thin layer of ovarian tissue is removed with the cyst wall. This reduction is greater for endometriomas. But the cyst itself has often already damaged part of the ovary before surgery. A conservative technique (minimal coagulation, careful haemostasis) limits this loss, and measuring AMH helps assess and anticipate it. Note: Dr Zeitoun does not manage endometriomas or pelvic endometriosis.
What is ovarian torsion?
Torsion is an emergency: the ovary (often containing a cyst, particularly a dermoid) twists on its pedicle, cutting off its blood supply. It causes sudden severe pelvic pain, often with nausea or vomiting, and requires emergency laparoscopy to untwist and save the ovary.
How long are the hospital stay and time off work?
Laparoscopy for an ovarian cyst is performed as day surgery or with one overnight stay. Return to normal activities usually takes one to two weeks, with time off work tailored to your occupation.
My CA-125 is elevated: does that mean cancer?
Not necessarily. CA-125 is non-specific before menopause: it can rise with endometriosis, a functional cyst, menstruation or infection. It is always interpreted together with imaging and the clinical context, never in isolation.
I am postmenopausal: is a cyst more concerning?
After menopause, the ovary no longer produces functional cysts. Any persistent cyst is therefore assessed more cautiously. The threshold for surgery is lower, and pathological analysis is systematic after removal.
When should I seek a surgical second opinion?
A second opinion is reasonable for a persistent or large cyst, an O-RADS 3-4 mass, or before any decision to remove an ovary. Dr Zeitoun reviews your ultrasound and MRI to clarify the indication and the surgical approach.
Is the surgery covered by insurance?
Surgery for an ovarian cyst is a medically justified procedure covered by French national health insurance. Dr Zeitoun charges additional fees (sector 2), explained during the consultation and set out in a written quote provided before surgery.
In young women, cystectomy spares healthy ovarian tissue: Dr Zeitoun also explains its effect on your ovarian reserve.