Women, during their postmenopausal years, have ovaries that gradually decrease in size. With the use of a gynecology microscope, the dimensions of ovaries before menopause are approximately 3.5 X 2 X 1.5 cm. In early menopause, the ovaries are approximately 2 X 1.5 X 0.5 cm. In late menopause, they are even smaller: 1.5 X 0.75 X 0.5 cm.

Postmenopausal Palpable Ovary (PMPO) syndrome is suggestive when an ovary is palpable during gynecologic examination even when the woman is beyond menopause. This syndrome is abnormal and deserves evaluation. However, this has not been shown to be a reliable predictor of malignancy. Malignancy can only be determined by biopsy and subsequent histologic examination with the use of a gynecology microscope. Clearly, body habits makes a difference in the ease of gynecologic examination, but a post-menopausal ovary that, on palpation, is comparable in size to a pre-menopausal ovary is abnormally large. The incidence of ovarian cancer increases with age and is predominantly a disease of postmenopausal women; the average patient age is 61 years.

Considering the ease of pelvic ultrasound evaluation, a new problem has arisen in post menopausal women: the discovery of a small ovarian cyst. This is particularly troublesome in gynecologic patient who is entirely asymptomatic and whose ultrasound examination was performed for indications unrelated to the pelvis. It has been suggested that when the cyst is asymptomatic, is small (less than 5 cm in diameter), unilocular, and thin-walled, the risk of malignancy is extremely low and these masses can be followed conservatively, without surgery. Surgery may be indicated in some women with an adverse pedigree with a strong family history of ovarian, breast, endometrial, or colon cancer, or if the mass, when viewed with a gynecology microscope, appears to be enlarging. The addition of color flow Doppler examination may be helpful in distinguishing benign from malignant masses. The risk of malignancy for gynecologic patients older than 50 years of age or for postmenopausal women (approximately the same groups) at the time of laparotomy for a pelvic mass is approximately 50%.

The rapid development of ultrasound technology and its frequent, if not routine, applica¬tion during gynecologic examinations has led to the more frequent detection of ovarian cysts. The treatment for ovarian masses that are suspected to be functional tumors is ex¬pectant. A classic study popularized the use of oral contraceptives as suppressive therapy, although the results of this study have been misinterpreted. In this study, 286 patients (aged 16-48 years) with adnexal masses were treated with combination oral contracep¬tives. Eighty-one women had a persistent mass after this therapy; surgery was performed on these women, none of whom was found to have a physiologic cyst. This study has been interpreted to indicate that suspected functional cysts should be treated with oral’ contra¬ceptives, although there are no data to indicate a more rapid resolution with oral contra¬ceptives than with time alone. If a woman needs contraception and wishes to use oral con¬traceptives for birth control, it is perfectly acceptable to prescribe them in this setting. However, a randomized prospective study showed no acceleration of the resolution of functional ovarian cysts (which were associated with the use of clomiphene citrate or human menopausal gonadotropins) with oral contraceptives compared with obser¬vation alone. Another study revealed that oral contraceptives are effective in leading to resolution of functional ovarian cysts, although they are no more effective than time alone. However, oral contraceptives are effective in reducing the risk of subsequent ovarian cysts.

Symptomatic cysts should be evaluated promptly; although mildly symptomatic masses suspected to be functional could be managed with analgesics rather than surgery. Surgical intervention is warranted in the face of significant pain or the sus¬picion of malignancy. On ultrasonography, large cysts and those that have multiloculations, septa, papillae, and increased blood flow are all suspected signs of neoplasia. If a malignant cyst is’ suspected, at any age, explorative laparotomy should be per¬formed promptly.

Ultrasonographic or CT scanning aspiration procedures should not be used in women in whom there is a suspicion of malignancy. Laparoscopic surgery should be reserved for diagnostic or therapeutic purposes for patients at very low risk for ma¬lignancy. One survey of gynecologic oncologists’ experiences with patients who had orig¬inally undergone laparoscopic management of malignant or borderline tumors suggested that so-called “benign” characteristics do not preclude malignancy and that laparoscopic management can be associated with partial or incomplete excision and delays in definitive surgery. The management of ovarian dermoid cysts and other benign masses with operative laparoscopy has been described, although the surgeon’s experience and skill are important in the prevention of spill of the cyst contents. The clear advantage of this tech¬nique is the shorter hospital stay, shorter recovery time, and less postoperative pain. Few controlled trials have been performed to compare the laparoscopic approach to laparotomy.