In what circumstances should hormonal treatment be considered for functional ovarian cysts?

Hormonal treatment for patients with functional ovarian cysts should be considered primarily when the cysts are associated with menstrual irregularities or symptoms of hyperandrogenism, such as acne or hirsutism, particularly in the context of polycystic ovary syndrome (PCOS) or anovulatory cycles. Combined oral contraceptives (COCs) are the mainstay of pharmacological management in these cases, as they help regulate menstrual cycles and reduce androgen excess symptoms, provided there are no contraindications. Cyclical progestogens may also be used to induce withdrawal bleeding in women with prolonged amenorrhea or irregular bleeding patterns. The choice of hormonal treatment should consider the patient's personal preferences, risk factors, and the lowest effective estrogen dose to balance efficacy and safety. Additionally, hormonal treatment is not typically indicated solely for the presence of functional ovarian cysts unless they contribute to symptomatic menstrual dysfunction or androgen excess. Lifestyle interventions, including weight loss and exercise, should precede or accompany hormonal therapy, especially in overweight or obese women, as these can improve ovulatory function and reduce cyst formation. In cases where hormonal treatment is declined or contraindicated, specialist referral is advised, and regular monitoring of ovarian morphology and endometrial thickness may be necessary to exclude other pathology. Hormonal treatment is not recommended for ovarian cysts related to endometriosis when fertility is a priority, as it does not improve pregnancy rates in that context.

Summary:

• Consider hormonal treatment (mainly COCs) for functional ovarian cysts when associated with menstrual irregularity or hyperandrogenism symptoms, especially in PCOS ¹.
• Use cyclical progestogens to induce withdrawal bleeding in cases of prolonged amenorrhea ¹.
• Prioritize lifestyle modification before or alongside hormonal therapy to improve ovulatory function and reduce cyst formation ¹.
• Choose the lowest effective estrogen dose and consider patient preferences and contraindications ¹.
• Refer to specialists if hormonal treatment is unsuitable or declined, with regular monitoring as needed ¹.
• Do not use hormonal treatment solely to treat functional ovarian cysts without symptomatic menstrual or androgenic issues ¹.
• Hormonal treatment is not advised for endometrioma-related cysts when fertility is desired, as it does not improve pregnancy rates ².