In addition to these evidence-based recommendations, the guideline developer also identifies points of best clinical practice in the original guideline document.
Classification of evidence levels (1++ to 4) and grades of recommendations (A-D) are defined at the end of the "Major Recommendations" field.
Preoperative Assessment of Women with Ovarian Masses
What Blood Tests Should Be Performed?
B - A serum CA-125 assay does not need to be undertaken in all premenopausal women when an ultrasonographic diagnosis of a simple ovarian cyst has been made (Kahraman et al., 2007; Zurawski et al., 1988; Van Calster et al., 2007).
C - Lactate dehydrogenase (LDH), alpha-fetoprotein (α-FP) and human chorionic gonadotrophin (hCG) should be measured in all women under age 40 with a complex ovarian mass because of the possibility of germ cell tumours.
What Imaging Should Be Employed in the Assessment of Suspected Ovarian Masses?
What Is the Role of Ultrasound in the Assessment of Suspected Ovarian Masses?
B - A pelvic ultrasound is the single most effective way of evaluating an ovarian mass with transvaginal ultrasonography being preferable due to its increased sensitivity over transabdominal ultrasound.
What Is the Role of the Routine Use of Computed Tomography and Magnetic Resonance Imaging (MRI) in the Assessment of Suspected Ovarian Masses?
C - At the present time the routine use of computed tomography and MRI for assessment of ovarian masses does not improve the sensitivity or specificity obtained by transvaginal ultrasonography in the detection of ovarian malignancy.
What Is the Best Way to Estimate the Risk of Malignancy?
B - An estimation of the risk of malignancy is essential in the assessment of an ovarian mass.
Which Risk of Malignancy Index (RMI) Should Be Used?
B - A systematic review of diagnostic studies concluded that the RMI I is the most effective for women with suspected ovarian cancer.
Refer to the original guideline document for a method for calculating the RMI I.
Is There Another Way to Estimate Accurately a Risk of Malignancy in Premenopausal Women without Using a CA-125?
B - There are simple ultrasound rules derived from the International Ovarian Tumor Analysis (IOTA) Group. The use of specific ultrasound morphological findings without CA-125 has been shown to have high sensitivity, specificity and likelihood ratios (Timmerman et al., 2008; Timmerman et al., 2010).
Please see Table 2 in the original guideline document for the IOTA Group ultrasound 'rules' to classify masses as benign (B-rules) or malignant (M-rules).
Management of Ovarian Masses Presumed to Be Benign in Non-Emergency Situations
Can Asymptomatic Women with Simple Ovarian Cysts Be Managed Expectantly?
C - Women with small (less than 50 mm diameter) simple ovarian cysts generally do not require follow-up as these cysts are very likely to be physiological and almost always resolve within 3 menstrual cycles.
C - Women with simple ovarian cysts of 50–70 mm in diameter should have yearly ultrasound follow-up and those with larger simple cysts should be considered for either further imaging (MRI) or surgical intervention.
How Should Persistent, Asymptomatic Ovarian Cysts Be Managed?
C - Ovarian cysts that persist or increase in size are unlikely to be functional and may warrant surgical management.
Does the Use of Combined Oral Contraceptives Help in the Treatment of Functional Ovarian Cysts?
A - The use of the combined oral contraceptive pill does not promote the resolution of functional ovarian cysts.
Is the Laparoscopic Approach Better for the Elective Surgical Management of Ovarian Masses?
A - The laparoscopic approach for elective surgical management of ovarian masses presumed to be benign is associated with lower postoperative morbidity and shorter recovery time and is preferred to laparotomy in suitable patients (Mais et al., 2003; Yuen et al., 1997; Panici et al., 2007; Fanfani et al., 2004).
A - Laparoscopic management is cost-effective because of the associated earlier discharge and return to work (Damiani et al., 1998).
C - In the presence of large masses with solid components (for example large dermoid cysts) laparotomy may be appropriate.
Should an Ovarian Cyst Be Aspirated?
B - Aspiration of ovarian cysts, either vaginally or laparoscopically, is less effective and is associated with a high rate of recurrence.
How Should an Ovarian Mass Be Removed?
A - Where possible removal of benign ovarian masses should be via the umbilical port. This results in less postoperative pain and a quicker retrieval time than when using lateral ports of the same size.
Grades of Recommendations
A - At least one meta-analysis, systematic review or randomised controlled trial rated as 1++, and directly applicable to the target population; or
A systematic review of randomised controlled trials or a body of evidence consisting principally of studies rated as 1+, directly applicable to the target population and demonstrating overall consistency of results
B - A body of evidence including studies rated as 2++ directly applicable to the target population, and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 1++ or 1+
C - A body of evidence including studies rated as 2+ directly applicable to the target population and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 2++
D - Evidence level 3 or 4; or
Extrapolated evidence from studies rated as 2+
Good Practice Point - Recommended best practice based on the clinical experience of the guideline development group
Classification of Evidence Levels
1++ High-quality meta-analyses, systematic reviews of randomised controlled trials or randomised controlled trials with a very low risk of bias
1+ Well-conducted meta-analyses, systematic reviews of randomised controlled trials or randomised controlled trials with a low risk of bias
1– Meta-analyses, systematic reviews of randomised controlled trials or randomised controlled trials with a high risk of bias
2++ High-quality systematic reviews of case–control or cohort studies or high-quality case–control or cohort studies with a very low risk of confounding, bias, or chance and a high probability that the relationship is causal
2+ Well-conducted case–control or cohort studies with a low risk of confounding, bias, or chance and a moderate probability that the relationship is causal
2– Case–control or cohort studies with a high risk of confounding, bias, or chance and a significant risk that the relationship is not causal
3 Non-analytical studies, e.g., case reports, case series
4 Expert opinion