In the post-menopausal group, I would say 50 percent of those are going to have a cancer risk associated with the cyst, and certainly as one gets older than 50, that increase goes markedly up. Certainly if a 75-year-old woman came in with any type of cyst, that should be looked into aggressively. So the problem in management really is when you have a prepubital girl who comes in and has a documented large cyst, you're going to operate. The post-menopausal woman is going to be followed very aggressively and most likely, she's going to be operated on. The key in management is, the challenge is, well how do you manage the reproductive age group? Which is the majority of where these cysts show up and we'll talk about here, that in a minute.

But I want to say something about the size of cysts. And a cyst depends on your definition. We've already said that a cyst is a fluid filled sac, but how big is it? Clearly it's any size, but most likely a cyst is going to be visible if it's about a centimeter. What is considered as a cyst that bears watching is usually something at three centimeters or greater. And if you have a cyst six centimeters, which is for the non-metric group, sometimes I have to check myself, the, it's about a little over two-and-a-third inches. If a woman presents with a cyst that's two-and-a-third inches, that bears definite watching and rather aggressive management. Indiana University trained Obstetrician Gynecologist, Christopher Freville suggests that certainly very large cysts have the necessity for more aggressive, aggressive management.

When you we have a woman with a cyst who has let's say something less than ten centimeters, it's just noticed. Unless we have substantial pain with that, and again that's one of the criteria we're looking at the age of the woman, we're looking at the size of the cyst and we're looking at the symptoms. Obviously if the woman's in excruciating pain, and we've got a documented cyst, well that bears investigating quickly, perhaps surgery, active imaging because it could be a complicated, complication of the cyst, which we'll talk about. If the cyst in most cases is say less than ten centimeters, and there are no severe symptoms pain associated with it, then most of these can be watched for a period of one to three menstrual cycles, so up to 90 days, come back periodically, have another exam and see if these resolve. Because most of them are going to be the functional cysts, the cyst associated with the period that we talked about in the first category.

Does that mean that you're monitoring them over two or three menstrual cycles that they could well reduce in size after that time?

Absolutely, many of these will go away spontaneously. But as part of the management process, it depends on what is the goal of the reproductive age patient. Again, we've already eliminated the children, they're going to be, they're going to have surgery, most likely. We've already - because there's no reason for a child under the age of 12 to have a cyst, we've already said that the woman over 50, if she has a cyst, say a six centimeter cyst and she's stopped her periods, we could watch her one or two cycles but most likely, it's not going to be a leftover renegade cyst, if it persists more than that, and she needs to have further testing beyond the ultrasound. She needs to have a surgery to actually go in a small incision can be made above the pubic bone a laparotomy and to remove it.