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Objective: To determine whether concentrations of gonadal steroids and fibrinolytic indices in fluid from benign ovarian cysts can discriminate between functional and neoplastic cysts and predict recurrence after ultrasound-guided puncture., Methods: Concentrations of gonadal steroids and components of the plasminogen-activating system were measured in cyst fluid obtained at ultrasound-guided puncture of 96 ovarian cysts and were related to subsequent cyst recurrence. In 83 patients who had surgery for benign ovarian cysts, components of the plasminogen-activating system in the cyst fluid were correlated with the histopathologic diagnosis., Results: Higher levels of plasminogen activators and lower levels of inhibitors were found in those 54 cysts that recurred after puncture and in cysts with low levels (below 2000 pmol/L) of estradiol (E2). This enzyme-inhibitor balance resulted in high fibrinolytic activity. In contrast, cysts with high E2 levels (above 2000 pmol/L) had lower levels of activators, higher levels of inhibitors, and virtually no fibrinolytic activity. A high E2 concentration in cyst fluid was the single best predictor of no recurrence after puncture. Sixteen of 18 cysts in postmenopausal women recurred, and all had low levels of E2. However, an index based on cyst fluid volume and concentrations of E2 and urokinase predicted recurrence even better. A high concentration of urokinase in the fluid correlated with neoplastic histology of the cysts obtained at laparotomy., Conclusion: The fluid content of ovarian steroids and plasminogen activators and inhibitors is related to histopathology and recurrence after puncture of benign ovarian cysts. Puncture and assay of these components may minimize surgery on functional cysts.