OBJECTIVE This review is intended to increase the understanding of normal ovarian physiology in neonates, prepubescent girls and adolescents and to outline management guidelines for ovarian cysts at each age. RESULTS Ultrasound has increased the level of understanding regarding the development of ovarian cysts. With ultrasound, ovarian cysts are recognized as a consequence of follicular growth and atresia that can be a normal developmental occurrence at all ages. Clinical experience has taught us that ovarian cysts are common, frequently regress without treatment and are seldom associated with malignancy. New management schemes are developing which rely on increased recognition of torsion and prompt intervention to untwist the adnexa and leave it in situ. In addition, new operative techniques are being developed that are less invasive and morbid, as well as being more conservative of ovarian tissue. CONCLUSIONS With the understanding of normal ovarian follicular growth in girls prior to full maturity, the normal development of ovarian cysts can be appreciated. Conservative therapies with observation can often replace surgical management. When treatment is necessary, knowledge of less invasive and morbid techniques can improve ovarian preservation rates.