Contemporary management of ovarian cysts in the adolescent consists of conservative management, whether expectant, medical, or surgical. An understanding of ovarian physiology in the perimenarcheal and postpubertal patient supports ovarian preservation surgery, as the rate of malignancy is low and the alternative can be devastating. The most common ovarian cysts in adolescents are functional and often regress without further treatment. Symptomatic ovarian cysts warrant further investigation. Endometriomas arising from endometriosis are extremely uncommon. Tubo-ovarian abscesses are managed medically and rarely by drainage or surgery. Ovarian torsion is a surgical emergency, and prompt conservative operative management is indicated. Consideration of additional imaging, tumor markers, and surgical management of persistent or complex masses with ultrasound findings suspicious for malignancy is appropriate. This article reviews all these conditions and conservative management using laparoscopy as the preferred method if surgical intervention is needed. Unilateral removal of malignancies is advocated when possible.