Gynecology: Adnexal Masses

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1. Overview. Ovaries usually 3 to 5 cm in length but influenced by hormones. Fallopian tubes normally cannot be felt. Ninety percent of adnexal masses involve the fallopian tube or ovary.

2. Differential Diagnosis will include ectopic pregnancy and masses arising from nearby structures including bladder, bowel, lymph nodes, or a pelvic kidney. Lateral uterine fibroids may be difficult to distinguish from adnexal masses. Benign parovarian cysts may be difficult to differentiate from ovarian cysts, even on ultrasound.

3. Evaluation.
1. History.
1. Ovarian neoplasms are often clinically silent, except for nonspecific "pressure" symptoms including urinary frequency, constipation, and pelvic heaviness.
2. Gynecological history including menses and STDs, sexual history including contraceptives, obstetric history, surgical history. Review of systems including bowel and bladder function, endocrine symptoms.
3. Family history of reproductive cancers (breast, uterine, ovarian) from both sides of family is critical because some ovarian tumors are familial (e.g., BRCA gene).
4. Multiparity, late menarche, early menopause, and the use of OPCs have all been shown to be protective against ovarian surface epithelial cell tumors.
5. Large tumors may cause increased abdominal girth and may be confused with pregnancy.
6. Pain may result from stretching of the ovarian capsule, torsion, rupture, or intracystic hemorrhage.
7. Functional cysts may cause menstrual abnormalities.

2. Physical exam. (1) Look for virilization, adenopathy, check breast, abdominal and pelvic exams including rectovaginal exam; (2) Benign tumors are characteristically unilateral, cystic, and mobile and do not cause ascites; (3) Malignancies are usually solid, fixed, and nodular and may cause ascites.

3. Diagnostic evaluation. Ultrasonography will help characterize the mass. Large cysts greater than 10 cm in diameter are more likely to be malignant and require immediate evaluation and probable excision. Solid ovarian tumors (by ultrasonography) are almost always malignant and demand immediate and aggressive evaluation and treatment. An exception to this is the rare luteoma of pregnancy. Check pregnancy test. Obtain CBC if there is bleeding, FSH and LH, if virilization present, and additional tests as indicated by the history and physical exam.

4. Treatment of Ovarian Masses. Evaluation and treatment is based on the patient’s age and reproductive status.
1. Premenarchial ovarian masses are at high risk for malignancy (germ cell tumors)
2. Premenopausal (benign functional ovarian cysts)
1. Women of childbearing age with an easily palpable, smooth, mobile ovarian mass less than 6 cm diameter may be observed with repeat pelvic exam in 6 weeks if the clinical picture is most con- sistent with a benign functional cyst: however, compliance with follow-up must be assured. Any mass 6 cm or greater should be evaluated by ultrasound.
2. If ultrasound demonstrates a simple ovarian cyst under 6 cm in diameter, this may be observed with repeat clinical exam and ultrasound in 6-8 weeks. If the cyst persists but decreases in size, it may be observed through another cycle. Oral contraceptives are sometimes used for 1-2 months to suppress ovarian function and prevent further cyst formation.
3. If an ovarian mass persists, is greater than 6 cm, or increases in size during an observation period of 2 months, surgical excision is indicated to exclude neoplasm.
3. Postmenopausal ovarian masses are at high risk for malignancy (surface epithelial or stromal tumors) and one should proceed to full evaluation without a period of observation. Early diagnosis is essential and usually necessitates surgical excision. Occasionally a postmenopausal woman will have a simple ovarian cyst less than 5 cm diameter on ultrasound. These cysts can be observed with repeat ultrasound in 2 months, and followed if unchanged or smaller.