Approach to adnexal masses: Clinical sciences

Chapters:

Watch video only

Introduction0:00–0:25

Adnexal masses arise from the ovary, fallopian tube, or surrounding tissues. They may be cystic or solid, simple or complex, unilateral or bilateral.
Most of these masses are benign, but an important diagnostic goal is to rule out malignancy. There are many types of adnexal masses, ranging from simple functional ovarian cysts to ovarian malignancy.

Unstable Patient0:25–0:52

When a patient presents with an adnexal mass, the first step is to perform a CABCDE assessment. If the patient is unstable, control hemorrhage; stabilize airway, breathing, and circulation; obtain IV access; and monitor vital signs.
Next, perform a focused history and physical examination, order an hCG to assess for pregnancy, and quickly obtain a pelvic ultrasound.

Ruptured ectopic pregnancy0:52–1:56

If the hCG test is positive, think about a ruptured ectopic pregnancy. In this case, the history will reveal unilateral pelvic pain, and possibly vaginal bleeding.
The patient may report a history of fallopian tube injury, such as prior pelvic inflammatory disease or tubal surgery, and may report a delayed or missed last menstrual cycle.
The physical examination may include abdominal or pelvic tenderness with possible rebound pain and guarding, and possibly an adnexal mass.
The ultrasound will demonstrate the absence of an intrauterine pregnancy and possibly an adnexal mass. In this case, consider an ectopic pregnancy and perform an operative laparoscopy.
If on laparoscopy, you find an extrauterine pregnancy with bleeding or a ruptured fallopian tube, as well as intraperitoneal blood and clot, the diagnosis is a ruptured ectopic pregnancy.
As a clinical pearl: remember that methotrexate is contraindicated in unstable patients!Okay, if the hCG is negative in unstable patients, they might have an adnexal torsion or a ruptured hemorrhagic cyst.

Adnexal torsion or ruptured hemorrhagic cyst1:56–2:52

The patient may report fever, nausea, and vomiting. The physical exam will reveal abdominal tenderness with possible rebound pain or guarding, and possibly a pelvic mass.
The ultrasound will show an adnexal mass, which represents an enlarged ovary, possibly with absent Doppler flow to the ovarian vessels; or free fluid in the pelvis.
In this case, consider adnexal torsion or a ruptured cyst and perform an operative laparoscopy. If the laparoscopy demonstrates an enlarged torsed ovary or adnexa, and possibly a blue or black ovary, diagnose adnexal torsion.
On the other hand, if there’s evidence of bleeding from an ovarian cyst and intraperitoneal blood and clot, diagnose a ruptured hemorrhagic cyst.Now that we’ve discussed unstable patients, let’s move on to stable patients.

Stable Patient2:52–3:37

Start with a focused history and physical examination, an hCG to assess for pregnancy, and a pelvic ultrasound. Here’s a clinical pearl!
Transvaginal ultrasound is the most commonly used imaging technique for the evaluation of adnexal masses. On the other hand, CT, MRI, and PET are not recommended in the initial evaluation of adnexal masses.
MRI may have superior ability compared with transvaginal ultrasound in correctly classifying malignant masses at the expense of a lower overall detection rate.
However, MRI often is helpful in differentiating the origin of pelvic masses that are not clearly of ovarian origin, especially leiomyomas.Okay, if the hCG is positive, first consider adnexal masses that are caused by pregnancy, such as ectopic pregnancy or a corpus luteum cyst.

Possible ectopic pregnancy or corpus luteum cyst3:37–3:56

Remember that pregnancy does not exclude other types of adnexal masses and consider the full differential diagnosis in pregnant patients.However, if the hCG is negative, your next step is to assess the patient's risk factors for malignancy.

Assess risk factors3:56–4:24

Risk factors include age greater than 55, a history of a family cancer syndrome like Lynch syndrome, or a family history of breast or ovarian cancer.
If the patient does not have any risk factors for malignancy, consider benign adnexal masses; but keep in mind that malignancy may also occur without predisposing risk factors.

Simple ovarian cyst4:24–5:43

Let’s start with simple ovarian cysts. The patient is likely to be premenopausal and may present with intermittent unilateral pain and pelvic pressure.
The physical examination may reveal abdominal or adnexal tenderness as well as adnexal fullness. If the ultrasound demonstrates a thin smooth-walled cyst that does not have any septations, internal blood flow, or solid components, the diagnosis is a simple ovarian cyst.
Here’s a clinical pearl! Simple ovarian cysts, also called functional or physiologic cysts, most commonly occur in premenopausal women because they arise from unruptured ovarian follicles or degeneration of the corpus luteum.
Generally, these cysts resolve spontaneously, but if they are persistent they can be managed expectantly with periodic ultrasound examinations.
Surgical intervention is indicated for cysts that cause persistent pain, or if there is a concern for malignancy such as an increase in size, development of loculations or solid components, or cyst measurement greater than ten centimeters.
In addition, simple cysts may leak or rupture, resulting in acute pain. When ovarian cysts rupture the symptoms are usually self limited and do not require intervention.

Hydrosalpinx5:43–6:15

Next, consider a hydrosalpinx. In this case, there may be a history of pelvic inflammatory disease or infertility, and the patient may report intermittent unilateral pain and pelvic pressure.
The physical exam is likely to reveal abdominal or adnexal tenderness as well as adnexal fullness. The ultrasound shows a dilated tubular cystic structure adjacent to the ovary that may contain incomplete septations but will not contain any solid components.
These findings are diagnostic for a hydrosalpinx.Okay, let’s discuss endometriomas. The history will reveal the four “Ds” of endometriosis: dysmenorrhea, dyspareunia, dyschezia, and dysuria.

Endometrioma6:15–6:47

Physical exam findings may include abdominal or pelvic tenderness, adnexal fullness, and rectovaginal nodularity. The ultrasound will show a cyst with homogeneous echogenicity, often referred to as a ground glass appearance, and it may contain one to four loculations, but no solid components.
This is consistent with an endometrioma.Now we can consider leiomyomas. This patient may have a history of uterine fibroids and may describe unilateral pelvic pain and abnormal uterine bleeding.

Leiomyoma6:47–7:14

The physical exam might show adnexal fullness. If the ultrasound reveals a solid mass that’s distinct from the ovary, and possibly has Doppler flow that demonstrates communication between the mass and the uterus, the diagnosis is a uterine leiomyoma.Next, let’s discuss mature cystic teratomas.

Mature cystic teratoma (aka dermoid cyst)7:14–8:10

The patient will probably be premenopausal, most likely under the age of forty. They may report unilateral pain but patients are often asymptomatic.
The physical exam may reveal adnexal fullness. If the ultrasound reveals a cystic mass with one or more of the following: mixed echogenicity, thick band-like internal echoes, a fat fluid level, and an echogenic nodule with posterior shadowing; you can diagnose a mature cystic teratoma.Here’s a high-yield fact!
Teratomas are also referred to as dermoid cysts, because they are mostly cystic and mostly contain ectodermal elements, typically resulting in abundant hair.
Nonetheless, a variety of mature, well-differentiated tissue elements can be found from all three embryological germ layers, so ectoderm, mesoderm, and endoderm.
Finally, let’s talk about cystadenomas. In this case, the history might include intermittent abdominal or pelvic pain, pressure, and bloating.

Serous or mucinous cystadenoma8:10–9:42

The physical exam will demonstrate a palpable adnexal or abdominal mass and adnexal fullness. The ultrasound will show a large, greater than 5 centimeters, thin-walled cyst, which may contain loculations but usually no solid components.
With these findings, consider a cystadenoma and, if there are ultrasonographic risk factors for malignancy, obtain tumor markers, such as Cancer Antigen 125, or CA-125.
If the tumor markers are normal, perform an operative laparoscopy and possibly a cystectomy or oophorectomy. Generally, the diagnosis can be made at the time of surgery.If the laparoscopy reveals a unilocular cyst containing serous material, you have a serous cystadenoma.
However, if the cyst is multilocular, very large, and filled with mucinous material, the diagnosis is a mucinous cystadenoma.
Here’s a clinical pearl! CA-125 level must be interpreted carefully.
Remember that the specificity of CA125 in the detection of malignancy is lower in premenopausal patients compared to menopausal ones, as elevation of CA-125 levels may occur in endometriosis, pregnancy, pelvic inflammatory disease, and in non gynecologic cancer.
Additionally, CA-125 is only a serum marker for ovarian neoplasms of epithelial origin. Okay, let’s return to our assessment of risk factors.

Malignancy9:42–11:41

If the patient has one or more risk factors, consider malignancy. Remember that patients in this case are most likely postmenopausal and may report a history of familial cancer syndrome.
Symptoms might be vague and can include abdominal or pelvic pain, bloating, or early satiety. The physical examination may show abdominal distension or a fluid wave, abdominal or pelvic tenderness, or an abdominal or pelvic mass.
The ultrasound will demonstrate a complex mass, possibly larger than 10 centimeters. The mass may have septations and or loculations with solid components, papillary projections, or mural nodules.
In addition, there might be evidence that the mass has increased internal Doppler flow and there may be free fluid in the pelvis.
When these findings are present, consider ovarian malignancy and obtain tumor markers, including a CA-125, and proceed with surgical exploration.
If it reveals a solid adnexal mass and possibly abdominal or pelvic adhesions, abdominal or pelvic ascites, omental caking or peritoneal and subdiaphragmatic studding, that’s an ovarian malignancy, most commonly epithelial ovarian carcinoma.After assessing for common causes of adnexal masses, consider and assess for alternative diagnoses like paratubal cysts, tubo-ovarian abscess, fallopian tube malignancy, stromal cell tumors, germ cell tumors, and metastatic cancer.One last high-yield fact!
Age is the most important independent risk factor for ovarian cancer in the general population, with the incidence increasing sharply after the onset of menopause.
Still, most adnexal masses in postmenopausal patients are benign neoplasms, such as cystadenomas, but the risk of malignancy is much greater than in premenopausal patients.Alright, as a quick recap… Common causes of benign adnexal masses are simple ovarian cysts, hydrosalpinx, endometriomas, leiomyomas, mature cystic teratomas, or cystadenomas.

Review11:41–11:58

The most common ovarian malignancy is epithelial ovarian