Disclosure During the course of her lifetime, every woman develops several adnexal masses. The normal functioning ovary produces a follicular cyst 6-7 times each year. In most cases, these functional masses are self-limiting and resolve within the duration of a normal menstrual cycle. In rare situations, they persist longer or become larger than 7 cm in diameter. At this point, they become a pathological condition. While most of these masses develop in menstruating women, their presence must be considered in both prepubertal girls and postmenopausal women, particularly when associated with pain. History of the Procedure: In the past, physicians relied on the findings of a pelvic examination to diagnose an adnexal mass. With the introduction of transabdominal or vaginal ultrasonography, Doppler color scans, CT scans, MRI scans, and positron emission tomography scans, the identification and evaluation of adnexal masses become entirely different. These radiologic tests allow physicians to identify subclinical masses and to delineate the internal structure of the mass (eg, wall complexity, mass contents). Problem: The following masses pose the greatest concern:
Frequency: Determining the frequency of adnexal masses is impossible because most develop and resolve without clinical detection. Importantly, keep in mind those masses that are clinically important and their relationship to the age of the woman. In girls younger than 9 years, 80% of ovarian masses are malignant and are generally germ cell tumors. During adolescence, 50% of adnexal neoplasms are adult cystic teratomas. Women with gonads that contain a Y chromosome have a 25% chance of developing a malignant neoplasm. Endometriosis is uncommon in adolescent women but may be present in as many as 50% of those who present with a painful mass. In sexually active adolescents, one must always consider a tubo-ovarian abscess as the cause of an adnexal mass. In women of reproductive age who have had adnexal masses removed surgically, the masses are found to have characteristic pathology. Ten percent of masses are malignant; most tumors in patients younger than 30 years have a low malignant potential. Thirty-three percent are adult cystic teratomas, and 25% are endometriomas. The rest are serous or mucinous cystadenomas or functional cysts. Historically, postmenopausal women with clinically detectable ovaries were felt to be at great risk of having a malignant neoplasm. With the introduction of radiologic testing, many smaller masses have been identified; therefore, the risk of malignancy may be only 10-20%. Radiologic testing allows the architecture of the mass to be determined, which greatly decreases the need to operate on benign masses in this age group. In all age groups, the physician must consider the possibility of uterine masses or structural deformities. Pregnancy is a frequent cause of a pelvic mass and must be considered in all menstruating women. Pathophysiology: The pathophysiology is not well understood for most adnexal masses; however, some theories have been proposed. Functional cysts may be the result of variation in normal follicle formation. Adult cystic teratomas (dermoid) may be the result of an abnormal germ cell. Endometriomas are thought to result from retrograde menstruation or coelomic metaplasia. The exact cause of epithelial neoplasms is unknown, but recent studies have suggested a complex series of molecular genetic changes is involved. Clinical: A woman presenting with an adnexal mass is most often unaware of the mass, and, as such, she will report no relevant history. Those women who have symptoms note urinary frequency, pelvic or abdominal pressure, and bowel habit changes due to the mass effect on these organs. Girls younger than 10 years frequently present with pain, as do older women who have infected masses or endometriosis. Women with twisted masses also have acute pain. When a woman presents with the symptoms of abdominal bloating, gastrointestinal upset, and pelvic pressure, she should be considered a likely candidate for a malignant adnexal mass. The clinical presentation can be quite variable, with many presenting symptoms, including the following:
Most adnexal masses present as asymptomatic, small, and simple cystic masses. Nearly all of these resolve spontaneously; therefore, care must be taken to not overreact to such a finding. Surgeons who rush these women into surgery often create more pathology than they cure. Any surgery performed on adnexal structures can result in impaired fertility. On the other hand, these same asymptomatic masses can be early ovarian cancers that require immediate attention. The use of radiologic testing often helps determine which women require attention (see Imaging Studies). The use of cancer antigen 125 (CA125) test values to screen for the presence of cancer should be discouraged. A large Swedish study has shown that approximately 50% of women with stage I ovarian cancer have a normal CA125 test value. In addition, a very high false-positive rate can be caused by pregnancy, endometriosis, cirrhosis, and pelvic or other intra-abdominal infections.
Relevant Anatomy: Adnexal masses are located deep in the pelvis, which allows easy assessment with a standard gynecologic examination. However, before surgical intervention is undertaken, several other anatomical structures must be located. The uterus is central to both adnexal regions and can be the source of a pelvic mass. The rectum and bladder are located posterior and anterior to the adnexal regions. Both can be the source of pelvic masses. In addition, they must be protected from injury when adnexal surgery is performed. The ureters are located near the ovarian blood supply and can be damaged easily during adnexal surgery. Many of the pathological processes associated with adnexal masses can alter the location of the ureters, increasing the chance of damage. Contraindications: Most adnexal masses present as asymptomatic, small, and simple cystic masses, nearly all of which resolve spontaneously. Therefore, take care not to overreact to such a finding because surgeons who rush these women into surgery often create more pathology than they cure. Any surgery performed on adnexal structures can result in impaired fertility. Most adnexal masses can be removed with relative ease and are associated with little postoperative complexity; however, in those women with significant preexisting medical problems and/or cancer, major postoperative problems can be encountered (see Postoperative Details and Complications). Always remember that functional cysts do not become larger than 7 cm and all nonfunctional cysts require treatment. Furthermore, this treatment is more successful when administered as early as possible in the natural history of the cysts. |
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Lab Studies:
Imaging Studies:
Diagnostic Procedures:
Medical therapy: Asymptomatic, small, well-characterized adnexal masses can be observed with regular pelvic examinations and radiologic evaluations. A surgical approach should be used if any growth occurs in these masses. Masses known to be leiomyomas can be approached with gonadotropin-releasing hormone agonists, with the expectation that 50% will decrease in size. Radiologic ablation of these masses can be used in certain cases. It has been suggested that women with adnexal masses be treated with low-dose birth control pills in an effort to reduce tumor size. Little data seem to be available to support this approach. Its major value seems to be the additional time it takes, which allows for spontaneous regression of many of the functional adnexal masses. The information obtained from ultrasonographic testing should allow the identification of the functional cysts that do not require active treatment. Symptomatic treatment is often all that these women need. Surgical therapy: All adnexal masses that are symptomatic or have characteristics of a malignancy must be addressed with surgical removal. Rarely will a functional cyst have either of these features; therefore, few unnecessary surgeries result from this approach. The nature of this approach must be discussed prior to the surgery. One must consider all possibilities during this discussion. Obvious benign masses can be treated with resection of the mass alone or removal of the adnexal structure. In those cases in which the presence of malignancy is questionable, one should limit the resection to the structures involved unless a preoperative decision has been made that a more aggressive approach should be taken. When an obvious malignancy is encountered, a complete staging protocol must be performed. This generally includes complete exploration of the abdomen, total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy, pelvic and para-aortic lymph node dissections, biopsies of the undersurface of the right and left diaphragms, and biopsies of the colic gutters followed by a maximal resection of the intra-abdominal tumor. In some cases, resecting portions of the small bowel or colon may be necessary; therefore, preoperative bowel preparation is necessary, as is a discussion about possible colostomy or other bowel changes. Preoperative details: Preoperative preparation is vital to the proper care of a woman with an adnexal mass. This should include the following:
Intraoperative details: During the procedure, several factors must be kept in mind, including the following:
Postoperative details: Most adnexal masses can be removed with relative ease and are associated with little postoperative complexity; however, in those women with significant preexisting medical problems and/or cancer, major postoperative problems can be encountered. They are best addressed with the following:
Follow-up care: Most adnexal masses require little more than the normal annual gynecologic examination for follow-up because they rarely recur. On the other hand, women found to have a malignancy require additional therapy, such as chemotherapy or radiation therapy. Their follow-up care should include frequent reexaminations to determine the disease status.
For excellent patient education resources, visit eMedicine's Women's Health Center. Also, see eMedicine's patient education article Ovarian Cysts.
The major adverse outcomes in the treatment of adnexal masses are related to complications resulting from surgical therapy. These may include the following:
Most adnexal masses are benign; outcome and prognosis are very good. Generally, no impact on life span or quality of life is noted. In fact, most women treated for adnexal masses have no interruption in their reproductive abilities. Those women who are found to have malignant adnexal masses fall into 3 groups, as follows:
Future The future holds 3 very interesting possibilities. First, the rapid expansion of new laparoscopic equipment makes minimally invasive surgery an area that will gain increasing importance in the treatment of adnexal masses. Second, the development of new radiologic techniques or expansion of the present techniques will allow the clinician to have a close look into an adnexal mass without entering the surgical suite. Third, new molecular genetic/molecular biologic drugs should become available that will allow the clinician to obtain new radiologic information and treat/dissolve adnexal masses, both benign and malignant. Controversies The major controversy surrounding adnexal masses is when and how to treat them. Always remember that functional cysts do not become larger than 7 cm. As such, cysts larger than this should be addressed as quickly as is convenient. The corollary to this is where the controversy develops. The fact that all functional cysts are smaller than 7 cm is not disputed; however, one must assume that all nonfunctional cysts, particularly the malignant variety, have a portion of their natural history during which they too are smaller than 7 cm. All nonfunctional cysts require treatment, and this treatment is more successful when administered as early as possible in the natural history of the cysts. How best to identify those masses that need treatment remains a difficult and controversial issue.
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