Pelvic Masses – Ovarian Cysts in Utah

Spencer P. Barney, MD, Carolyn Y. Muller, MD, Karen D. Bradshaw, MDb

Department of Obstetrics and Gynecology, University of New Mexico Health Science Center, 2211 Lomas Blvd. NE, Albuquerque, NM 87131, USA
Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center. 5323 Harry Hines Blvd., Dallas, TX 75390-9032, USA

Much fear and anxiety surround the evaluation of masses within the female pelvis, driven mainly by the potential of missing a malignancy. The limitations of physical examination, the apparent invasiveness of such examinations, and the patient’s perception of malignant risk can further heighten provider anxiety. The impact of invasive diagnostics on fertility in premenopausal women adds another layer of complexity to the diagnostic dilemma. This article reviews key concepts in a common-sense approach to diagnosing and managing pelvic masses in women of all age groups.

Pelvic cystic masses are a common occurrence in women of all age groups, with approximately 8% of asymptomatic women aged 25 to 40 who were randomly sampled from a population register having a cyst larger than 2.5 cm [l]. Another study found that of women aged 50 and older, 18% had a finding of a unilocular ovarian cyst of 10 cm or less [2]. Given these findings, all practitioners who care for women will, at some point in their careers, encounter the finding of a pelvic mass. Pelvic masses often are asymptomatic and found at the time of routine health care visits, during screening for other unrelated complaints, or when evaluating a specific gynecologic complaint. This article assists primary care providers in the targeted evaluation, management, and appropriate referral of women with a newly identified pelvic mass.

Differential diagnosis

The initial evaluation of a pelvic mass requires a consideration of the mUltiple organ systems present within the female pelvis and an adequate understanding of female pelvic anatomy. The reproductive organs include the vagina, cervix and uterus, fallopian tubes, and ovaries. Nonreproductive organs within the female pelvis include bowel (both large and small intestines), bladder, ureters, nerves, vascular structures, lymph nodes, and muscles. Any anatomic structure that resides in the female pelvis has the capacity to form a pelvic mass, so a variety of potential sources must be taken into consideration when the diagnosis of a pelvic mass is made. Because most pelvic masses within the female pelvis originate from the reproductive structures, this article specifically focuses on tbe diagnosis of masses of these organs. A list of common masses, both benign and malignant, is found in Table 1.

Clinical evaluation

Physical examination

Every evaluation should begin with a thorough history and physical examination. The history should include menstrual history, location, qualification, and quantification of pain, if present, fever, and any noted change in bowel or bladder habits. Age and family history of cancer should be included in every history because they are the two most important risk factors for the development of ovarian cancer. The physical examination can be somewhat directed by the information elicited when obtaining the patient history. A thorough abdominal and pelvic examintion is critical in determining the differential diagnosis. The pelvic examination includes a speculum examination and an evaluation or any purulent vaginal discharge followed by a bimanual and rectovaginal examination. Stool should be tested for blood. The location, consistency, mobility, and size of any masses palpated should be documented, along with location and characteristics of any pain elicited when performing the examination. Texture of the pelvic floor, including fixation, thickened tissue planes, or nodularilY, should be noted.

Table 1

Differential diagnosis of common causes of a pelvic mass

  • Curvix and uterus Fallopian tube Ovaries Nongynecologic
  • Benign Benign Benign Benign
  • Pregnancy Hydrosalpinx Functional cyst Appendicitis
  • Lejomyoma Tubo-ovarian abscess Endometrioma Bowel adhesions
  • Adenomyoma Ectopic pregnancy Polycystic ovaries Diverticulitis
  • Nabothian cyst Paraovarian cyst Fibroma; fibrothecoma Urinary retention
  • Uterine polyp Torsion
  • Hydrometra Mature cystic teratomas
  • Pyometra Benign cystadenomas
  • Malignant Malignant Malignant Malignant
  • Endometrial Cancer Fallopian tube cancer Ovarian cancer Colorectal cancer
  • Leiomyosarcoma Borderline tumor Lymphoma
  • Cervical cancer Metastatic cancer Carcinomatosis

Endometrial biopsy should be performed on any perimenopausal or postmenopausal woman who presents with associated abnormal bleeding. Any visible masses on the cervix or protruding from the vagina should be biopsied. This initial examination aids in establishing the differential diagnosis. Many physicians rely on imaging and do only a superficial examination or no examination at all (“the electronic pelvic examination”), but imaging cannot replace the additional useful information obtained by clinical hands-on evaluation and may result in a narrowed and erroneous diagnosis. For example, a mass can seem to represent a degenerating fibroid on a CT scan obtained during an emergency room visit for abdominal pain, but a thorough examination could reveal a normal sized uterus separate from a mass and additional nodularity within the cul-de-sac, which would increase the clinical suspicion of an ovarian malignancy. Should the diagnosis be made solely on the CT suggestion of a degenerating fibroid, treatment could be delayed, appropriate referrals not made, and survival subsequently compromised for that patient.

Despite the need for a thorough examination, studies have shown that the physical examination is not reliable as a diagnostic tool in and of itself. Padilla and colleagues [3] showed that even under ideal circumstances, the sensitivity of the pelvic examination is only 51%. This study attempted to eliminate difficulties, such as patient discomfort and anxiety, that are found in awake patients by assessing the effectiveness of examinations performed on anesthetized patients before surgery. Even this control does not eliminate difficulties caused by variables such as patient habitus, scars, or other findings, however, which can make assessment of pelvic masses more difficult.

A similar study, also by Padilla and colleagues [4], showed the importance of experience when performing a pelvic examination under the same optimal examination conditions. The accurate identification of uterine size, contour, and adnexal pathology during pelvic examinations under general anesthesia was 70.2% for attending gynecologists, 64.0% ror residents, and 57.3% for medical students when compared with surgical findings. They also found that uterine assessment seemed to be more accurate than adnexal assessment. Because even in the most experienced hands under optimal examination conditions pelvic examination does not always accurately assess pelvic pathology, other diagnostic studies such as ultrasound, used in fandem with the initial history and physical examination, are necessary to achieve a more complete evaluation of the pelvis.

Ultrasound

Transabdominal and transvaginal ultrasounds are still the leading modalities used to visualize female pelvic anatomy and examine pelvic masses. Generally, transabdominal and transvaginal ultrasound should be performed to assess the adnexa adequately. The transabdominal ultrasound gives an overall assessment of organ size and anatomy, whereas the transvaginal ultrasound, with its higher image resolution, gives more detailed information about pelvic structures and masses. Many characteristic findings seen on ultrasound help to differentiate benign from malignant masses. Benign masses are more often smooth in contour and have a single, thin-walled cyst with minimal vascularity (Fig. 1). Malignant masses, on the other hand, often show thick walls or septations, solid components such as mural nodules, increased vascularity, and increased pelvic fluid or frank ascites (Fig. 2). Other nonmalignant masses, such as hemorrhagic cysts, endometriomas, and mature teratomas, have their own characteristic findings on ultrasound.

After visualizing the mass generally, it is important to determine if the mass is intraovarian or extraovarian, which often can be accomplished by visualizing the ipsilateral ovary. The distinction is important because most extraovarian masses are benign [5]. Most pelvic malignancies arise from
ovarian tissue; however, most intraovarian masses are benign, especially in premenopausal women. The five most common masses seen within the ovary are simple functional cysts, mature teratomas (dermoid), endometriomas, corpus lutea, and hemorrhagic cysts [5].

A normal premenopausal ovary averages 3.5 x 2 x 1.5 cm; a postmenopausal ovary measures 1.5 x 0.75 x 0.5 cm [6]. Any postmenopausal ovary that is twice as large as the contralateral ovary is concerning [7]. For unilocular cysts (single cysts without septations or solid components), ovarian size does not correlate well with the risk for malignancy, however. Studies show that unilocular ovarian cysts smaller than 5 to 10 cm had no findings associated with malignancy on ultrasound and were likely benign or had a low malignant potential, even in postmenopausal patients [2,8]. Many of these cysts stayed the same size or resolved spontaneously over a prolonged period of time. Of those that had spontaneous resolution (69%), most resolved within 3 months.

Apart from the size, another aspect of a pelvic mass that can be evaluated by ultrasound is its consistency. Cysts that have septae, excrescences, papillations,
or solid areas are significantly more concerning for malignancy than simple cysts with a smooth contour. One study of a mixed population of pre- and postmenopausal patients showed that among women with unilocular cysts, only 0.3% (1/296) of cysts were malignant, whereas 8% (20/229) that were classified as multilocular were found to be malignant. Multilocular tumors with solid components and solid tumors were much more likely to be malignant than those without solid components [9]. More recent studies confirm this finding that unilocular and even multilocular cysts without solid components are most often benign [10,11].

Vascularization is another aspect of a mass that can be characterized sonographically. Malignancies are much more likely to have neovascularization and often are found to have a low resistive index (RI) on Doppler flow imaging of the mass. The Rl is defined as the difference between the peak systolic and the maximum end diastolic flow velocity in arterial vessels divided by the peak systolic flow velocity. New vessels associated with malignancy have little smooth muscle in the arterial wall; they have less resistance to flow and subsequently a lower RI. Benign cysts, on the other hand, generaJly do not have this same neovascularization. At our institution we use a cut-off of 0.4 when looking at the RI of ovarian masses. Anything below this number has a higher suspicion of being malignant.

The uterus also can be visualized sonographically, which is helpful when evaluating for abnormal or postmenopausal bleeding or evaluating for or characterizing presumed fibroids. Generally, in postmenopausal patients the endometrial thickness or stripe should measure less than 5 mm (Fig. 3). In premenopausal patients, measurement of the endometrial stripe is generally of little value because there is a large variation in the endometrial thickness throughout the menstrual cycle. Fibroids typically have a characteristic appearance on ultrasound. They are generally round, well-circumscribed masses with a circumferential blood flow pattern (Fig. 4). These characteristics can vary, and fibroids can have degenerative changes, including calcifications or cystic degeneration. Such degeneration and necrosis can be seen as fibroids outgrow their blood supply. Smaller fibroids can be seen and mapped out using transvaginal ultrasound. Large fibroids often are better visualized and measured transabdominally given the shallow depth of penetration of the transvaginal transducer, which makes it less effective at evaluating large masses. Submucosal fibroids and endometrial polyps may be better visualized with a sonohysterogram, in which saline is instilled within the endometrial cavity to allow for better visualization of the space (Fig. 5). It may be difficult to distinguish pedunculated serosal fibroids from ovarian masses unless the ipsilateral ovary can be well visualized separate from the mass or unless bridging vessels are seen between the uterus and the mass.

Hemorrhagic cysts occur when bleeding occurs in a functional cyst-typically at the time of ovulation. They can vary widely in appearance. As the clot organizes, it forms fibrin strands that can be mistaken for septations. The difference between septations and fibrin strands is determined by the number seen and their ultrasonographic characteristics. Septations are usually limited in number, whereas fibrin strands are innumerable. The fibrin strands are generally much thinner and tract over less distance than do septations. Given these initial findings, hemorrhagic cysts can be-and at times are-mistaken for neoplastic masses. The difference is that hemorrhagic cysts nearly always resolve spontaneously over a short time period of 2 to 8 weeks (Fig. 6) [12]. The appearance of these cysts can vary greatly as they continue to reabsorb. The fibrin strands disappear, and the retracting thrombus can appear as a solid structure on the sidewall of an otherwise normal appearing cyst. This variance stresses the value of re-examination and reimaging of equivocal pelvic masses within a 6- to 8-week period.

Endometriomas are another example of a pelvic mass that can take on multiple ultrasonographic appearances. These masses can be found in association with endometriosis, although endometriosis itself is not rteliably seen on ultrasound. They can occur in a large range of ages and often are present for long periods of time unless they are surgically excised. Most endometriomas are represented on ultrasound by diffuse, homogeneous, low-evel echoes. Occasionally, these masses can vary in appearance and contain septations or hyperechoic wall foci and nodularity [5]. There may be some overlap between the ultrasound appearance of endometriomas and that of hemorrhagic cysts, and endometriomas may contain an apparent solid component caused by fibrin or clot. In one study, 17 of 58 surgically proven endometriomas (29.3%), which measured larger than 2 cm, had no mention of endometrioma or hemorrhagic cyst on the prospective differential diagnosis. In this article, ultrasonographic findings that were atypical included retracted clots that appeared as solid components without any blood flow, areas with heterogeneous internal echoes, or areas of central calcification [13].

CT

CT is generally not recommended for initial evaluation of pelvic masses because ultrasound is less expensive and better at evaluating masses of gynecologic origin and results in no exposure to radiation. CT is most helpful as a second line study for in-depth evaluation of the abdomen and pelvis when malignancy is suspected; CT studies should be ordered by a specialist after referral. More pelvic abnormalities are being initially found on CT evaluation because it is becoming a more common first-line tool for the evaluation of patients with various symptoms who present to the emergency department [14]. CT is less operator-dependent than ultrasound and often has round-the-clock availability that may be lacking for ultrasound evaluation. Because of its availability, many gynecologic abnormalities, which normally would have been evaluated by ultrasound, ar initially being found during these evaluations (Fig. 7). Many are incidental findings during CT evaluation of nonpelvic complaints, whereas others may be the cause of thc pelvic pain or other complaints that initially led to the CT.

Historically, given the comfort of gynecologists with ultrasound findings, these CT images would be followed-at times unnecessarily-with ultrasound for evaluation. Many of these conditions, such as hemorrhagic ovarian cysts, pelvic inflammatory disease, cystic teratomas, endometriosis, fibroids, and endometrial or ovarian cancers, have findings that can be reliably recognized on CT (Fig. 8) [1 5]. If these masses have a characteristic diagnostic appearance, then reimaging is not necessary. Patel and Dubinsky [16] described three instances in which reimaging with ultrasound is useful after pelvic CT findings of an abnormality: (1) evaluation of the mass in relationship to ovarian tissue, (2) better clarification of the vascularity of the mass, especially for noncontrasted CT images, and (3) evaluation for indications that are uniquely suited to ultrasound evaluation, such as pregnancy or follow-up for a suspected ectopic pregnancy. In most other instauces, immediate reimaging by ultrasound of abnormalities found on CT is not necessary. Follow-up imaging (ultrasound evaluation at some future point to re-evaluate findings) of these abnormalities may still be clinically indicated.

MRI

MRI, much like CT, has little place in tbe initial evaluation of pelvic masses. Like CT, it can be used for further evaluation of masses suspected to be malignant. Chang and colleagues [17] defined some instances when MRI is useful after sonographic evaluation, including the evaluation of large masses that are not well visualized by transvaginal ultrasound and indeterminate pelvic masses in which the origin of the pelvic mass cannot be determined by ultrasound. Patel [12] similarly stated that adnexal findings that cannot be classified confidently should be followed-up with MRI for further evaluation. MRI also can be helpful for the evaluation of small masses found within soft tissue, such as masses felt along the vaginal sidewall, if not well characterized by ultrasound. Traditionally, MRI has been the modality of choice for uterine findings felt to be adenomyosis, and this application continues to be appropriate. Studies currently show that transvaginal ultrasound also has adequate image resolution to diagnose adenomyosis, as long as the sonographer has sufficient experience and training [18]. In cases in which an experienced sonographer is available, the relative cost and availability of ultrasound make it an ideal first-line choice for the evaluation of pelvic pain suspected to be adenomyosis.

MRl is useful in assessing an adnexal mass in pregnancy, in which exposure to radiation is avoided and palpation and sonographic visualization are difficult. As the gestation progresses, the adnexa are moved out of the pelvis and may not be adequately evaluated by transabdominal sonography. Because surgical intervention in pregnancy is reserved for acute complications or malignant suspicions, MRl may be helpful in further characterizing the mass and evaluating the safety of waiting until after delivery to intervene.

Tumor markers

The most commonly used tumor marker for ovarian cancer is CA-125, which is a serum glycoprotein that is elevated in 80% of women with epithelial ovarian cancer [19]. No single tumor marker (including CA-125) has been found to be reliably helpful for screening purposes, however. Instead, tumor markers are used as a tool to help assess likelihood of ovarian cancer in someone found to have a suspicious mass, especially in postmenopausal patients. Because many benign diseases, including nongynecologic conditions and physiologic ovulatory events, can increase CA-125, it is of limited value in premenopausal women and should not be obtained unless
interpretation of the result is understood by the practitioner. Elevated results and normal results should be interpreted with caution and in conjunction with the clinical scenario and cancer risk assessment. Findings such as pelvic inflammatory disease, adenomyosis, endometriosis, pregnancy, menstruation, and functional cysts can increase the serum CA-125 level. On the other hand, a negative CA-125 result does not rule out ovarian cancer. Up to 50% of early malignancies and 20% to 25% of late stage cancers are found to have normal CA-125 values [20].

The greatest use of CA-125 is to assess the effectiveness of surgery and other treatments or monitor for recurrence of ovarian cancer when the diagnosis is histologically known. Other tumor markers have been studied. including CA-l5.3 [21], which showed a high specificity and positive predictive value, and CA-19.9 [22], which had a high association with mucinous-type tumors. Neither of these markers-either individually or in conjunction with CA-125-seemed to show a significant increase in detection of cancer over CA-125 combined with physical examination and ultrasound. A flurry of translational genomic and proteomic research efforts has yielded promising biomarkers for early detection of ovarian cancer, such as He-4, mesothelian, osteopontin, lysophospatidic acid, kallikreins, and soluble epidermal growth factor receptor [23]. Although not ready for clinical use, active validation studies are underway to define a panel that will have optimal sensitivity and specificity profiles to improve early diagnosis of ovarian cancer.

If a germ cell tumor is of concern because of a solid mass seen in a premenopausal woman, then lactate dehydrogenase, alpha-fetoprotein, and human chorionic gonadotropin levels can be helpful. Obtaining a human chorionic gonadotropin value is essential to rule out pregnancy, either intrauterine or ectopic, as the cause of a pelvic mass.

Management

Initial management of a pelvic mass is based on patient age, size and characteristics of the mass, and findings on ultrasound and laboratory tests. The initial evaluation should focus on ruling out malignancy, torsion, or rupture. It is important to decide which masses require surgery and which do not. Some masses may require further management by a specialist, although many masses or cysts can be dealt with medically or conservatively in a generalist setting. This section explores the management of adnexal masses-after initial evaluation-stratified by age.

Adolescents

A human chorionic gonadotropin level should be obtained in every adolescent or woman of childbearing age to rule out pregnancy as the primary cause of a pelvic mass. This is especially true if a history of irregular menses or missed menses is elicited in the initial interview. An ectopic pregnancy can be life threatening if not promptly diagnosed early in the growth process. Once pregnancy is ruled out, then clinical examination and ultrasound findings can be reviewed. Because the risk of malignancy is low in this age group and the desire to preserve fertility is high, many masses can be followed expectantly. Any simple cystic mass that is smaller than 10 cm should be followed expectantly unless symptoms, such as significant pain, suggest torsion. During the reproductive years, 70% of cysts of this size resolve spontaneously [24]. Generally, follow-up ultrasound in approximately 2 to 3 months is a reasonable time period to look for resolution of, or change in, a cystic mass. If there does not seem to be resolution within 3 months or if the mass is growing or seems to be more complex, then referral to a gynecologist may be warranted.

It has been a common practice to prescribe oral contraceptive pills for the treatment of women with simple cysts. The use of oral contraceptive pills for treatment of ovarian cysts, however, has been shown to have no effect. A Cochrane Review in 2006 concluded that “treatment with combined oral contraceptives did not hasten resolution of functional cysts in any trial” [25]. Most of these cysts resolve on their own if followed expectantly. Some providers use oral contraceptives for women with ovarian cysts, not to treat the cyst but with the hope that use will prevent new cysts from forming while awaiting the resolution of the cyst in question. The use of oral contraceptive pills for this indication is not well studied.

Fine needle aspiration of cysts is another traditionally used method of treatment that has not been found to be useful. The diagnosis of cancer based on cytologic findings is not sensitive enough to warrant routine aspiration as part of the evaluation for pelvic masses, and the resolution rate of cysts after aspiration is not statistically different than cysts followed expectantly [26,27].

Any cyst larger than 10 cm or any cyst with septations or solid components should undergo further evaluation. The use of CA-125 in adolescents is of limited value because of its nonspecific nature. Endometriosis, pelvic inflammatory disease, pregnancy, and even functional ovarian cysts can elevate CA-12S. The American College of Obstetricians and Gynecologists advises that “in premenopausal women with symptoms, a CA 125 measurement has not been shown to be useful in most circumstances” [20]. Because of this difficulty, the American College of Obstetricians and Gynecologists recommends a CA-125 level of more than 200 U/mL as a threshold in average-risk premenopausal women for referral to a gynecologic oncologist. Although solid masses are concerning and often require surgical management, most are still benign. Dermoid cysts, or mature cystic teratomas, which are more common in younger, reproductive-aged women, are almost universally benign [28].

One concern of large cysts, or any large mass of the ovary, is that of torsion, which refers to the twisting of the ovary around its ligamentous support. Torsion can result in venous obstruction of the ovary and cause engorgement and eventually ischemia because of diminished blood flow. Torsion often presents as intermittent sharp pain. Evaluation should begin with a pelvic examination and ultrasound to evaluate blood flow of the ovary in question. Ultrasound imaging, however, is not an infallible way to diagnose torsion, so clinical suspicion should guide the evaluation. Studies need to be completed quickly and followed by urgent surgical management, when indicated, to help salvage the ovary and preserve ovarian function. When surgery is performed soon after discovery of torsion, the vessels can be untwisted and the ovary, along with fertility, can be preserved.

Pelvic inflammatory disease is also more prevalent in adolescent and young adult women. It can lead to tubo-ovarian abscesses and adhesions and can be a cause of long-term infertility if not diagnosed and treated early. Women generally present with pelvic pain and a history or fever or purulent vaginal discharge or both. They often have an elevated white blood cell count because of the infectious process. Infection and the inflammatory response are what lead to abscesses and eventually scarring and tubal occlusion if not treated in a timely fashion. Gonorrhea and chlamydia cultures should be obtained during the evaluation of pelvic inflammatory disease because they are often the primary causes.

Premenopausal women

The principles that direct management of pelvic masses in adolescents also apply to most premenopausal women. As patients age, however, the risk of ovarian malignancy increases. As patients approach menopause, the suspicion of malignancy also should increase proportionately. As in adolescents, evaluation begins with a human chorionic gonadotropin test to rule out pregnancy. Risk of ectopic pregnancy also increases as patients age because of the increased likelihood that they have had pelvic inflammatory disease or pelvic surgery, which can cause scarring around the fallopian tubes, so attention should be paid to this possibility. A history of previous ectopic pregnancy should place this diagnosis higher on the differential until pregnancy is ruled out or until an intrauterine pregnancy has been confirmed.

With the increased use of first trimester ultrasound in pregnancy and the increased sensitivity of ultrasound equipment, the incidence of diagnosis of pelvic masses during pregnancy has increased. Most of these masses resolve spontaneously by the second trimester [29,30]. In most cases, early surgical management is unwarranted. The risk of malignancy of an ovarian mass encountered during pregnancy is between 2% and 3% [30]. As in other pelvic masses, the malignant potential can be evaluated with the same ultrasound guidelines used for nonpregnant women, with solid tumors with irregular vascularity carrying a higher risk of malignancy. If pelvic masses persist into the second trimester, then consideration should be given to the possible need for surgical intervention. Surgery is more likely necessary if, after evaluation, there remains a strong suspicion of malignancy, the mass is large (> 10 cm) or symptomatic, or there is an increased concern for torsion, rupture, or obstruction of labor [30].

In nonpregnant patients, once a mass has been detected by physical examination, an ultrasound should be used for characterization of the mass. In limited instances, a CA-125 test may be useful. Ultrasound appearance combined with tumor size has been found to be the best predictor of malignancy in premenopausal women. In postmenopausal women, CA-125 combined with ultrasound appearance is the best predictor of malignancy [31]. A CA-125 test values in premenopausal women can be elevated because of several nonmalignant causes, and it is not a reliable marker for malignancy in this age group. These guidelines apply to premenopausal women of average risk for ovarian malignancy. Women with a hereditary high risk of premenopausal ovarian cancer and a pelvic mass should be referred for a more comprehensive evaluation for ovarian malignancy. Women with known BRCA2 or BRCA1 mutations have a 26% to 50% lifetime risk of developing ovarian cancer and a 3% to 23% risk of developing cancer by age 50, respectively [32]. Family history of cancer is critical when assessing these women, as is a personal history of premenopausal breast cancer.

Pelvic masses that are suspected to be caused by uterine fibroids, based on ultrasound or CT findings, do not require evaluation with CA-125. Most fibroids can be followed expectantly if symptoms are well tolerated. In any woman over the age of 35 years with abnormal bleeding, an endometrial biopsy should be performed to rule out endometrial cancer. If the endometrial biopsy shows malignant cells, then the patient should be referred to a gynecologic oncologist. Once cancer has been ruled out, bleeding associated with fibroids can be treated with oral contraceptive pills or endometrial ablation, depending on the size and number of fibroids present. Large fibroids that cause pain or other symptoms, such as incontinence, can be treated surgically and should be referred to a gynecologist. Many fibroids begin to regress after menopause and can be treated expectantly until menopause if surgery is not desired or is deemed unsafe because of a patient’s medical status.

Solid adnexal masses, although not often malignant in premenopausal women, generally require surgical intervention and warrant referral to a gynecologist. These recommendations apply to average-risk premenopausal women. The decision for referral to a gynecologic oncologist is based on several other criteria discussed later in this article.

Postmenopausal women

Previously, conventional wisdom held that postmenopausal ovaries did not produce cysts; however, this is not thc case. Along with the increasing use of sonography, the diagnosis of unilocular cysts in postmenopausal patients is also increasing. The malignant potential of a unilocular cyst in postmenopausal women, like that of premenopausal women, is low [2,8]. These cysts should be evaluated initially with ultrasound and a CA-125. If the CA-125 is normal (< 21 U/mL or < 35 U/mL, depending on the laboratory), then the cyst can be followed by repeat ultrasound. Any blood
flow seen within the mass also can be evaluated. A resistance index of less than 0.4 is associated with neovascuiarization and is more concerning for malignancy.

Any cysts with true complex septations or solid components found in postmenopausal women require surgical exploration. Again, a CA-125, according to the previous guidelines, can help determine if the mass should be approached by a general gynecologist or if it should be referred to a gynecologic oncologist for surgical management or presumed ovarian cancer. It should be noted that 50% of early-stage ovarian cancers have a normal CA-125, so clinical risk assessment, examination findings, and ultrasound characteristics of the ovarian mass should work in conjunction with laboratory values to dictate the presumed risk for malignancy.

Referral guidelines

As a general guideline, women with ovarian cancer have a better outcome and a longer survival rate if the initial surgery is performed by a gynecologic oncologist [20,21,33,34]. Appropriate surgical staging in presumed early-stage ovarian malignancies upstages the cancer in more than 30% of cases, thus changing the treatment recommendations and likelihood of survivorship [35,36]. In more advanced cases, adequate cytoreductive surgery that results in microscopic residual disease followed by appropriate chemotherapy improves survival [34,37]. This makes referral to the proper physician

Family history of one or more first-degree relatives with ovarian or breast cancer of vital importance for best patient outcome. The American College of Obstetricians and Gynecologists has developed guidelines to aid in the referral process [20]. These guidelines vary slightly for premenopuusal versus postmenopausal women, as listed in Box 1. Meeting anyone of these criteria warrants referral 10 a gynecologic oncologist. Following these referral guidelines was shown to capture 70% of ovarian cancer in premenopausal women and 94% of ovarian cancers in postmenopausal women [38].

This same study showed that strict adherence to the referral guidelines did tend to overrefer patients who were later found to have benign masses with a positive predictive value of 33.8% in premenopausal women and 59.5% in postmenopausal women. The guidelines presented in this article relate most to women at average risk for ovarian cancer. Fig. 9 displays a basic algorithm for referral of patients based on initial findings of an adnexal mass. All providers should recognize that women deemed at high risk for ovarian cancer because of significant family history, personal history, or premenopausal breast cancer or known BRCA mutation carrier status with symptoms or an adnexal mass should be managed by a gynecologic oncologist.

Summary

Initially, evaluation of any pelvic mass begins with a thorough history and physical examination, which should include a pelvic examination to determine the location, size, and characteristics of the mass. The first-line imaging modality for evaluation of any pelvic mass is ultrasound, which can aid in further defining the characteristics of the mass and evaluating its potential for malignancy. Pregnancy always must be excluded in reproductive- aged women. Most masses in premenopausal women are benign and, after appropriate evaluation, can be managed conservatively. Tumor markers such as CA-125 are not generally helpful in the evaluation of a pelvic mass in premenopausal patients but can be useful in evaluating postmenopausal patients with a pelvic mass. Management can be directed based on these findings and may vary depending on patient age. Any mass that needs surgical management should be referred to a gynecologist. If malignancy is of concern, then referral to a gynecologic oncologist should be made to enhance a palient’s likelihood of survival.

Acknowledgements

We would like to thank Rebecca Hall, PhD, and Benjamin Brooks, MD,
for helping to provide the ultrasound and CT images, respectively.

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