II. Epidemiology

  1. Most Ovarian Incidentalomas are benign (e.g. functional Ovarian Cysts, cystadenomas)
  2. Ovarian Cancer risk increases with age

III. History

  1. Ectopic Pregnancy risk (premenopausal women)
    1. Last Menstrual Period
    2. Contraception method
  2. Tubo-ovarian abscess risk
    1. Sexually Transmitted Infection (e.g. Gonorrhea or Chlamydia risk or potential exposures)
    2. Pelvic Inflammatory Disease history
  3. Adhesions risk
    1. Prior abdominal or pelvic surgeries
  4. Ovarian Cancer risks
    1. See Ovarian Cancer
    2. Age over 40 years old (most over 50)
    3. Family History (esp. BRCA, Lynch syndrome with Colon Cancer)
    4. Nulliparity
    5. Obesity
  5. Ovarian Cancer symptoms
    1. Abdominal bloating, increased abdominal girth or early satiety
    2. Pelvic Pain or Abdominal Pain
    3. Urinary tract symptoms

IV. Exam

  1. Speculum exam
  2. Pelvic Exam (bimanual exam)
    1. Performed in Adnexal Mass evaluation
    2. Useless in screening for Ovarian Cancer
      1. Buys (2011) JAMA 305(22):2295-303 [PubMed]
  3. Rectal exam (consider)
  4. Lymph node exam (inguinal region and generally)

V. Labs

  1. Urine Pregnancy Test
    1. Obtain in all premenopausal patients (exclude Ectopic Pregnancy)
  2. Tuboovarian abscess risk
    1. See Pelvic Inflammatory Disease
    2. Gonorrhea and Chlamydia DNA Probe
    3. Complete Blood Count
  3. CA 125 indications
    1. Avoid as a screening tool
    2. Follow algorithm (see below)
    3. Obtain as an adjunct to evaluation in those at Ovarian Cancer high risk

VI. Differential Diagnosis: Adnexal Mass

  1. Ovary
    1. Functional cyst or Corpus Luteal Cyst
    2. Theca lutein cyst
    3. Benign ovarian tumor (teratoma, cyst adenoma)
    4. Ovarian Torsion
    5. Ovarian hyperstimulation syndrome
    6. Ovarian Cancer
    7. Polycystic Ovary Syndrome
  2. Fallopian Tube
    1. Tuboovarian abscess in Pelvic Inflammatory Disease
    2. Hydrosalpinx
    3. Ectopic Pregnancy
    4. Malignancy
  3. Uterus
    1. Leiomyomata or Uterine Fibroids (pedunculated)
    2. Endometriosis
  4. Gastrointestinal Tract
    1. Stool-filled bowel
    2. Diverticulitis
    3. Appendicitis or appendiceal abscess
    4. Inflammatory Bowel Disease
    5. Small Bowel leiomyoma
    6. Colon Cancer
    7. Krukenberg Tumor (metastasis to ovary)
  5. Urinary Tract
    1. Bladder distention
    2. Urachal Cyst

VII. Imaging: Ultrasound

  1. Technique
    1. Transvaginal Ultrasound
  2. Characteristic findings suggestive of benign mass
    1. Premenopausal women with physiologic Ovarian Cysts <3 cm
    2. Postmentopausal women with simple cysts <1 cm
    3. Simple Ovarian Cyst
    4. Hemorrhagic Ovarian Cyst
    5. Endometrioma
    6. Benign Cystic Teratoma
    7. Fibroma
    8. Hydrosalpinx
  3. Intermediate lesions (based on ACR guidelines)
    1. Large, benign appearing cysts or BAC (round/oval, unilocular, smooth walled)
      1. Larger than 5 cm in early postmenopausal women
      2. Larger than 3 cm in late postmenopausal women
    2. Large, probably benign cysts or PBC (not round/oval, angulated margins, imaging inadequate)
      1. Larger than 5 cm in premenopausal women
      2. Larger than 3 cm in early postmenopausal women
      3. Larger than 1 cm in late postmenopausal women
  4. Characteristic findings suggestive of malignancy (Complex cyst or solid mass)
    1. Solid component within Ovarian Mass
    2. Thick septations >2-3 mm
    3. Large volume of free fluid present
    4. Color doppler Ultrasound shows blood flow within mass
    5. Thick cyst wall >2-3 mm
      1. Also seen in benign conditions
        1. Hemmorhagic Ovarian Cyst
        2. Endometrioma
    6. Cyst size does not distinguish benign from malignant
      1. However size my risk stratify postmenopausal cysts
      2. See Simple Ovarian Cyst

VIII. Evaluation: Risk of Malignancy Index (RMI) Scoring System

  1. Criteria: Ultrasound (assign 1 point if 1 characteristic, 2 points if >1 characteristic)
    1. Bilateral lesions
    2. Findings consistent with metastases
    3. Solid areas
    4. Multilocular cyst
    5. Ascites
  2. Criteria: Menopausal Status
    1. Premenopausal: 1 point
    2. Postmenopausal: 3 points
  3. Criteria: Serum CA-125 Level
    1. Use actual level in U/ml in calculation
  4. Calculation
    1. RMI = U * M * C
    2. Where U is Ultrasound criteria, M is menopausal status, and C is CA-125 level
  5. Interpretation
    1. RMI >200 is associated with a higher Ovarian Cancer risk
    2. RMI Threshold may vary by ethnicity and race
  6. References
    1. Dodge (2012) Curr Oncol 19(4): e244-57 [PubMed]

IX. Evaluation: Protocol

  1. Based on initial tests
    1. Urine Pregnancy Test (bHCG) if not postmenopausal
    2. Pelvic Ultrasound
    3. Consider CA-125 in postmenopausal women with nondiagnostic pelvic Ultrasound
  2. Exclude pregnancy first (bHCG)
    1. Evaluate for Ectopic Pregnancy if bHCG positive
  3. Refer to gynecology if red flag findings on history or Ultrasound
    1. See referral indications below
    2. Family History of Ovarian Cancer or high risk (see BRCA)
    3. Ultrasound with concerning findings (see findings suggestive of malignancy above)
    4. Adnexal Mass >6 cm
    5. Postmenopausal AND CA-125 >35 U/ml
    6. Risk of Malignancy Index (RMI) >200
  4. Repeat Ultrasound in 4-12 weeks
    1. Refer to gynecology if persistent adexal mass present >12 weeks

X. Management: Gynecology Referral Indications

  1. Prepubescent girls
    1. Adnexal Mass represents malignancy in 25% of girls <18 years old
    2. Refer all Adnexal Masses
  2. Pregnancy
    1. Acute presentation with positive Urine Pregnancy Test
      1. Evaluate for Ectopic Pregnancy (serial Quantitative hCG and pelvic Ultrasound)
    2. Adnexal Mass diagnosed during intrauterine pregnancy
      1. Simple Ovarian Cysts (<5 cm) are common during pregnancy
      2. Most Adnexal Masses resolve after pregancy
      3. Adnexal Masses identified during pregnancy are malignant in <1% of cases
      4. Refer large (>5 cm), complex, septated, irregular or bilateral Adnexal Masses
      5. MRI may be indicated in some cases
  3. Premenopausal women
    1. Ultrasound with complex cyst or solid mass (suspicious findings)
    2. Ultrasound with mass >10 cm
    3. Serial Ultrasounds (every 4-6 weeks) with mass that persists >12 weeks
    4. CA-125 is not recommended in evaluation of premenopausal women
      1. However if obtained, a CA-125>200 U/ml should prompt referral in this group
  4. Postmenopausal women
    1. Ultrasound with complex cyst or solid mass
    2. Ultrasound with mass >10 cm
    3. Serial Ultrasounds (every 4-6 weeks) with mass that persists >12 weeks
    4. CA-125 >35 U/ml

XI. Management: General

  1. Monitor intermediate lesions (not clearly benign, but not clearly suspicious)
    1. Transvaginal Ultrasound repeated in 6-12 weeks
    2. Some lesions may be monitored less frequently, up to one year (e.g. endometrioma, Cystic Teratoma)

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Ontology: Ovarian Cysts (C0029927)

Definition (MEDLINEPLUS)

A cyst is a fluid-filled sac. In most cases a cyst on the ovary does no harm and goes away by itself. Most women have them sometime during their lives. Cysts are rarely cancerous in women under 50. Cysts sometimes hurt - but not always. Often, a woman finds out about a cyst when she has a pelvic exam.

If you're in your childbearing years or past menopause, have no symptoms, and have a fluid-filled cyst, you may choose to monitor the cyst. You may need surgery if you have pain, are past menopause or if the cyst does not go away. Birth control pills can help prevent new cysts.

A health problem that may involve ovarian cysts is polycystic ovary syndrome (PCOS). Women with PCOS can have high levels of male hormones, irregular or no periods and small ovarian cysts.

Dept. of Health and Human Services Office on Women's Health

Definition (NCI) A cyst that arises from the ovary. Representative examples include simple, complex, corpus luteum, and endometrioid cysts. Symptoms include pelvic and abdominal pain and irregular periods.
Definition (CSP) fluid-filled closed cavity or sac in the ovary that is lined by epithelium; can be of normal, abnormal, non-neoplastic, or neoplastic tissues.
Definition (MSH) General term for CYSTS and cystic diseases of the OVARY.
Concepts Disease or Syndrome (T047)
MSH D010048
ICD10 N83.29 , N83.20
SnomedCT 79883001, 155999003, 237054003, 155996005, 198298009, 198292005
English Cysts, Ovarian, OVARIAN CYST, Cyst, Ovarian, Ovarian cyst NOS, Benign retention cyst, Ovarian cysts, cyst of ovary (diagnosis), cyst of ovary, Cyst ovary, Retention cyst of ovary, Unspecified ovarian cysts, Ovarian Cysts [Disease/Finding], ovarian cysts, ovary cyst, cystic ovarian mass, ovarian cyst, ovarian cystic mass, Ovarian retention cyst, Ovarian cyst NOS (disorder), Benign retention cyst (disorder), Ovarian cyst (disorder), Ovarian cyst benign (excl physiological), Ovaries--Cysts, Ovarian cyst, Ovarian cystic mass, Cyst of ovary, Cyst of ovary (disorder), cyst; ovary, ovary; cyst, retention, ovary; cyst, Ovarian cyst, NOS, Ovarian retention cyst, NOS, Ovarian Cyst, Cyst of Ovary, Cyst of the Ovary, Retention Cyst of Ovary, Retention Cyst of the Ovary, Retention Ovarian Cyst, Ovarian Cysts, Cyst of ovary NOS, Retention cyst of ovary NOS, Ovarian cyst benign (excluding physiological), Cyst;ovarian
Italian Cisti ovarica, Cisti ovarica benigna (fisiologica esclusa), Cisti dell'ovaio, Cisti ovarica NAS, Cisti ovariche
Dutch ovariaalcyste NAO, cyste ovarium, eierstokcyste benigne (excl. fysiologisch), cyste; ovarium, ovarium; cyste, retentie, ovarium; cyste, eierstokcyste, Cyste, ovarium-, Cysten, ovarium-, Ovariumcyste, Ovariumcysten
French Kyste ovarien, Kyste ovarien SAI, Kyste ovarien bénin (excl physiologique), KYSTE OVARIEN, Kyste de l'ovaire, Kystes de l'ovaire, Kystes des ovaires, Kystes ovariens
German Eierstockzyste NNB, Zyste des Eierstocks, Zyste des Eierstocks gutartig (ausschl physiologisch), OVARIALZYSTE, Ovarialzyste, Ovarialzysten, Zysten, Ovarial-
Portuguese Quisto do ovário NE, Quisto benigno do ovário (excl. fisiológico), QUISTO DO OVARIO, Quisto do ovário, Cistos Ovarianos
Spanish Quiste del ovario, Quiste benigno de ovario (excl fisiológico), Quiste ovárico NEOM, Quiste de ovario, QUISTE OVARICO, quiste ovárico (trastorno), masa quística en ovario, quiste ovárico, quiste de ovario, quiste de retención ovárico, quiste de ovario (trastorno), quiste ovárico, SAI (trastorno), quiste ovárico, SAI, Ovarian cyst NOS, Quiste ovárico, Quistes Ováricos
Japanese 卵巣嚢胞NOS, 卵巣嚢胞, 卵巣良性嚢胞(生理的なものを除く), ランソウノウホウNOS, ランソウノウホウ, ランソウリョウセイノウホウセイリテキナモノヲノゾク
Swedish Äggstockscystor
Czech ovarium - cysty, Benigní ovariální cysta (kromě fyziologické), Cysta vaječníku, Ovariální cysta NOS, Ovariální cysta
Finnish Munasarjakystat
Russian IAICHNIKOV KISTY, ZHELTOGO TELA KISTA, ЖЕЛТОГО ТЕЛА КИСТА, ЯИЧНИКОВ КИСТЫ
Croatian OVARIJSKE CISTE
Polish Torbiel ciałka żółtego, Torbiel jajnika
Hungarian Jóindulatú ovarialis cysta (kivéve physiologiás), Ovarialis cysta k.m.n., Ovarialis cysta, Ovarium cysta
Norwegian Eggstokkscyster, Cyster på eggstokkene

Ontology: Adnexal mass (C0149614)

Definition (NCI_NCI-GLOSS) A lump in tissue near the uterus, usually in the ovary or fallopian tube. Adnexal masses include ovarian cysts, ectopic (tubal) pregnancies, and benign (not cancer) or malignant (cancer) tumors.
Concepts Anatomical Abnormality (T190)
Dutch adnexgezwel
French Masse annéxielle
German Raumforderung der Adnexe
Italian Massa annessiale
Portuguese Massa anexial
Spanish Masa anexial
Japanese 付属器腫瘤, フゾクキシュリュウ
Czech Adnextumor
English adnexal masses, adnexal mass, Adnexal mass, Adnexal Mass
Hungarian Adnexumok térfoglaló folyamata

Ontology: Mass of ovary (C0240611)

Concepts Finding (T033)
SnomedCT 289922002
Italian Massa ovarica
Japanese 卵巣腫瘤, ランソウシュリュウ
English adnexa ovarian mass (___ cm), ovarian mass (___ cm), mass of ovary, mass of ovary (physical finding), mass ovary, masses ovarian, mass ovarian, ovary mass, mass ovaries, ovarian mass, Ovarian mass, Mass of ovary, Mass of ovary (finding), Mass of Ovary, Ovarian Mass
Czech Útvar v ovariu
Hungarian Ovarialis térfoglaló folyamat
Spanish masa en ovario (hallazgo), masa en ovario, Masa ovárica
Portuguese Massa ovárica
Dutch eistokgezwel
French Masse ovarienne
German ovarielle Raumforderung

Ontology: ovarian neoplasm (C0919267)

Definition (NCI) A benign or malignant, primary or metastatic neoplasm involving the ovary.
Definition (CSP) new abnormal ovary tissue that grows by excessive cellular division and proliferation more rapidly than normal and continues to grow after the stimuli that initiated the new growth cease.
Definition (MSH) Tumors or cancer of the OVARY. These neoplasms can be benign or malignant. They are classified according to the tissue of origin, such as the surface EPITHELIUM, the stromal endocrine cells, and the totipotent GERM CELLS.
Concepts Neoplastic Process (T191)
MSH D010051
SnomedCT 123843001
English Neoplasm, Ovarian, Neoplasms, Ovarian, Ovarian Neoplasms, ovary neoplasm, OVARIAN NEOPL, NEOPL OVARIAN, OVARY NEOPL, neoplasm of ovary, neoplasm of ovary (diagnosis), Ovarian neoplasia, Ovarian neoplasm NOS, Neoplasm, Ovary, Neoplasms, Ovary, Ovary Neoplasm, Ovary Neoplasms, Ovarian Neoplasms [Disease/Finding], ovarian tumor, tumor of ovary, ovarian tumour, ovarian tumors, ovarian tumours, ovary tumors, ovary neoplasms, ovarian neoplasms, ovary tumor, ovary tumour, ovarian neoplasia, Ovaries--Tumors, Ovarian neoplasm, Ovarian tumor, Ovarian tumour, Tumor of ovary, Tumour of ovary, Neoplasm of ovary (disorder), Neoplasm of ovary, ovary; tumor, Ovarian Neoplasm, Neoplasm of Ovary, Neoplasm of the Ovary, Ovarian Tumors, Ovarian Tumor, Tumor of Ovary, Tumor of the Ovary, ovarian neoplasm
Italian Tumore dell'ovaio, Neoplasia dell'ovaio, Tumore dell'ovaio NAS, Neoplasie ovariche, Neoplasie dell'ovaio
Dutch eierstokneoplasma NAO, eierstok neoplasie, ovarium; tumor, eierstokneoplasma, Gezwel, ovarium-, Gezwellen, ovarium-, Ovariumgezwel, Ovariumgezwellen, Carcinoom, ovarium-, Kanker, ovarium-
French Tumeur ovarienne SAI, Tumeur ovarienne, Tumeurs de l'ovaire, Tumeurs ovariennes, Tumeurs des ovaires
German Neubildung der Ovarien NNB, Neoplasie des Eierstocks, Neubildung der Ovarien, Ovarialtumoren
Portuguese Neoplasia do ovário NE, Neoplasia do ovário, Neoplasias Ovarianas
Spanish Neoplasia de ovario NEOM, Neoplasia ovárica, neoplasia de ovario (trastorno), neoplasia de ovario, tumor de ovario, tumor ovárico, Neoplasia de ovario, Neoplasias Ováricas
Japanese 卵巣の新生物, ランソウノシンセイブツ, ランソウシンセイブツ, 卵巣新生物NOS, ランソウシンセイブツNOS, 卵巣腫瘍, 卵巣新生物
Swedish Äggstockstumörer
Finnish Munasarjojen kasvaimet
Russian IAICHNIKOV NOVOOBRAZOVANIIA, ЯИЧНИКОВ НОВООБРАЗОВАНИЯ
Czech Novotvar vaječníku NOS, Novotvar vaječníku, Ovariální neoplazie, ovarium - nádory, nádory vaječníků, nádory ovarií, nádor vaječníku, vaječníky - nádory
Croatian OVARIJSKI TUMORI, TUMORI JAJNIKA
Polish Nowotwory jajników
Hungarian Petefészekdaganat, Ovarialis neoplasia k.m.n., Ovarialis neoplasia
Norwegian Svulster i eggstokkene, Eggstokksvulster, Neoplasmer i eggstokkene, Ovalialneoplasmer, Ovariesvulster