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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