Adnexal mass
Gynaecology
Clinic, or an incidental finding
The first question
Is it likely benign, and does it need surgery or surveillance?
- 01
Context
Age and menopausal status, symptoms, pregnancy test.
- 02
Ultrasound morphology
Simple, unilocular, size; solid components, papillary projections, septa, ascites, Doppler flow.
- 03
Tumour markers by age
CA-125 after menopause (and with the RMI before); AFP, hCG, LDH in the young.
- 04
Decide
Simple cysts under 5 cm need no follow-up; larger or complex ones are surveilled or removed; concerning features go to gynaecological oncology.
Where it is
Each opens the structure on the 3D pelvis.
History that discriminates
- Pain, bloating, early satiety, urinary frequency
- Cycle relation
- Menopausal status
- Family history of ovarian, breast or colorectal cancer
- Prior cysts, endometriosis
Examination that discriminates
- Abdominal mass, ascites
- Bimanual: size, mobility, tenderness, fixed or nodular
- Lymph nodes, pleural effusion in advanced disease
Investigations
- hCG
- Transvaginal ultrasound with Doppler (IOTA simple rules)
- CA-125 (and RMI after menopause); AFP, hCG, LDH under 40
- MRI for indeterminate masses
- CT for staging when cancer is suspected
What the image changes
Transvaginal
Look first. Then commit in the Ultrasound Lab.
The differential
| Diagnosis | Favours | Against | Urgency |
|---|---|---|---|
| Functional cyst (follicular, corpus luteum) | Reproductive age, simple or haemorrhagic, resolves in 6 to 12 weeks | Persistent, postmenopausal | routine |
| Endometrioma | Ground-glass content, pain, endometriosis | Anechoic | routine |
| Dermoid | Shadowing echogenic focus, fat, hair lines, young | Simple cyst | routine |
| Hydrosalpinx | Tubular, incomplete septa, prior infection | Round ovarian lesion | routine |
| Fibroid (pedunculated) | Solid, whorled, attached to the uterus | Clearly ovarian | routine |
| Epithelial ovarian cancer | Postmenopausal, solid components, papillae, ascites, raised CA-125 | Simple cyst, normal markers | urgent |
| Germ-cell or sex cord-stromal tumour | Young, solid, raised AFP or hCG, hormonal effects | Cystic, normal markers | urgent |
| Ectopic pregnancy | Positive test | Negative test | emergent |
Pitfalls this pathway refuses
- Ordering CA-125 in a young woman with an endometrioma and acting on the result
- Removing an ovary for a functional cyst
- Not referring a complex postmenopausal mass to oncology before surgery