Gynecology [ADNEXAL MASS]

Introduction Premenarchal Reproductive Postmenopausal

Much like vaginal bleeding, the most common and most
dangerous cause of adnexal masses changes based on the age. In Ovarian Cancer 11 Physiologic 51 Ovarian Cancer
the premenarchal group think cancer (germ cell). In the post GERM CELL “Simple Cysts” EPITHELIAL
menopausal group think cancer (epithelial). In the reproductive
or
age group, where physiologic (simple) cysts can occur, and where
cycles, pregnancy, and infections occur a more expansive
differential exists. Regardless, all age groups need a sonogram Complex Cyst
(ultrasound) if a mass is felt. It’ll help us distinguish a simple
(smooth, small, like a balloon) versus a complex (loculated,
lobulated, large) cyst. The simple cyst needs watchful
management while a complex cyst requires additional workup.
Simple Cyst Complex Cyst
Simple Cyst Teratoma TOA
A simple cyst implies “no big deal,” and something that can be Ectopic Torsion
observed. This decision is based on history, imaging, and size. It Endometrioma Cancer
has to look like clearly not-a-cancer. This will present as an
asymptomatic adnexal mass found on exam or imaging for
something else. Transvaginal ultrasound is used to evaluate the
cyst, which will be simple: smooth, anechoic, unilocular and
small. In the US we use < 10 cm to mean “small” and should
expect those cysts to resolve spontaneously. If it’s tiny (< 3 cm)
it doesn’t warrant re-evaluation. Between 3 cm-10 cm, it should
be reimaged within 12 weeks. Any growth over time, size > 10
cm, or multiple loculations or multiple echoes suggest this is a
complex cyst and need evaluation. OCPs have shown NO
BENEFIT in reducing the size; they shouldn’t play a part in our Single, Fluid Filled, Loculated, Lobulated
thinking.
Homogenous Multiple Spaces
Complex Cyst
Once a cyst crosses over the definition from simple cyst, it Resolves in 2-3 months Ø Resolution
becomes complex. Cysts should NOT be aspirated. If additional <10cm > 10cm
anatomy is required and imaging is to be considered, MRI is the
best radiographic test, but is often not needed and shouldn’t be
the next step. Laparoscopy to remove the cyst is preferred over
laparotomy (ex-lap). Oophorectomy and salpingostomy is
dependent on the likelihood that it’s cancer, but isn’t routine in
the evaluation of a complex cyst.
Ovary Ovary
Teratoma / Dermoid Cyst
The teratoma is a benign (in girls) germ cell tumor of the ovary.
Since it’s a germ cell tumor expect the patient to be young (< 20).
She’ll complain of weight gain or increased abdominal girth.
The ultrasound will show a complex cyst which is enormous.
Due to the weight it’s likely to cause the ovary to twist about its
vascular supply; it’s a risk factor for torsion. Since it’s complex it
must be removed. Cystectomy without oophorectomy is the
treatment of choice. Because it’s benign, the patient is young, the
chance for recurrence on the contralateral side is high, and we Cyst (can be enormous)
don’t want to put her into menopause early we spare the ovary.
If you happen to find one in a woman past child-bearing,
Salpingo-oophorectomy is ok.

Ectopic Pregnancy
A complex cyst may simply be an ectopic pregnancy. In a patient
with a history of salpingitis where inflammation may have
created a stricture, fertilized eggs can’t pass. Ectopics most
commonly occur in the ampulla. This is a botched pregnancy.
The patient will present with amenorrhea (pregnant), lower
abdominal pain (as the cyst grows), and vaginal spotting. The
ultrasound will show a complex cyst and

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 Gynecology [ADNEXAL MASS]

absent uterus. An elevation of the B-HCG quant confirms
ectopic. If there isn’t a rupture a salpingostomy is performed. If
there is a rupture perform a salpingectomy. In very select patients
where the diagnosis is made very early (< 3.5cm and HCG< 8000)
and the patient is not on Folate, methotrexate can be used. The Risk of ectopic: 1%
risk of ectopic pregnancy is about 1% in the general population. Risk with previous ectopic: 15%
The risk with previous ectopic, previous ectopic with -ostomy, Risk with previous ectopic with salpingostomy: 15%
and previous ectopic with -gectomy are all 15%. This is discussed Risk with previous ectopic with salpingectomy: 15%
in greater detail in the Obstetrics section.

Endometrioma / Endometriosis / Chocolate Cyst

Retrograde menses (presumed, unknown true cause) leaves Retrograde “Ectopic”
estrogen-sensitive endometrial tissue outside of the uterus. This Endometrioma
produces proliferation and hemorrhage with each cycle, leading
to many problems: dysmenorrhea, dyspareunia, and infertility.
A sonogram will show a complex cyst. It may be anywhere: on
the uterus, ovary, or even distant in the peritoneal cavity. This
often takes time to diagnose - as in weeks to months. While a
diagnostic scope with laser ablation (i.e. laparoscopic
exploratory laparotomy) is both diagnostically superior and
curative, it’s invasive. Symptomatic relief with NSAIDs for
pelvic pain is usually first. OCPs are first line, though GnRH
analogs (Leuprolide) or danazol (not used because of androgen Anterograde Normal endothelial
side effects) often show some benefit. Ultimately, surgical Normal proliferation
resection (ablation, resection) is needed. In the setting of an
adnexal mass an endometrioma as the presenting complaint of
endometriosis requires resection.

Torsion of the Ovary

This won’t be a diagnostic mystery as it’s a surgical emergency.
The suspensory ligament acts as a hinge that the ovary spins
around, cutting off its own vascular supply. Often, it’s the weight
of the cyst that causes torsion. There will be a severe and sudden
onset abdominal pain that was not provoked by any inciting
event. The sonogram will show a cyst, but can’t tell if the ovary
is necrotic or not. Ultrasound Doppler will show limited blood
flow to the ovary. The patient must be brought to the OR
immediately so the ovary can be untwisted. If the ovary pinks up
simply remove the cyst only and tac it down. If the ovary is
necrotic remove the cyst and ovary.

Tubo-ovarian Abscess
This is discussed in gyn infections. Essentially - repeated acute See Gyn Infections for more details on abx coverage
PID (Gc/Chla) causes inflammation and allows the vaginal flora
to access the uterus, tubes, and ovary. One consequence is 1. Inpatient
abscess. The patient will present with a fever, leukocytosis, and a.
Cefoxitin, Doxycycline, Metronidazole
an adnexal mass. The sonogram will show said abscess. Treat it b.
Clindamycin, Gentamycin
with antibiotics x 72 hrs and continue if there’s improvement. If 2. Outpatient (not for an Abscess)
not, the abscess needs to be drained. Other indications to go to a. Ceftriaxone x 1, Doxycycline, Metronidazole
emergent surgery for TOA are if the patient is very ill or if it’s b. Cefoxitin+Probenecid, Doxycycline, Metronidazole
very large (>8 cm). TOA is one of the few abscess conditions that
doesn’t require emergent drainage.

Ovarian Cancer
Any complex cyst can be cancer. Please see the Ovarian Cancer
section for details.

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