Gynecology
[ADNEXAL MASS]
Introduction
Much like vaginal bleeding, the most common and most
dangerous cause of adnexal masses changes based on the age. In
the premenarchal group think cancer (germ cell). In the post
menopausal group think cancer (epithelial). In the
reproductive 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 (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
A simple cyst represents a follicle of the corpus luteum that’s
become fluid filled. It looks like a mass but is physiologic, not
pathologic. It’ll present as an asymptomatic adnexal mass. The
ultrasound will show a simple cyst: smooth, continuous, and
small. Because follicles grow in response to FSH/LH, if we turn
off the axis with OCPs x 2 months the cyst should resolve on
its own. Resolution must always occur within 2 months, else it’s
designated complex regardless of appearance. If there’s no
resolution, or the cyst occurred while she was already on
OCPs, or if it’s large (>7cm), it’s automatically a complex cyst
and requires a CT scan.
Complex Cyst
A complex cyst can be anything. Often “a mass” is the
presenting complaint. Let’s use this opportunity to discuss some
topics that are pathologic and present as a mass.
Teratoma / Dermoid Cyst
The teratoma is a benign (in girls) germ cell tumor of the
ovary. Since it’s germ cell 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 often
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 don’t want to put her into
menopause early we spare the ovary.
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 cannot 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
Premenstrual
Reproductive
Postmenopausal
Ovarian Cancer 11
GERM CELL
Physiologic
“Simple Cysts”
or
51 Ovarian Cancer
EPITHELIAL
Complex Cyst
Simple Cyst
Complex Cyst
Teratoma
PID Abscess
Ectopic
Torsion
Endometrioma Cancer
Single, Fluid Filled,
Homogenous
Loculated, Lobulated
Multiple Spaces
Resolves in 2 months
<7cm
Ø OCP at onset
Ø Resolution
> 7cm
OCP at onset
Ovary
Ovary
Cyst (can be enormous)
Risk of Ectopic: 1%
Risk with previous ectopic: 15%
Risk with previous ectopic with salpingostomy: 15%
Risk with previous ectopic with salpingectomy: 15%
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Gynecology
[ADNEXAL MASS]
show a complex cyst and absent uterus. An elevation of the BHCG 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
pregnancy is about 1% in the general population. The risk with
previous ectopic, previous ectopic with ostomy, and previous
ectopic with gectomy are all 15%. This is discussed in greater
detail in the Obstetrics section.
Endometrioma / Endometriosis / Chocolate Cyst
Retrograde menses (presumed, unknown true cause) leaves
estrogen-sensitive endometrial tissue outside of the uterus. This
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. Usually, the goal’s to 1) turn
off the axis with OCPs, continuous Leuprolide, or Progesterone
2) see symptomatic improvement 3) and only then go in for
surgery when suspicion is high enough.
“Ectopic”
Endometrioma
Retrograde
Anterograde
Normal
Normal endothelial
proliferation
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. 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. If the ovary is necrotic
remove the cyst and ovary.
Tubo-ovarian Abscess
This is discussed in gyn infections. Essentially - repeated acute
PID (Gc/Chla) causes inflammation and allows the vaginal
flora to access the uterus, tubes, and ovary. One consequence is
abscess. The patient will present with a fever, leukocytosis, and
an adnexal mass. The sonogram will show said abscess. Treat it
with antibiotics x 72 hrs and continue if there’s improvement.
If not, the abscess needs to be drained. Indications to go to
emergent surgery for TOA is if the patient is very ill or if it’s
very large. TOA is one of the few abscess conditions that does
not require emergent drainage.
Ovarian Cancer
Any complex cyst can be cancer. Please see the Ovarian Cancer
section for details.
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