II. Epidemiology
- Most Ovarian Incidentalomas are benign (e.g. functional Ovarian Cysts, cystadenomas)
- Ovarian Cancer risk increases with age
III. History
- Ectopic Pregnancy risk (women of child-bearing age)
-
Tubo-Ovarian Abscess risk
- Sexually Transmitted Infection (e.g. Gonorrhea or Chlamydia risk or potential exposures)
- Pelvic Inflammatory Disease history
- Adhesions risk
- Prior abdominal or pelvic surgeries
-
Ovarian Cancer risks
- See Ovarian Cancer
- Age over 40 years old (most over 50)
- Delayed child bearing
- Unopposed Estrogen (e.g. Anovulatory Bleeding)
- Family History (esp. BRCA, Lynch Syndrome with Colon Cancer)
- Nulliparity
- Obesity
-
Ovarian Cancer symptoms (esp. persistent, refractory >2 weeks)
- Abdominal Bloating, increased abdominal girth or early satiety
- Pelvic Pain or Abdominal Pain
- Unintentional Weight Loss
- Urinary tract symptoms (urine frequency, urgency or Urinary Incontinence)
IV. Exam
- Lymph Node exam (inguinal region and generally)
- Abdominal exam
- Abdominal masses
- Ascites
- Pelvic Exam
- Speculum exam
- Bimanual exam
- Performed in Adnexal Mass evaluation
- Useless in screening for Ovarian Cancer (esp. BMI>30 kg/m2)
- Rectal Exam (consider)
V. Labs: General
-
Pregnancy Test (urine HCG or serum HCG)
- Obtain in all women of child bearing age
- Exclude Ectopic Pregnancy
-
Tuboovarian Abscess risk
- See Pelvic Inflammatory Disease
- Gonorrhea and Chlamydia DNA Probe
- Complete Blood Count with differential
VI. Labs: Biomarkers
-
CA 125 indications
- Avoid as a screening tool
- High False Positive Rate (elevated in pregnancy, PID, Menstruation and Obesity)
- Test Sensitivity <50% in stage 1 disease)
- Follow algorithm (see below)
- Obtain as an adjunct to evaluation in those at Ovarian Cancer high risk
- Avoid as a screening tool
- Human Epididymis Protein 4 (HE4)
- Increased in 50% of Ovarian Cancer patients despite normal serum CA-125 Levels
- Less commonly due to benign ovarian tumors or Endometriosis
- Discriminatory values vary
- Only indicated in monitoring epithelial Ovarian Cancer or screening for its recurrence
- Biomarker panels
- As of 2023, panels with up to 5 biomarkers are FDA approved (e.g. Multivariant Index Assay)
VII. Differential Diagnosis: Adnexal Mass
-
Ovary
- Functional cyst or Corpus Luteal Cyst
- Theca lutein cyst
- Benign ovarian tumor (Teratoma, cyst adenoma)
- Ovarian Torsion
- Ovarian Hyperstimulation Syndrome
- Ovarian Cancer
- Polycystic Ovary Syndrome
- Fallopian Tube
- Tuboovarian Abscess in Pelvic Inflammatory Disease
- Hydrosalpinx
- Ectopic Pregnancy
- Malignancy
-
Uterus
- Leiomyomata or Uterine Fibroids (pedunculated)
- Endometriosis
-
Gastrointestinal Tract
- Stool-filled bowel
- Diverticulitis
- Appendicitis or appendiceal abscess
- Inflammatory Bowel Disease
- Small Bowel leiomyoma
- Colon Cancer
- Krukenberg Tumor (metastasis to ovary)
- Urinary Tract
VIII. Imaging: Ultrasound
- See Ovarian Cancer for other imaging techniques and their findings
- Technique
- Transvaginal Ultrasound
- Transabdominal Ultrasound (children and preteens)
- Characteristic findings suggestive of benign mass
- Premenopausal women with physiologic Ovarian Cysts <3 cm
- Postmentopausal women with simple cysts <1 cm
- Simple Ovarian Cyst with thin smooth walls
- Hemorrhagic Ovarian Cyst
- Endometrioma
- Benign Cystic Teratoma
- Fibroma
- Hydrosalpinx
- Intermediate lesions (based on ACR guidelines)
- Large, benign appearing cysts or BAC (round/oval, unilocular, smooth walled)
- Larger than 5 cm in early postmenopausal women
- Larger than 3 cm in late postmenopausal women
- Large, probably benign cysts or PBC (not round/oval, angulated margins, imaging inadequate)
- Larger than 5 cm in premenopausal women
- Larger than 3 cm in early postmenopausal women
- Larger than 1 cm in late postmenopausal women
- Large, benign appearing cysts or BAC (round/oval, unilocular, smooth walled)
- Characteristic findings suggestive of malignancy (Complex cyst or solid mass)
- Solid component within Ovarian Mass or cyst
- Thick septations >2-3 mm
- Large volume of free fluid or Ascites present
- Color Doppler Ultrasound shows high Blood Flow within mass
- Thick cyst wall >2-3 mm
- Also seen in benign conditions
- Hemmorhagic Ovarian Cyst
- Endometrioma
- Also seen in benign conditions
- Cyst size does not distinguish benign from malignant
- However size my risk stratify postmenopausal cysts (esp >10 cm)
- See Simple Ovarian Cyst
IX. Evaluation: Tools
- Various protocols combine labs and scoring systems to estimate Ovarian Cancer risk
- Lab Studies (see above)
- Scoring Systems
- Risk of Malignancy Index for Ovarian Cancer
- International Ovarian Tumour Analysis ADNEX
- Symptom Index for Ovarian Cancer
- General
- Four or more symptoms: Test Sensitivity 27%, Test Specificity 96%
- Symptoms present at least 12 times per month for <1 year
- Criteria
- Abdominal Bloating
- Abdominal Pain
- Difficulty eating
- Early satiety
- Increased abdominal size
- Pelvic Pain
- References
- General
X. Evaluation: Adult Protocol
- Based on initial tests
- Urine Pregnancy Test (bHCG) if not postmenopausal
- Pelvic Ultrasound
- Consider CA-125 in postmenopausal women with nondiagnostic pelvic Ultrasound
- Exclude pregnancy first (bHCG)
- Evaluate for Ectopic Pregnancy if bHCG positive
- Refer to gynecology if red flag findings on history or Ultrasound
- See referral indications below
- Family History of Ovarian Cancer or high risk (see BRCA)
- Ultrasound with concerning findings (see findings suggestive of malignancy above)
- Adnexal Mass >6 cm
- Postmenopausal AND CA-125 >35 U/ml
- Risk of Malignancy Index (RMI) >200
- Repeat Ultrasound in 4-12 weeks
- Refer to gynecology if persistent adexal mass present >12 weeks
XI. Management: Gynecology Referral Indications
- Prepubescent girls
- Refer all Adnexal Masses
- Causes
- Ovarian Malignancy in 25% of girls <18 years old (esp. germ cell tumors)
- Benign Dermoid Cysts (50% of Adnexal Masses)
- Labs
- Alpha Fetoprotein
- Beta-HCG
- L-Lactate Dehydrogenase
- Surgery Indications
- Suspected Ovarian Torsion
- Persistent mass or other concerns for malignancy
- Acute Abdominal Pain
- Pregnancy
- Acute presentation with positive Urine Pregnancy Test
- Evaluate for Ectopic Pregnancy (serial Quantitative hCG and pelvic Ultrasound)
- Adnexal Mass diagnosed during intrauterine pregnancy
- Simple Ovarian Cysts (<5 cm) are common during pregnancy
- Adnexal Masses are common in pregnancy (2.4%) and most (>70%) resolve after pregancy
- Adnexal Masses identified during pregnancy are malignant in 1 to 5% of cases
- Repeat imaging of benign or indeterminate masses at 18 to 20 weeks, and 32 to 36 weeks
- Refer large (>5 cm), complex, septated, irregular or bilateral Adnexal Masses
- MRI may be indicated in some cases
- Acute presentation with positive Urine Pregnancy Test
- Premenopausal women
- Ultrasound with complex cyst or solid mass (suspicious findings)
- Ultrasound with mass >10 cm
- Serial Ultrasounds (every 4-6 weeks) with mass that persists >12 weeks
- CA-125 is not recommended in evaluation of premenopausal or perimenopausal women
- However if obtained, a CA-125>200 U/ml should prompt referral in this group
- Postmenopausal women (highest risk for Ovarian Cancer)
- Ultrasound with complex cyst or solid mass
- Ultrasound with mass >10 cm
- Serial Ultrasounds (every 4-6 weeks) with mass that persists >12 weeks
- CA-125 >35 U/ml
XII. Management: General
- Monitor intermediate lesions (not clearly benign, but not clearly suspicious)
- Transvaginal Ultrasound repeated in 6-12 weeks
- Some lesions may be monitored less frequently, up to one year (e.g. endometrioma, Cystic Teratoma)
XIII. References
- Chambers in Noble (2001) Primary Care, p. 385
- Barney (2008) Med Clin North Am 92(5): 1143-61 [PubMed]
- Biggs (2016) Am Fam Physician 93(8): 676-81 [PubMed]
- Givens (2009) Am Fam Physician 80(8): 815-22 [PubMed]
- Hitzeman (2014) Am Fam Physician 90(11): 784-9 [PubMed]
- Laing (2001) Radiol Clin North Am 39(3):523-40 [PubMed]
- Webb (2004) Radiol Clin North Am 42(2):329 [PubMed]
- Wheeler (2023) Am Fam Physician 108(6): 580-7 [PubMed]