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KembaraXtra- Medicine – Adnexal Masses
An adnexal mass refers to any mass arising from the structures adjacent to the uterus, collectively known as the adnexa, which include the ovaries, fallopian tubes, and surrounding connective tissues. Adnexal masses may also originate from nearby nongynecologic structures such as the bowel, bladder, ureters, or peritoneum. These masses represent a broad spectrum of pathology ranging from benign physiologic cysts to life-threatening malignancies, making careful evaluation essential.
Adnexal masses occur in females of all ages, from childhood through the reproductive years and into postmenopause. Because their causes are diverse and include both gynecologic and nongynecologic conditions, a single prevalence estimate is not particularly useful. Age is the most important independent risk factor for ovarian malignancy, with risk increasing significantly after menopause. A family history of breast or ovarian cancer represents the most significant personal risk factor for malignancy. Other risk factors depend on the specific underlying etiology.
Most adnexal masses are asymptomatic and discovered incidentally during pelvic imaging or routine physical examination. When symptoms do occur, they commonly include intermittent or acute pelvic or abdominal pain, bloating, or pressure. Certain presentations require urgent evaluation, particularly adnexal torsion or ectopic pregnancy, which often present with sudden, severe pain or first-trimester vaginal bleeding and constitute surgical emergencies.
The etiology of adnexal masses depends on the tissue of origin. Gynecologic causes may be ovarian, tubal, or uterine and can be benign or malignant. Common benign gynecologic causes include physiologic ovarian cysts, corpus luteum cysts, endometriomas, cystadenomas, mature teratomas, hydrosalpinx, paratubal cysts, and tubo-ovarian abscesses. Malignant gynecologic causes include epithelial ovarian carcinoma, borderline tumors, germ cell tumors, sex-cord stromal tumors, and metastatic disease. Nongynecologic causes include pelvic abscesses, appendiceal or bowel tumors, bladder or ureteral diverticula, pelvic kidney, retroperitoneal sarcoma, and metastatic cancer from sites such as the breast or colon.
Diagnostic evaluation begins with a thorough history and physical examination, including a detailed gynecologic history, family history of malignancy, and assessment of risk factors. Physical examination should include evaluation of lymph nodes, abdominal palpation, and a comprehensive pelvic examination. Laboratory and imaging studies are then tailored to the individual patient and clinical suspicion.
Laboratory testing should include a pregnancy test in all women of reproductive age. If infection is suspected, a complete blood count and testing for gonorrhea and chlamydia should be obtained. Tumor markers may be useful when malignancy is a concern and include CA-125, carcinoembryonic antigen (CEA), beta-human chorionic gonadotropin (β-hCG), alpha-fetoprotein (AFP), and lactate dehydrogenase (LDH). These markers are adjunctive tools and should not be used in isolation to determine management.
Transvaginal ultrasonography is the imaging modality of choice for initial evaluation of adnexal masses. Ultrasound assesses size, laterality, cystic versus solid composition, septations, papillary projections, and vascular flow. Abdominal ultrasonography may be useful when masses extend beyond the pelvis or when anatomy is distorted. Computed tomography and MRI are not recommended as first-line studies but have specific roles. MRI is helpful in differentiating ovarian from non-ovarian masses such as leiomyomas, while CT is most useful when malignancy is suspected to evaluate for metastases, ascites, lymphadenopathy, or obstructive uropathy.
Management depends on patient stability, symptoms, imaging characteristics, menopausal status, and suspicion for malignancy. Surgical intervention is mandatory for emergencies such as ruptured ectopic pregnancy, adnexal torsion, or suspected appendicitis. Masses with concerning ultrasound features—such as size greater than 10 cm, solid or papillary components, irregular borders, ascites, or high Doppler flow—generally warrant surgical exploration. Even masses that appear benign but exceed 5 cm carry an increased risk of torsion and may require surgical consideration.
Observation is appropriate for selected patients when imaging suggests benign disease and the patient is clinically stable. There is no universally accepted follow-up interval; however, a repeat ultrasound at six months is reasonable for masses larger than 5 cm, symptomatic patients, or those with increased concern for malignancy. In asymptomatic premenopausal patients with small masses and low suspicion for malignancy, repeat imaging in one year is often appropriate.
Referral to a gynecologic oncologist is strongly recommended when ultrasound or laboratory findings raise concern for malignancy, as specialized surgical management improves outcomes. Referral to general surgery or surgical oncology should be considered when a nongynecologic source of the mass is suspected. Early and appropriate referral is a critical component of optimal care in patients with adnexal masses.
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