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Management of an adnexal mass
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Management of an adnexal mass
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Nov 2016. | This topic last updated: Apr 25, 2016.

INTRODUCTION — An adnexal mass (mass of the ovary, fallopian tube, or surrounding connective tissues) is a common gynecologic problem. In the United States, it is estimated that there is a 5 to 10 percent lifetime risk for women undergoing surgery for a suspected ovarian neoplasm [1]. Adnexal masses may be found in females of all ages, fetuses to the elderly, and there is a wide variety of types of masses (table 1). The management of an adnexal mass depends upon the type of mass, urgency of the presentation (eg, ectopic pregnancy or ovarian torsion require immediate intervention), and degree of suspicion that the mass is malignant.

The management of patients with an adnexal mass is reviewed here. The initial approach to, and an overview of, the evaluation of patients with an adnexal mass and other topics related to the management of an adnexal mass are discussed separately:

(See "Approach to the patient with an adnexal mass".)

(See "Ectopic pregnancy: Clinical manifestations and diagnosis".)

(See "Ovarian and fallopian tube torsion".)

(See "Evaluation and management of ruptured ovarian cyst".)

(See "Ovarian cysts and neoplasms in infants, children, and adolescents".)

OVERVIEW — The management of an adnexal mass depends upon the location and etiology of the mass (table 1) and the characteristics of the patient. In general, there are three options for managing an adnexal mass:

Surgery – Surgery is performed for the following indications: malignancy is suspected; there are other risks associated with the mass (eg, torsion, infection), or the mass is symptomatic. For ovarian masses, an oophorectomy or ovarian cystectomy may be performed. For other adnexal masses, the mass may be biopsied or resected.

Continued surveillance – Continued surveillance is indicated if the suspicion of malignancy is low, but it has not been completely excluded. Surveillance usually includes serial pelvic ultrasounds and/or measurement of serum tumor markers.

Expectant management – If the apparent etiology of the mass is benign and there are no other indications for surgery or surveillance, no further follow-up is needed.

The choice between these management options for different adult patient populations is discussed in the sections that follow. Management of an adnexal mass in a child or adolescent is discussed separately. (See "Ovarian cysts and neoplasms in infants, children, and adolescents".)

CLINICAL SCENARIOS FOR OVARIAN MASSES — The management of an ovarian mass according to the clinical presentation and potential for malignancy is discussed in this section.

Suspected malignancy or uncertain etiology — Excluding malignancy is a principal goal of the evaluation of an adnexal mass. For women with a mass that is suspicious for malignancy after an initial evaluation, surgical exploration is required.

Surgical evaluation is the standard approach to the evaluation of an adnexal mass because there is no noninvasive technique for the diagnosis of ovarian cancer. Unfortunately, this approach results in many women undergoing surgery for a benign mass. As an example, in a large ovarian cancer screening randomized trial, among 570 women who underwent surgical evaluation for suspected ovarian cancer, 20 cases of malignancy were found (3.5 percent) [2]. Another large ovarian cancer screening trial, the United Kingdom Collaborative Trial of Ovarian Cancer Screening (UKTOCS), found that for each ovarian or peritoneal cancer detected by ultrasound screening, an additional 10 women underwent surgery for normal ovaries or benign pathology [3]. However, the prognosis of ovarian cancer is poor unless the disease is treated at an early stage and the risk of failing to diagnose a life-threatening condition, no matter how small, must be weighed against the potential morbidity associated with surgical intervention.

In some cases, if malignancy seems unlikely but has not been fully excluded, continued surveillance is warranted. (See 'Surveillance' below.)

The information used to evaluate an adnexal mass is briefly reviewed here, and is discussed in detail separately. (See "Approach to the patient with an adnexal mass", section on 'Evaluation for malignancy'.)

Assessing risk — The most important factor used to determine the clinical suspicion of malignancy of an adnexal mass is the appearance of the mass on imaging; transvaginal ultrasound is the preferred study. The sensitivity of pelvic ultrasound for the diagnosis of ovarian cancer ranged from 86 to 91 percent and the specificity ranged from 68 to 83 percent in a large meta-analysis [4].

Ultrasound morphology associated with malignancy includes (table 2): (1) a solid component or nodularity, particularly with color or power Doppler demonstration of flow in the solid component; (2) thick septations (>2 to 3 mm). Based upon the ultrasound morphology, in our practice, we categorize masses into the following risk groups:

High risk – Features of malignancy, ie, solid, nodular, thick septations (table 2)

Intermediate risk – Not anechoic and/or unilocular, but no features of malignancy (eg, a mass with thin septations or low level echoes)

Low risk – Anechoic unilocular fluid filled cysts with thin walls

Other characteristics of the mass that may contribute to the suspicion of malignancy, but are less important, are size and bilaterality. Observational series have generally found the average size of malignant adnexal masses to be >10 cm [5-7]. Large size and bilaterality were not found to impact the likelihood of resolution of mass in a large prospective study, described below [8] (see 'Surveillance' below). There are few other data regarding bilateral masses but, in our experience, this is a feature associated with malignancy. (See "Ultrasound differentiation of benign versus malignant adnexal masses".)

If imaging findings suggestive of metastatic disease are present, even in the absence of malignant features in the mass itself, surgical exploration is required. These features include: ascites or evidence of metastatic disease (eg, peritoneal masses, enlarged lymph nodes). (See "Epithelial carcinoma of the ovary, fallopian tube, and peritoneum: Clinical features and diagnosis", section on 'Assessing for metastatic disease'.)

Other factors, such as menopausal status, an elevated tumor marker, symptoms, or risk factors (table 3) may add to the degree of suspicion.

This discussion is intended to provide a general framework of the indications for surgery. The management of an individual patient depends upon the clinical features of that patient and upon clinical judgement. If there is uncertainty about the appropriate management decision, a gynecologic oncologist should be consulted. (See 'Referral to a specialist' below.)

Women with a hereditary ovarian cancer syndrome (BRCA mutation or Lynch syndrome) are managed differently than the general population. In these women, the presence of almost any adnexal mass is an indication for surgical exploration. This is discussed in detail separately. (See "Risk-reducing bilateral salpingo-oophorectomy in women at high risk of epithelial ovarian and fallopian tubal cancer".)

Postmenopausal women — The degree of clinical suspicion of ovarian cancer is significantly higher for postmenopausal than for premenopausal women; thus, surgical exploration is required for many postmenopausal women with an ovarian mass. (See "Approach to the patient with an adnexal mass", section on 'Age and reproductive status'.)

If there is evidence on imaging studies of metastatic disease, surgical exploration is required, even in the absence of malignant features in the mass itself.

Based upon the ultrasound morphology risk categories described above, we manage postmenopausal patients as follows (see 'Assessing risk' above):

High risk – Women with a high risk mass require surgical exploration (table 2).

Intermediate risk – Women with an intermediate risk mass are managed based upon coexisting tumor marker levels, risk factors (table 3), and symptoms (table 4). Many women may be managed with surveillance, but surgical exploration should be performed if clinically significant risk factors or symptoms are present.

Low risk – For most women with a unilocular anechoic ovarian cyst and no other findings suggestive of malignancy, we suggest surveillance rather than surgery because the risk of malignancy is less than the risk of complications associated with surgical exploration [9].

For postmenopausal women with a mass with an intermediate or low risk appearance, surgical exploration is required if a serum tumor marker is elevated. CA 125 is the tumor marker used most commonly for the detection of epithelial ovarian cancer. CA 125 >35 U/mL has a sensitivity of 69 to 97 percent and a specificity of 81 to 93 percent for the diagnosis of ovarian cancer, based upon data from a meta-analysis of six studies [4]. The marker algorithms OVA1 and ROMA may be used to decide whether to refer a patient to a gynecologic oncologist. Other serum markers are used to evaluate women for less common histologic types, germ cell and sex cord-stromal tumors. (See "Serum biomarkers for evaluation of an adnexal mass for epithelial carcinoma of the ovary, fallopian tube, or peritoneum", section on 'Referral to a gynecologic oncologist' and "Approach to the patient with an adnexal mass", section on 'Serum markers for other histologic types'.)

Size of the mass must also be considered. There are limited data to establish the size threshold that requires surgical removal. We suggest surgical exploration rather than surveillance for postmenopausal women with a mass that is ≥10 cm in diameter [5-7]. In addition, in our practice, we proceed with surgical exploration for women with a 5 to 10 cm mass who also have symptoms suggestive of ovarian cancer (table 4). However, some patients without symptoms or other findings suggestive of malignancy may request removal of a mass <10 cm. In such cases, removal is reasonable if the patient strongly prefers surgical evaluation and removal of the mass and is willing to accept the risks of surgical morbidity and loss of an ovary.  

Risk factors (other than a hereditary ovarian cancer syndrome) or symptoms alone are not typically an indication for surgery in a woman with a mass with an intermediate or low risk appearance. The absence of risk factors and symptoms helps to support a decision to manage the patient with surveillance.

In some cases, an adnexal mass in a postmenopausal woman was noted on imaging prior to menopause and is unchanged; this information is reassuring and surveillance is typically appropriate for these patients.

Premenopausal women — An ovarian mass in a premenopausal woman is often a diagnostic dilemma. The risk of ovarian, fallopian tubal, or peritoneal cancer is low in this age group, but the possibility of malignancy should be considered in all patients with an adnexal mass [10]. The incidence of ovarian cancer increases with age (1.8 to 2.2 per 100,000 women for ages 20 to 29 years; 3.1 to 5.1 for ages 30 to 39 years; and 9.0 to 15.2 for ages 40 to 49 years) [11].

For premenopausal women with an adnexal mass, the decision whether to proceed with surgical evaluation depends upon the characteristics of the mass and the patient. If there is evidence on imaging studies of metastatic disease, surgical exploration is required, even in the absence of malignant features in the mass itself. As with postmenopausal women, we categorize patients according to risk of malignancy based upon ultrasound morphology (see 'Assessing risk' above):

High risk – Similar to postmenopausal women, surgery is required for women with a mass with features associated with malignancy or any adnexal mass combined with ascites and/or evidence of metastatic disease consistent with ovarian cancer (table 2).

Intermediate/low risk – Many masses related to reproductive function occur in premenopausal women, and thus, there is likely to be a greater proportion of patients with a mass with an intermediate or low risk appearance. For most premenopausal women with a mass with an intermediate or low risk appearance, we suggest surveillance rather than surgery. The exceptions to this are women with a very elevated serum CA 125 or those in whom a germ cell or sex cord-stromal tumor is suspected. These neoplasms are uncommon, but often occur in younger women. (See "Ovarian germ cell tumors: Pathology, clinical manifestations, and diagnosis", section on 'Diagnosis overview' and "Overview of sex cord-stromal tumors of the ovary", section on 'Diagnosis'.)

In premenopausal women, we measure a serum CA 125 only if the ultrasound appearance of a mass raises sufficient suspicion of malignancy to warrant a repeat ultrasound or surgical evaluation. In this population, a CA 125 value of >35 U/mL has a sensitivity and specificity of less than 80 percent, and possibly as low as 50 to 60 percent, based upon data from a meta-analysis of six studies [4]. The low specificity in premenopausal women is because an elevated CA 125 is also associated with many conditions other than ovarian cancer, and many of these are found in reproductive age patients (table 5). Based upon the poor diagnostic performance of CA 125 in premenopausal women, there has been some discussion of using a higher CA 125 level (>200 U/mL), but this has been evaluated in few studies [12]. The markers OVA1 and ROMA may be used to decide whether to refer a patient to a gynecologic oncologist. (See "Approach to the patient with an adnexal mass", section on 'Serum markers for epithelial ovarian carcinoma' and 'Referral to a specialist' below.)

Risk factors (other than a hereditary ovarian cancer syndrome) or symptoms may increase the degree of suspicion of malignancy, but are not typically the sole indication for surgery in a woman with a mass with an intermediate or low risk appearance.

Management options

Surgery — Surgical exploration for an adnexal mass may be performed laparoscopically (conventional or robotic) or via a laparotomy. The choice of surgical approach depends upon the degree of suspicion of malignancy and surgeon and patient preference. Ovarian cancer staging can be performed using an open or laparoscopic approach, although the majority of surgeons in current practice prefer laparotomy if there is a high degree of suspicion of malignancy. If there is a low or moderate suspicion of malignancy, a laparoscopic approach is typically used. Laparoscopy is associated with a shorter recovery and decreased perioperative morbidity compared with laparotomy. When choosing a surgical approach for a suspected malignancy, it is important to keep in mind that it is unclear if laparoscopy is as sensitive as laparotomy in the detection of small metastatic implants in small bowel mesentery and epigastrium. Laparoscopy is clearly superior to laparotomy for inspection of the diaphragm and for visible peritoneal surfaces.

The surgical technique used must minimize the potential for tumor disruption or dissemination. If malignancy is suspected, oophorectomy is required rather than ovarian cystectomy. Patients with early stage ovarian cancer (ie, no malignant cells in ascites or peritoneal cytology) benefit from removal of the adnexal mass intact, since opening the mass results in a more advanced stage and adversely affects prognosis (table 6) [13,14]. In addition, every attempt must be made to provide the pathologist with an ovarian specimen with an intact cortex. If a laparoscopic approach is used, the ovary can be placed in a tissue recovery bag. If the specimen is too large to remove through the existing incisions, cyst fluid may be aspirated (but the collapsed cyst should not be disrupted) or the incision may be enlarged. The practice of morcellating an ovarian mass in a bag is discouraged because it may compromise pathology evaluation. In general, aspiration of cyst contents is not advisable as the sole surgical intervention because no tissue is obtained for histopathology and cytology of cyst fluid is not reliable for exclusion of malignancy, and there is a high rate of recurrence. (See "Oophorectomy and ovarian cystectomy", section on 'Aspiration and fenestration versus cystectomy'.)

For premenopausal women, ovarian cystectomy is reasonable if the preoperative suspicion of malignancy is low, the mass appears benign intraoperatively, and there is no evidence of metastatic disease. Every safeguard against intraoperative rupture of the mass should be taken.

Surveillance — Women for whom the likelihood of ovarian cancer appears low, but has not been fully excluded, should be managed with continued surveillance with serial pelvic ultrasounds, and, if appropriate, a serum tumor marker. There is no evidence to establish the best approach to surveillance of an ovarian mass. The approach we use in our practice is presented here.

Physiologic cysts typically resolve on follow-up, non-physiologic non-neoplastic benign simple cysts usually remain unchanged, and neoplastic simple cysts enlarge over time [15].

The largest study to-date to evaluate use of serial pelvic sonography for adnexal masses was a prospective study of over 39,000 asymptomatic women followed with annual transvaginal pelvic sonography during the 25-year period of the study (average duration of follow-up was 7.3 years) [8]. The criteria for inclusion were: (1) age 50 years or older or (2) age 25 years or older with a family history of ovarian cancer (genetic testing was not part of the study protocol); mean age was 58.6 years (range 25 to 95). Over the period of follow-up, 17.3 percent were found to have an ovarian abnormality on their first or later visits and 42.1 percent of abnormalities resolved within one year. As expected, the prevalence of abnormalities was significantly higher in premenopausal than postmenopausal women (34.9 versus 17.0 percent) and low-risk abnormalities (unilocular cyst, cyst with septation) were more common than high-risk (cyst with solid area, solid mass) (prevalence 21.3 versus 8.9 percent). Interestingly, low-risk compared with high-risk abnormalities were less likely to resolve within one year and took longer to resolve (resolved at one year: 33 to 44 percent versus 77 to 81 percent; median time to resolution 53 to 56 weeks versus 8 to 9 weeks). Surgery was performed on 557 women for 85 ovarian malignancies and 472 nonmalignant abnormalities.  

This study also evaluated the impact of bilaterality and ovarian mass size for high-risk abnormalities [8]. Most masses resolved, whether unilateral or bilateral, but bilateral solid masses compared with cysts with a solid area resolved more quickly (approximately one versus seven years). Similarly, larger masses (>10 cm3) resolved more slowly, but this effect was most notable in solid masses (<5 cm3 resolved in three years versus 10 to 19.9 cm3 in five years). The findings of this study support the practice of serial sonography to evaluate indeterminate adnexal masses, but don’t provide data regarding the frequency of surveillance. The ability to generalize these results to the general population is somewhat limited, since the premenopausal participants were chosen based upon a family history of ovarian cancer. The biologic basis of the finding that complex masses resolved more quickly is uncertain, unless the majority of these were hemorrhagic cysts. This warrants further analysis of these data and further study.

For postmenopausal women with a simple ovarian cyst, several studies have examined the role of pelvic examination, ultrasound, and tumor marker measurement (particularly CA 125) [16-22]. In the largest of these studies, 2763 postmenopausal women were diagnosed with 3259 simple cysts up to 10 cm in diameter [21]. Serial follow-up ultrasounds were performed every three to six months. Spontaneous resolution of the simple cysts occurred in 2261 women (69 percent) over a mean follow-up of six years. Ten patients were subsequently diagnosed with ovarian cancer: 7/10 had additional abnormal areas which were identified on an interval ultrasound examination, 2/10 developed ovarian cancer after the cyst in question had resolved on sonographic follow-up, and 1/10 developed cancer in the ovary opposite the cyst being followed.

In premenopausal women, 70 percent of adnexal masses will resolve over the course of several menstrual cycles [6].

When patients with an adnexal mass are managed with surveillance, it is important to counsel the patient about what morphologic or size changes would prompt surgical exploration and when surveillance will be stopped if there are no significant changes. During surveillance, if the mass develops features of malignancy, increases in size to ≥10 cm, or the CA 125 increases to >35 U/mL, we proceed with surgery. If the mass resolves, we discontinue surveillance. If the mass remains unchanged or decreases in size and the CA 125 remains <35 U/mL, surveillance continues until the planned stopping point is reached.

For postmenopausal women:

Intermediate risk mass – We repeat a transvaginal ultrasound and CA 125 in six weeks and then again six weeks later. We then repeat the ultrasound and CA 125 every three to six months for a year. We do a final ultrasound and CA 125 one year later.

For low risk masses, we repeat an ultrasound and CA 125 at three months then six months.

For premenopausal women:

Intermediate risk masses – We repeat a transvaginal ultrasound in six weeks. This allows visualization of the mass at a different point of the menstrual cycle. We then repeat an ultrasound in three months and then six more months. We then do a final ultrasound one year later.

Low risk masses – We repeat an ultrasound in three months and then six more months.

We do not routinely follow with CA 125 in premenopausal women. If an initial level was drawn and was very elevated, we proceed with surgery. If the initial level was <35 U/mL, we do not repeat it. If it was moderately elevated (35 to <200 U/mL), we draw it with each ultrasound until a pattern emerges. If it is consistently low or moderately elevated, we discontinue CA 125 testing.

Benign mass — Some benign ovarian masses have characteristic sonographic features and the diagnosis is fairly certain without surgical exploration, including: follicular or corpus luteal cysts, endometriomas, and mature teratomas (dermoid). Surgery is not required for follicular or corpus luteal cysts. Surgical treatment of endometriomas depends upon whether the patient is symptomatic. Most mature teratomas are benign, but surgery is indicated to exclude malignancy and prevent malignant transformation (see "Ovarian germ cell tumors: Pathology, clinical manifestations, and diagnosis", section on 'Mature cystic teratoma (dermoid cyst)'). For any ovarian mass, however, if the diagnosis is uncertain, further evaluation is required. (See 'Suspected malignancy or uncertain etiology' above.)

Acute pain — Women who present with acute pain and an ovarian mass should be evaluated without delay and may require urgent intervention. (See "Approach to the patient with an adnexal mass", section on 'Evaluation for urgent conditions'.)

In addition to the conditions listed below, an ectopic pregnancy is a common gynecologic emergency, but ectopic gestations are usually located in the fallopian tube, and are discussed below. Rarely, an ovarian pregnancy is present. (See 'Ectopic pregnancy' below.)

Ovarian torsion — Torsion of the ovary or fallopian tube requires urgent surgical treatment to avoid ischemic injury. The evaluation and management of adnexal torsion are discussed separately. (See "Ovarian and fallopian tube torsion" and "Approach to the patient with an adnexal mass", section on 'Adnexal torsion'.)

Ruptured or hemorrhagic ovarian cyst — Ovarian masses may rupture or become hemorrhagic. This occurs most commonly in physiologic cysts that are associated with the menstrual cycle (follicular cysts, corpus luteal cysts).

A ruptured or hemorrhagic ovarian cyst is occasionally accompanied by significant bleeding. Women with uncomplicated cyst rupture (hemodynamically stable, no evidence ongoing blood loss on laboratory evaluation or pelvic imaging) can be managed expectantly. Women with complicated cyst rupture require hospital admission for close monitoring, with a possible need for surgical intervention and/or blood product replacement.  

The evaluation and management of a ruptured ovarian cyst are discussed separately. (See "Evaluation and management of ruptured ovarian cyst" and "Approach to the patient with an adnexal mass", section on 'Ruptured or hemorrhagic ovarian cyst'.)

Persistent pain or pressure — Ovarian cysts may cause pain or pressure symptoms. Since many cysts are transient and the pain will resolve with the cyst, these symptoms are best managed with analgesics in the short term while the patient is evaluated and it is determined whether surgery is needed for another indication (eg, suspicion of malignancy, infertility).

A particular type of ovarian mass, an endometrioma, may be associated with dysmenorrhea, pelvic pain, or dyspareunia. These masses are usually recognized by their characteristic appearance on ultrasound. They are also often associated with endometriosis at other sites within the pelvis. Surgical removal is the usual treatment of a symptomatic endometrioma. (See "Endometriosis: Management of ovarian endometriomas", section on 'Our approach'.)

Some women will have an ovarian mass with an indeterminate appearance on ultrasound, but with no features of malignancy. In such cases, other sources of pelvic pain should be investigated. However, if no other etiology of the pain is identified and the pain is persistent and not relieved by analgesics, we suggest ovarian cystectomy or oophorectomy.

Infertility — Endometriomas are a type of ovarian mass that is associated with infertility, and these should be removed in infertile patients. (See "Endometriosis: Management of ovarian endometriomas", section on 'Our approach'.)

Other types of ovarian masses are not typically removed for the indication of treating infertility. However, an ovarian mass may adversely affect fertility if it undergoes torsion or ruptures.  

On the other hand, removal of an adnexal mass in a premenopausal woman may lead to adhesion formation and/or reduce ovarian reserve, potentially adversely impacting fertility.

A hydrosalpinx is another type of adnexal mass that is associated with infertility. (See 'Hydrosalpinx' below.)

Recurrent physiologic cysts — Some patients with a history of recurrent painful ovarian cysts are managed with hormonal contraceptives to inhibit ovulation. This prevents the formation of new physiologic ovarian cysts. Oral contraceptives (OCs) do not decrease the size of existing cysts [23]. Numerous studies have investigated the effects of OCs on follicular cyst development and ovulation [24-31]. In general, current OCs with a dose of ≤35 mcg ethinyl estradiol resulted in the development of fewer follicular cysts, but to a lesser extent than higher dose formulations (50 mcg ethinyl estradiol). There was no difference in the suppression of cyst development between monophasic and multiphasic OCs.

The typical regimen is an OC once daily; this can be continued for as long as the patient desires to remain on an OC. Other types of estrogen-progestin contraceptives (eg, patch, ring) have not been studied for this indication, but are likely to have the same effect.

Pregnant women — Ovarian or other adnexal masses in pregnant women are managed by the same principles as in other patients, although the choice of treatment depends upon issues of maternal and fetal safety.

The evaluation and management of adnexal masses in pregnant women is discussed in detail separately. (See "Adnexal mass in pregnancy".)

OTHER ADNEXAL MASSES — An adnexal mass may involve the fallopian tube or the connective tissue surrounding the ovary and tube.

Fallopian tubal cancer — High grade serous epithelial ovarian carcinoma, fallopian tubal, and peritoneal carcinomas are considered a single clinical entity due to their shared clinical behavior and treatment. There is also accumulating evidence of a common pathogenesis for these carcinomas. Fallopian tubal cancer rarely presents as a tubal mass alone; ovarian involvement is typically also present at time of diagnosis. (See "Epithelial carcinoma of the ovary, fallopian tube, and peritoneum: Clinical features and diagnosis".)

The management of fallopian tubal cancer is discussed in detail separately. (See "Cancer of the ovary, fallopian tube, and peritoneum: Staging and initial surgical management" and "First-line chemotherapy for advanced (stage III or IV) epithelial ovarian, fallopian tubal, and peritoneal cancer".)

Ectopic pregnancy — Ectopic pregnancy is a potentially life-threatening condition; the fallopian tube is the most common site of an ectopic pregnancy, although ovarian or cervical pregnancy may also occur.

The management of ectopic pregnancy is discussed in detail separately. (See "Ectopic pregnancy: Clinical manifestations and diagnosis" and "Ultrasonography of pregnancy of unknown location".)

Tuboovarian abscess — The classic presentation of a tuboovarian abscess includes acute lower abdominal pain, fever, chills, vaginal discharge, and an adnexal mass. Pelvic imaging typically shows a complex multilocular mass that obliterates normal adnexal architecture. Timely diagnosis and management are required to diagnose or avoid sepsis and to prevent further damage to the ovary and fallopian tubes.  

The diagnosis and management of a tuboovarian abscess are discussed in detail separately. (See "Epidemiology, clinical manifestations, and diagnosis of tubo-ovarian abscess" and "Management and complications of tubo-ovarian abscess".)

Paratubal or paraovarian cyst — A paratubal or paraovarian cyst arises from the broad ligament in the area of the fallopian tube or ovary. The most common findings in this area are simple cysts that originate from the remnants of paramesonephric (Müllerian) or mesonephric (Wolffian) ducts that are present during urogenital embryologic development. (See "Differential diagnosis of the adnexal mass", section on 'Paraovarian/paratubal cysts and tubal and broad ligament neoplasms'.)

A simple, asymptomatic paratubal or paraovarian cyst can be managed expectantly without further follow-up. Surgical removal is indicated for these lesions if they undergo torsion, cause persistent pain or pressure symptoms, or appear neoplastic. (See "Ovarian and fallopian tube torsion", section on 'Paratubal or paraovarian cyst torsion'.)  

Hydrosalpinx — A hydrosalpinx is an edematous fallopian tube, typically caused by an infection. A hydrosalpinx may be asymptomatic or may result in chronic pelvic pain or infertility and sometimes be the source of chronic pelvic pain [32]. Other etiologies of chronic pelvic pain should be excluded before salpingectomy is performed. An asymptomatic hydrosalpinx does not generally need to be removed or followed with imaging. The exception to this is women undergoing in vitro fertilization. (See "Reproductive surgery for female infertility", section on 'Salpingectomy before in vitro fertilization'.)

Broad ligament leiomyoma — A broad ligament leiomyoma may be located proximal to the ovary and fallopian tube. These are usually diagnosed with pelvic ultrasound and are managed in the same manner as other leiomyomas. (See "Overview of treatment of uterine leiomyomas (fibroids)".)

REFERRAL TO A SPECIALIST — For masses that are highly suspicious for ovarian, fallopian tubal, or peritoneal cancer, referral to a gynecologic oncologist is advised, since outcomes of staging and cytoreduction have been shown to be better than when the procedure is performed by other surgeons [33-37]. This was illustrated in a systematic review of observational studies that found that, in patients with advanced disease, there was a six- to nine-month median survival benefit for patients operated on by gynecologic oncologists and that, in patients with early stage disease, gynecologic oncologists were significantly more likely to perform optimal staging [36].

The American College of Obstetricians and Gynecologists (ACOG) and the Society of Gynecologic Oncologists (SGO) have published a joint guideline about referral of women with an adnexal mass to a gynecologic oncologist (table 7) [33]. For premenopausal women, the guideline advises referral for those with a “very elevated” CA 125, but a specific value is not given. A version of the guideline published in 2002 used a value of >200 U/mL, but this was removed in the 2011 guideline [38].

Studies have evaluated the performance of this guideline for the diagnosis of ovarian cancer, and found the following: premenopausal women (sensitivity 70 to 79 percent and specificity 70 percent) and postmenopausal women (sensitivity 93 to 94 percent and specificity 60 percent) [12,39].

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, “The Basics” and “Beyond the Basics.” The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on “patient info” and the keyword(s) of interest.)

Basics topics (see "Patient education: Ovarian cancer (The Basics)" and "Patient education: Ovarian cysts (The Basics)")

Beyond the Basics topics (see "Patient education: Ovarian cysts (Beyond the Basics)" and "Patient education: Ovarian cancer diagnosis and staging (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

An adnexal mass (mass of the ovary, fallopian tube, or surrounding connective tissues) is a common gynecologic problem. The management of an adnexal mass depends upon the type of mass, urgency of the presentation, and degree of suspicion that the mass is malignant. (See 'Introduction' above.)

Excluding malignancy is a principal goal of the evaluation of an adnexal mass. The most important factor used to determine the clinical suspicion of malignancy of an adnexal mass is the sonographic appearance of the mass. Other factors, such as menopausal status, an elevated tumor marker, symptoms, or risk factors (table 3) may add to the degree of suspicion. (See 'Suspected malignancy or uncertain etiology' above.)  

Based upon the ultrasound morphology, in our practice, we categorize masses as high (features of malignancy, ie, solid, nodular, thick septations (table 2)), intermediate (not anechoic and/or unilocular, but no features of malignancy, eg, a mass with thin septations or low level echoes), or low risk (anechoic unilocular fluid filled cysts with thin walls). (See 'Suspected malignancy or uncertain etiology' above.)

If malignancy has not been excluded, we manage patients according to these risk categories (see 'Postmenopausal women' above and 'Premenopausal women' above):

Women with a high risk mass require surgical exploration. In addition, surgical exploration is required if imaging findings suggestive of metastatic disease are present, even in the absence of malignant features in the mass itself.

For most women with an intermediate risk mass, we suggest surveillance rather than surgical exploration (Grade 2C).

For postmenopausal women with an intermediate risk mass, we suggest surgical exploration if clinically significant risk factors or symptoms are present or if the patient places a higher value on a definitive diagnosis than on avoiding surgery (Grade 2C). For premenopausal women, risk factors or symptoms do not typically determine management.

Size of the mass is an important factor. We suggest surgical exploration rather than surveillance for women with a mass that is ≥10 cm in diameter (Grade 2C). In addition, in our practice, we proceed with surgical exploration for postmenopausal women with a 5 to 10 cm mass who also have symptoms suggestive of ovarian cancer (table 4).  

For most women with a low risk mass, we suggest surveillance rather than surgical exploration (Grade 2C).

Tumor markers influence the management of women with an intermediate or low risk mass. Surgical exploration is required if a serum tumor marker is elevated in a postmenopausal woman. For premenopausal women, surgical exploration is reasonable if a serum CA 125 is very elevated or if a germ cell or sex cord stromal tumor is suspected.

Oophorectomy rather than ovarian cystectomy is required for women with an ovarian mass that is suspicious for malignancy. For premenopausal women, ovarian cystectomy is reasonable if the preoperative suspicion of malignancy is low, the mass appears benign intraoperatively, and there is no evidence of metastatic disease. (See 'Surgery' above.)

Women who present with acute pain and an ovarian mass should be evaluated without delay and may require urgent intervention. Etiologies that present in this manner include ovarian torsion and rupture of an ovarian mass. (See 'Acute pain' above.)

For women with an ovarian mass with no clinical features of malignancy who have persistent pain, analgesics are first line therapy. For those with persistent pain despite analgesics, we suggest surgical treatment (Grade 2C). (See 'Persistent pain or pressure' above.)

Surgical treatment of some types of adnexal masses (eg, endometrioma, hydrosalpinx) may be therapeutic in women with infertility. (See 'Infertility' above.)

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