The ovaries and tubes together are called the adnexa. Since masses and tumors originating from the tubes are extremely rare, the term adnexal mass is generally understood to be ovarian-derived masses. These masses can be ovarian cysts, different tumors or inflammatory growths. It is not always easy to say that an adnexal mass that is palpable on examination originates from the ovary. These masses may also originate from the uterus, tubes, or even bowel or bladder, apart from the ovary. In the presence of an adnexal mass, a careful history and correct and appropriate use of auxiliary diagnostic methods, in addition to examination, are especially important in terms of treatment approach in order to understand the origin and structure of this mass.
It is extremely important to take a good history in the evaluation of adnexal masses, as in all branches of medicine and in the diagnosis of all diseases. Some seemingly insignificant details to be captured from this history can be extremely helpful in diagnosis. One of the most important points in the history is the age of the patient. For example, while the probability of a palpable mass being malignant in a postmenopausal woman is extremely high, this mass is most likely a dermoid cyst in people younger than 20 years old. Functional cysts are most common in women of reproductive age. While it is a pathological condition that the ovaries can be palpated on examination after menopause, the ovaries can be normally palpated in young and thin patients.
Naturally, after the age of the patient, the most emphasized subject in the anamnesis is the symptoms, namely the patient’s complaints. Since masses of ovarian origin usually do not show many symptoms, the presence of a prominent complaint can be very helpful in the diagnosis. For example, pain in ovarian cysts is not a common complaint. The presence of pain suggests inflammatory events or endometriosis rather than a cyst or tumor. Similarly, in tumors that cause menstrual irregularity, follicle cyst or corpus luteum cyst is considered first.
Gynecological examination is important for the differential diagnosis of the mass. The size of the mass, its localization, whether it is cystic or solid, whether it is mobile or fixed is important. Lesions in the midline are usually of uterine origin, while unilateral lesions are highly likely to be of ovarian origin. While most cystic and unilateral masses are benign, solid and bilateral masses are more likely to be malignant. If there is a collection of fluid in the abdominal cavity, it is most likely a malignancy.
Ultrasound in modern obstetrics is like the hands and feet of the physician. The diagnosis of many diseases and the follow-up of pregnancy have become extremely comfortable with ultrasound. Especially in the last 15 years, ultrasonography machines have taken their place in almost all gynecologists’ offices, thanks to devices that have become smaller and cheaper in price. In parallel with the dizzying developments in technology, the widespread use of Doppler ultrasound, which determines the blood flow in developed vessels and the shape of this flow, has opened new horizons especially in the evaluation of adnexal masses.
Ultrasound takes the first and most important place among the diagnostic methods used in the evaluation of adnexal masses. With ultrasound, the shape, dimensions, localization, solid or cystic nature of the mass, and whether it contains septa can be determined. Septa is in favor of malice. In Doppler ultrasonography, the vascular status of the mass and the calculation of the resistance to blood flow in these vessels provide valuable ideas about whether it is malignant or not.
Tomography (CT) and magnetic resonance (MR)
These methods can provide more detailed information than ultrasound, especially in very large masses or in cases where malignancy is suspected. They help in staging and extent of lymph node enlargement or spread of the disease, especially if cancer is considered. There are no routine applications in the diagnosis of ovarian cysts.
Some ovarian tumors can show themselves with the hormones they secrete or some similar substances. The most commonly used tumor marker is the one called Ca-125. This substance is especially increased in serous cystadenocarcinoma type of cancer. Although the increase in Ca–125 in the blood is in favor of malignancy, it is not very reliable as it can be seen in conditions such as endometriosis, infection and even smoking. Hormone levels can be checked in the blood to understand whether the mass is secreting hormones.
Other tumor markers used are substances such as Ca–19–9, hCG, fetoprotein, and CEA. However, none of them are reliable enough. These tests are only important to give an idea.
After understanding that adnexal masses originate from the ovary using one or more of the above methods, the most important issue is to decide whether it is malignant and/or whether surgery is required.
- If the mass is greater than 6 centimeters
- If the mass is less than 6 cm but in solid form
- If it still has not shrunk after 1–2 menstrual cycles
- If the follow-ups are growing
- In a postmenopausal woman
- If there is a collection of fluid in the abdominal cavity
- If there are septa in the cyst, surgery is usually required in these cases. In cases where these criteria are not met, the patient is followed for a certain period of time. Giving birth control pills during this time can help shrink the cyst.
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