Women with endometriosis may develop ovarian endometri¬omas (”chocolate” cysts), which can enlarge to 6-8 cm in size. A mass that does not re¬solve with observation may be an endometrioma. A proper examination using gynecology microscopes can help with the diagnosis.
Although enlarged, polycystic ovaries were originally considered the sine qua non of poly¬cystic ovarian syndrome (PCOS), polycystic ovaries probably represent a final common phenotype of a wide variety of causes; they have been described as a sign, not a diagnosis. The prevalence of PCOS among the general population depends on the diagnostic criteria used. In one study, 257 volunteers were examined with ultrasound; 22% were found to have polycystic ovaries. Thus, the finding of bilateral generously sized ovaries on examination or polycystic ovaries on ultrasound examination should prompt evaluation for the full-blown syndrome, which includes hyperandrogenism and chronic anovulation as well as polycystic ovaries. However, surgical intervention should not be recommended on the basis of this finding alone.
Neoplastic Masses
More than 80% of benign cystic teratomas (dermoid cysts) oc¬cur during the reproductive years. The median age of occurrence is 30 years. One-third of women younger than 30 years of age who underwent laparotomy for pelvic mass were found in one series to have a dermoid cyst. Histologically, benign cystic teratomas have an admixture of elements when examined using gynecology microscopes. In one study of ovarian masses that were surgically excised, dermoid cysts represented 62% of all ovarian neoplasms in women younger than 40 years of age. When further examined under gynecology microscopes, it was found out that malignant transformation occurs in less than 2% of dermoid cysts in women of all ages; more than three-fourths of cases of malignant transformation occur in women older than 40 years of age. The risk of torsion with dermoid cysts is approximately 15%, and it occurs more frequently than with ovar¬ian tumors in general, perhaps because the high fat content of most dermoid cysts, al¬lowing them to “float” within the abdominal and pelvic cavity. As a result of this fat content, on pelvic examination, a dermoid cyst frequently is described as ante¬rior in location. They are bilateral in approximately 10% of cases, although many have ad¬vanced the argument against bivalving a normal-appearing contralateral ovary because of the risk of adhesions, which may result in fertility. An ovarian cystectomy is almost always possible, even if it appears that only a small amount of ovarian tissue remains. Preserving a small amount of ovarian cortex in a young patient with a benign lesion is preferable to the loss of the entire ovary.
The risk of epithelial tumors increases with age. Although some texts report that serous cystadenomas are the more common benign neoplasm, a recent study indicated that benign cystic teratomas occurred most frequently, representing 66% of benign tumors in women younger than 50 years of age; serous tumors accounted for only 20%. Serous tumors are generally benign; 5-10% have borderline malignant potential and 20-25% are malignant. Malignancy can only be diagnosed when tissue samples are examined under a microscope such as gynecology microscopes.
Serous cystadenomas are often multilocular, sometimes with papillary com¬ponents. The surface epithelial cells secrete serous fluid, resulting in a watery cyst content. Psammoma bodies, which are areas of fine calcific.granulation, maybe scat¬tered within the tumor and are visible on x-ray. A frozen section is necessary to distinguish between benign, borderline, and malignant serous tumors, because gross ex¬amination alone cannot make this distinction. Mucinous ovarian tumors may grow to large dimensions. Benign mucinous tumors typically have a lobulated, smooth sur¬face, are multilocular, and may be bilateral in up to 10% of cases. Mucoid material is pre¬sent within the cystic loculations. Five to 10% of mucinous ovarian tumors are malignant. They may be difficult to distinguish histologically from metastatic gas¬trointestinal malignancies. Other benign ovarian tumors include fibromas (a focus of stromal cells), Brenner tumors (which appear grossly similar to fibromas and which are frequently found incidentally), and mixed forms of tumors such as the cystadenofibroma.
Other Adnexal Masses
Masses that include the fallopian tube are related primarily to inflammatory causes in this age group. A tubo-ovarian abscess can be present in association with PID. In addition, a complex inflammatory mass consisting of bowel, tube. And ovary may be pre¬sent without a large abscess cavity.
Ectopic pregnancies can occur in the reproductive age group and must be excluded when a patient presents with pain, a positive pregnancy test, and an adnexal mass.
Paraovarian cysts may be noted either on examination using gynecology microscopes or on imaging studies. In many in¬stances, a normal ipsilateral ovary can be visualized using ultrasonography. The fre¬quency of malignancy in paraovarian tumors is quite low, although one review reported malignancy in 2% of patients.
A complete pelvic examination, including rectovaginal examination and PAP test, should be performed. Estimations of the size of a mass should be presented in centimeters rather than in comparison to common objects or fruit (e.g., orange, grapefruit, tennis ball, golf ball). After pregnancy has been excluded, one simple office technique that can help determine whether a mass is uterine or adnexal includes sounding and measuring the depth of the uterine cavity.