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Pelvic Mass. Alexander Dufort and Sean Mindra OBGYN boot camp October 17 th , 2014. Objectives. List pelvic tumors of ovarian origin. Classify ovarian pathology as benign vs. malignant. Compare and contrast functional vs. neoplastic ovarian cysts. Case.

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pelvic mass

Pelvic Mass

Alexander Dufort and Sean Mindra

OBGYN boot camp

October 17th, 2014

  • List pelvic tumors of ovarian origin.
  • Classify ovarian pathology as benign vs. malignant.
  • Compare and contrast functional vs. neoplastic ovarian cysts.
  • An 18 yo G0 young woman presents to your office for routine gynecologic examination. She reports that her last menstrual period began about 23 days ago. It was light in flow, and lasted 4 days in length. She has minimal dysmenorrhea. She denies any history of sexually transmitted infections, and has been sexually active with two male partners in the last 2 weeks. She was given a prescription for OCP 3 months ago; however, she has not started taking these. She has no other complaints or medical/surgical history.
case continued
Case – Continued
  • During her pelvic examination, you perform a PAP and bimanual examination. You discover a 6 cm non-tender left adnexal mass that is mobile. She has no rebound tenderness or guarding.
  • Using the above case as a starting point, review Pelvic Masses – focus on ovarian pathology;
    • Review Classification of Pelvic Mass; physiologic vs. non-physiologic
    • Discuss necessary investigations
    • Review management options for this case
    • Review management options for pelvic mass diagnosed in a perimenopausal/postmenopausal patient
classification of ovarian masses
Classification of Ovarian masses
  • Physiological/Functional cysts
  • Neoplastic
    • Benign and malignant
  • Pregnancy related
    • Ectopic pregnancy
  • Other
    • Endometrioma (Chocolate cyst) – from endometriosis


  • Hydrosalpinx (blocked tube - typically bilateral – serous/clear)
  • Tubo-ovarian cyst
  • Pyosalpinx (pus-filled tube)


-can happen in the broad ligament, upper third of vagina, uterus, fallopian tubes

physiological functional mass
Physiological/functional Mass
  • Follicular cyst
    • Formed by a dominant follicle that fails to rupture during ovulation
  • Luteal cyst
    • Formed by the premature

sealing of the CL after the

egg is released, causing the

CL to enlarge

question 1
Question 1
  • Which of the following is true regarding the natural progression of a functional ovarian cyst?

A) Generally asymptomatic unless bleeding or torsion occur

B) 10% chance of progression to malignancy

C) Grow to sizes larger then 10 cm

question 2
Question 2

Which of the following is a risk factor for developing ovarian cancer?

1) Childbearing

2) Early menarche

3) Early menopause

4) OCP

risk factors
Risk Factors
  • Increasing age
  • Lifestyle (smoking, obesity, lack of physical activity)
  • infertility
  • Family history of ovarian ca
  • BRCA1 & BRCA2
  • History of endometriosis
  • HRT
neoplastic masses
Neoplastic Masses
  • Epithelial
    • Serous – most common subtype [mostly in 40-60yrs of age]
    • Mucinous [30-50yrs of age]
    • Endometrioid [50-70yrs of age]
    • Clear cell [40-80yrs of age]
    • Brenner/transitional cell [very rare]
    • Undifferentiated [account for about 15% of epithelial tumors]
  • Germ cell
    • Mature teratoma (Dermoid Cyst)
  • Sex cord / stromal
  • Metastatic
question 3
Question 3

Which of the following is TRUE regarding

this type of mass?

A) They are most commonly derived from ectoderm

B) It has a thin wall

C) Marsupialization is a common surgical technique used for treatment

D) They have short vascular pedicles

neoplastic masses1
Neoplastic masses
  • Most common neoplastic masses in a pre-menopausal women
    • Serous cystadenoma
    • Endometrioma
    • Mature cystic teratoma
symptoms of ovarian masses
Symptoms of ovarian masses
  • Asymptomatic
  • Increased abdominal girth and distension
  • Acute pain
    • torsion, rupture and hemorrhage
  • Signs of infection (Fever, pain)
  • Chronic Pain:
    • Deep Dysparunia, Dysmenorrhea
  • Ovarian cancer can present with
    • Weight loss, anorexia, respiratory symptoms, urinary frequency, constipation, ascites
physical findings benign vs malignant
Physical findings: Benign vs. Malignant
  • Benign
    • Unilateral
    • Cystic
    • Mobile
  • Malignant
    • Fixed
    • Solid/irregular shape
    • Associated with ascites
    • Rapidly increase in size
back to the case
Back to the Case!
  • 18 yo, asymptomatic, 6 cm andexal mass
  • Likely etiologies
  • Neoplastic
    • Mature cystic teratoma  
    • Serous cystadenoma
    • Endometrioma
  • Functional
    • Follicular Cyst
    • Corpus luteum cyst
back to the case1
Back to the Case!
  • What is the next step in management?
    • Imaging, Serum bHCG, CBC
  • What would be the Imaging modality of choice to further investigate our patient’s mass?
    • X-ray
    • CT scan
    • Pelvic ultrasound
    • MRI
ultrasound findings
Ultrasound findings
  • Findings suggestive of a benign process
    • Anechoic
    • Unilocular
    • Fluid filled cysts with thin walls
    • Calcification (pathognomonic for dermoid cyst)
  • Follicular cyst
ultrasound findings1
Ultrasound findings
  • Findings suggestive of malignant process
    • Solid or complex cystic/solid mass
    • Nodular
    • Thick Septations
    • Presence of ascities
    • Peritoneal masses and nodularity
    • Doppler demonstrating flow
  • Ovarian cancer
management premenopausal
Management: Premenopausal
  • If U/S is suggestive of a benign process
    • Surveillance
      • If asymptomatic, simple cyst (i.e. physiological), < 8 cm
      • Reassess in 6 weeks for regression
    • Suppression
      • OCP or GnRH analogue (ex. Lupron)
      • Recurrent physiological cysts
    • Excision
      • Ovarian cystectomy vs. oophorectomy 
      • > 8 cm, symptomatic, findings suggestive of dermoid cyst
      • Intervention for torsion, sever hemorrhage, abscess
management premenopausal1
Management: Premenopausal
  • If findings suggestive of a malignant process
    • Surgical exploration to investigate etiology
    • Open (preferred) or laparoscopic oophorectomy or Hysterectomy + BSO
    • Staging and histological diagnosis
management post menopausal
Management: Post-menopausal
  • Why is the management different between premenopausal and postmenopausal women?
management post menopausal1
Management: Post-menopausal
  • Investigations and work up
    • History and risk factors, physical, pelvic U/S
    • CA-125
  • Management
  • Features suggestive of malignancy and/or CA-125 level above 35 U/ml and+/-or mass > 10 cm
    • Hysterectomy + BSO
    • +/- adjuvant chemotherapy (Carboplatin/Taxol)
  • Benign features (Low CA-125, <5 cm)
    • Continued CA-125 and U/S screening
  • Many different types of ovarian masses
  • Functional vs. neoplastic
    • Functional will regress
  • Benign lesions common in pre-menopausal women
    • Often present asymptomatically
  • Treatment dictated by symptoms and imaging findings.
    • Suspicion of malignancy requires surgery
  • Up to Date
  • Pelvic Masses and Pelvic Pain lecture
  • Toronto Notes 2014