Ovaries and tubes together are called adnexa. Since masses and tumors originating from the tubes are extremely rare, adnexal mass is usually understood as ovarian masses. These masses may be ovarian cysts, as well as different tumors or inflammatory growths. It is not always easy to say that a palpable adnexal mass originates from the ovary. These masses may also originate from the uterus, tubes, even intestines or bladder, as well as ovaries. In the presence of an adnexal mass, a careful history and correct and appropriate use of auxiliary diagnostic methods are important, especially in terms of the 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 story 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 palpable mass in a postmenopausal woman is highly likely to be malignant, this mass is most likely a dermoid cyst in individuals younger than 20 years old. Functional cysts are the most common in women of reproductive age. While it is pathological to feel the ovaries by hand on examination after menopause, ovaries can normally be palpable in young and weak patients.
After the patient’s age, the most emphasized issue in the anamnesis is the symptoms, that is, the patient’s complaints. Since ovarian masses usually do not show much symptoms, the presence of a pronounced complaint can be very helpful in diagnosis. For example, pain in ovarian cysts is not a common complaint. Presence of pain suggest inflammatory phenomena or endometriosis rather than cysts or tumors. Similarly, follicle cyst or corpus luteum cyst is considered first in tumors that cause menstrual irregularity.
Gynecological examination is important for differential diagnosis of the mass. The size, localization, cystic or solid structure of the mass, whether it is mobile or fixed are important. While lesions in the midline are usually of uterine origin, unilateral lesions are highly likely to be of ovarian origin. While most of the cystic and unilateral masses are benign, solid and bilateral ones are more likely to be malignant. If there is accumulation of fluid in the abdominal cavity, it is most likely a malignancy.
During the gynecological examination, the presence of male pattern hair loss or an increase in hair growth should suggest a tumor that secretes male hormone.
In modern gynecology, ultrasound is like the foot of the physician. Diagnosis of many diseases and follow-up of pregnancy has become extremely comfortable with ultrasound. Ultrasonography machines have taken their place in almost all gynecologists’ offices, especially in the last 15 years, thanks to the devices that have gotten smaller and their prices cheaper. Parallel to the dizzying developments in technology, the widespread use of doppler ultrasound, which determines the blood flow in the advanced 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, size, localization, solid or cystic nature of the mass, and whether it contains septa can be determined. Seeing the septa is in favor of malice. In Doppler ultrasonography, the vascularization status of the mass and the calculation of the resistance against the blood flow in these vessels give valuable insight into 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 cases suspected of malignancy. Especially if cancer is considered, they are helpful in lanf node enlargement or the extent and staging of the disease. There is no routine practice in the diagnosis of ovarian cysts.
Some ovarian tumors can manifest themselves by secreting hormones or some similar substances. The most commonly used tumor marker is the one called Ca-125. This substance increases especially in serous cystadenocarcinoma type 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 cases such as endometriosis, infection, and even smoking. Hormone levels in the blood can be measured 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 these 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 larger than 6 centimeters
• If the mass is less than 6 centimeters but solid structure
• If it still has not shrunk after 1–2 menstrual period
• If it grows in the pursuits
• If in a woman after menopause
• If there is fluid accumulation in the abdominal cavity
• If there are septa in the cyst, operation is usually required in these cases.
In the absence of these criteria, the patient is followed for a certain period of time. Giving birth control pills during this time can help shrink the cyst.