Approach to the patient with an adnexal mass

Author:
Michael G Muto, MD
Section Editors:
Howard T Sharp, MD
Barbara Goff, MD
Deputy Editor:
Alana Chakrabarti, MD
Contributor Disclosures
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Mar 2021. | This topic last updated: Dec 02, 2020.

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 principal goals of the
evaluation are to address acute conditions (eg, ectopic pregnancy) and to determine whether a
mass is malignant.

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

PREVALENCE

An adnexal mass may be found in females of all ages, fetuses to the elderly. The reported
prevalence varies widely depending upon the population studied and the criteria employed. In a
random sample of 335 asymptomatic women aged 25 to 40 years, the prevalence of an adnexal
lesion on ultrasound examination was 7.8 percent (prevalence of ovarian cysts 6.6 percent) [2].
In another series, transvaginal ultrasonography was performed on 8794 asymptomatic
postmenopausal patients as part of their routine gynecologic check-up and 2.5 percent had a
simple unilocular adnexal cyst [3]. A study of 33,739 patients in the University of Kentucky
Ovarian Cancer Screening Program showed similar results [4].
A study of over 600 women showed the distribution of histologic types of adnexal masses (table
2).

CLINICAL APPROACH
The goal of the evaluation of a patient with an adnexal mass is to determine the most likely
etiology of the mass. This process is often challenging, since there are many types of adnexal
masses and a definitive diagnosis often requires surgical evaluation.

The evaluation is guided in large part by the anatomic location of the mass and age and
reproductive status of the patient. As an example, a solid ovarian mass in a postmenopausal
patient raises a high suspicion of ovarian cancer. Alternatively, a fallopian tube mass
accompanied by pain and bleeding in a patient of reproductive-age requires immediate
pregnancy testing and exclusion of an ectopic pregnancy.

Excluding urgent conditions or malignancy — An adnexal mass may represent a serious

health issue, a condition that requires urgent intervention (eg, ectopic pregnancy, adnexal
torsion) or an ovarian or fallopian tube cancer (or malignant disease metastatic for a peritoneal
cancer or other primary). A general evaluation is performed initially to confirm the presence of a
mass and to identify patients who should be further evaluated for an urgent condition or for
malignancy. For other patients, the general evaluation continues as the diagnostic evaluation. (

The clinical features of patients with urgent conditions are fairly specific (eg, severe pain, first
trimester bleeding, fever), and these represent a minority of patients.

Similarly, few patients who present with an adnexal mass will ultimately be diagnosed with a
malignancy. However, many patients will need to undergo an evaluation to fully exclude
malignancy, which may require follow-up with pelvic ultrasound for a prolonged period of time
or surgical exploration. This is because malignancy must be excluded for any mass that is not
clearly benign, including most complex masses (characterized on ultrasound by solid
components, thick walls, septations, or other hyperechoic findings).

The remaining patients include those with a simple ovarian cyst (characterized on ultrasound by
an anechoic fluid filling the cyst cavity with thin walls), ovarian masses for which the ultrasound
diagnosis is fairly certain (teratoma, endometrioma, hemorrhagic cyst), or other adnexal masses
that are invariably benign (eg, paratubal or paraovarian cyst, broad ligament leiomyoma) (table
1).
Anatomic location — The anatomic location helps to narrow the differential diagnosis. Most
adnexal masses are ovarian, but some arise from a fallopian tube or the surrounding tissues or
structures. The differential diagnosis of an adnexal mass is listed briefly here and is also shown
in the table (table 1) and discussed in detail separately.

Ovarian masses include:

●Physiologiccysts (follicular or corpus luteum)

●Benign ovarian neoplasms (eg, endometrioma, mature teratoma [dermoid cyst])
●Ovarian cancer or metastatic disease from a non-ovarian primary cancer

A mass in the fallopian tube may be:

●Ectopic pregnancy
 ●Hydrosalpinx
●Fallopian tube cancer

The ovary and fallopian tube are surrounded by the mesosalpinx or mesovarium, condensations
of connective tissue that are part of the broad ligament. Some adnexal masses arise from these
tissues. In addition, some adnexal masses are adherent to the adnexa or derive from nearby
structures:

●Paratubal or paraovarian cyst

●Tubo-ovarian
●Broad ligament leiomyoma
Age and reproductive status — Different types of adnexal masses are more likely depending
upon the age and reproductive status of the patient.
Children and adolescents — Adnexal masses occur less frequently in children and adolescents
than in reproductive-age patients. However, when an adnexal mass is found in this patient
population, there is a significant likelihood of adnexal torsion or an ovarian malignancy
(approximately 10 to 20 percent) [6-10]. Germ cell tumors are the most common type of ovarian
cancer in children and adolescents, comprising 35 percent compared with 20 percent in adults.
The approach to adnexal masses in this age group is discussed in detail separately
Premenopausal patients — The great majority of adnexal masses occur in reproductive-age
patients (including postmenarchal adolescents), and most of these masses are benign [11]. This is
because the pathogenesis of many benign adnexal masses is associated with reproductive
function. Pregnancy-related etiologies occur exclusively in reproductive-age patients by
definition. Many other types of adnexal masses are associated with the menstrual cycle or
reproductive hormones (eg, follicular cysts, endometriomas) and are common findings found in
this patient population.
Ovarian or fallopian tube cancer is less likely in premenopausal than postmenopausal patients,
but the possibility of malignancy should be considered in all patients. The incidence of ovarian
cancer increases with age (eg, 1.8 to 2.2 per 100,000 women age 20 to 29 versus 9.0 to 15.2 per
100,000 women age 40 to 49.)
Pregnant patients — There are several types of adnexal masses that are associated with
pregnancy. These include (
●Ectopic pregnancy and luteomas – These occur solely during pregnancy.
●Corpus luteum cysts – These persist longer during pregnancy and thus are likely to reach
a larger size and may become hemorrhagic, rupture, or undergo torsion. If a corpus luteum
is surgically removed during pregnancy, supplemental progesterone may be required,
depending upon gestational age.
●Theca lutein cysts – These are most likely to occur in patients with ovarian
hyperstimulation due to ovulation induction for infertility or gestational trophoblastic
disease.
●Management of an adnexal mass during pregnancy is discussed separately.
Postmenopausal patients — Excluding malignancy is the main priority in postmenopausal
patients with an adnexal mass (the average age of diagnosis of ovarian cancer in the United
States is 63 years old) [12]. Many of these patients will require a surgical evaluation..)
Urgent conditions (eg, adnexal torsion, tubo-ovarian abscess) may also occur in postmenopausal
patients, but are less common and are more likely to be associated with malignancy.
 GENERAL EVALUATION

Patients with an adnexal mass typically present with gynecologic symptoms and a mass is
identified on pelvic imaging. Alternatively, an adnexal mass is discovered incidentally on pelvic
examination or imaging in many patients.
Patients with a known or suspected adnexal mass should undergo a general evaluation to confirm
the presence of a mass and determine its characteristics and any associated symptoms or physical
findings. Patients should be assessed for features that indicate immediate intervention or suggest
malignancy, and these patients should undergo a focused evaluation for these conditions. (
Medical history — Pelvic pain or pressure is the most common symptom associated with an
adnexal mass [13]. Some patients present with genital tract bleeding. Ovarian cancer may be
associated with pelvic or abdominal symptoms or, for particular histologic types (eg, sex cord-
stromal tumors), with symptoms related to hormone production by the tumor.
Patients who present with symptoms or findings suggestive of an adnexal mass should undergo
pelvic examination and imaging to confirm whether a mass is present.

For patient with a known adnexal mass, the clinician should inquire about associated symptoms.
Symptom patterns that suggest a particular etiology help to guide further evaluation or
management.

If pain or pressure is present, the characteristics of the discomfort should be elicited, including
the acuity of onset, location, duration, whether it is constant or intermittent, and whether it is
associated with any other factors (eg, menstrual cycle). An adnexal mass that is associated with
severe pain, particularly of abrupt onset, or pelvic pain in a pregnant patient requires immediate
evaluation. The relationship of pain symptoms to particular types of adnexal masses is discussed
below.
Benign masses that do not require immediate intervention may also present with pelvic pain.
Ovarian physiologic cysts or neoplasms are typically associated with a dull, achy pain that is
usually localized to the side of the mass or may be asymptomatic, as noted above. An
endometrioma may be associated with dysmenorrhea or dyspareunia.
A patient who presents with an adnexal mass and vaginal bleeding and who may be pregnant
should have pregnancy testing. Types of adnexal masses that are particular to pregnancy are an
ectopic pregnancy, which requires urgent intervention, or a corpus luteum cyst.
Patients should be asked about a history of fever or vaginal discharge. Patients who complain of
fever and vaginal discharge and are found to have an adnexal mass should be evaluated for a
tubo-ovarian abscess. The combination of a tubal mass and a history of pelvic inflammatory
disease may also represent a hydrosalpinx. Persistent serosanguineous vaginal discharge without
fever has been associated with fallopian tube cancer.
Patients should also be asked about a history of infertility since an endometrioma or
hydrosalpinx may contribute to infertility. In addition, infertility is associated with an increased
risk of ovarian tumors of low malignant potential.
The medical history should include questions about risk factors and symptoms associated with
ovarian or fallopian tube cancer
Physical examination — A thorough pelvic examination is performed to assess for an adnexal
mass in a symptomatic patient and determine its characteristics. The approaches to the pelvic
examination in adults and in children are discussed in detail separately.
A finding of an adnexal mass on pelvic examination should be further evaluated with pelvic
imaging. Imaging may reveal an adnexal mass, no mass, or a mass that derives from another
anatomic location in the genital (eg, uterine leiomyoma), gastrointestinal (eg, mucocele of the
appendix), or urinary (eg, urachal cyst) tracts or other sites (eg, enlarged mesenteric lymph
nodes).

The absence of an adnexal mass on examination does not fully exclude the presence of a pelvic
mass. Small adnexal masses are difficult to palpate due to the deep anatomic location of the
ovary. In addition, larger masses can float out of the pelvis and be difficult to feel. Ovaries are
not usually palpable in postmenopausal patients, and a finding of a palpable ovary in this
population should prompt pelvic imaging to assess for an ovarian or tubal neoplasm.

The size, consistency, and mobility of a mass, if present, should be noted. Features that are
suggestive of malignancy include a solid mass that is irregular or fixed or is associated with
posterior cul-de-sac nodularity. On the other hand, endometriomas and tubo-ovarian abscesses
are benign lesions that may be fixed and irregular. Posterior cul-de-sac nodularity is highly
suspicious for malignancy in a postmenopausal patient, but may signify endometriosis in a
premenopausal patient.

Patients with an inflammatory process exhibit tenderness with palpation of the adnexal mass (eg,
tubo-ovarian abscess). However, some patients with an ovarian neoplasm have tenderness on
pelvic examination.

Rectovaginal examination is performed to allow palpation of the ovary posteriorly. A rectal mass
or positive fecal occult blood testing is not usually associated with an adnexal mass. These
findings should be noted, if present, and further evaluated for colorectal cancer or other
conditions, as appropriate. A rectal mass is an uncommon finding in epithelial ovarian cancer
(EOC) since direct transmural extension is rare. Infrequently, rectal bleeding may occur in cases
of rectal endometriosis or clear cell or endometrioid cancers arising in endometriotic implants in
the rectal wall.

Presacral tumors may also occur. On physical examination, a presacral mass will be posterior to
the rectum, while an ovarian mass will be anterior to the rectum. The location of the mass can
then be confirmed with imaging studies.

Abdominal examination includes assessment for abdominal distention and ascites and/or an
abdominal mass. The diagnosis of malignancy is almost certain in patients with both a fixed,
irregular pelvic mass and an abdominal mass or ascites.

If malignancy is suspected, the examination should also include sites of cancer that may
metastasize to the ovaries (eg, stomach, colorectal, breast). If there is a moderate to high
suspicion of ovarian cancer, further examination should be performed of potential sites of EOC
metastases (rectum, liver, spleen, lungs, inguinal or supraclavicular lymph nodes).
Imaging studies — The evaluation of adnexal masses with ultrasound and other imaging
modalities is discussed in detail separately. A brief summary is included here.
 ●Pelvic ultrasound – Pelvic ultrasound is the imaging study of choice for the evaluation of
an adnexal mass. Ultrasound is relatively less expensive than other imaging modalities and
its diagnostic performance is similar [14].
Both a transvaginal and transabdominal ultrasound should be obtained in most patients.
Transabdominal ultrasound is better tolerated and is more helpful in visualizing abdominal
processes. Transvaginal ultrasound provides better resolution of pelvic structures with less
artifact and does not require a distended bladder. The endometrial thickness should also be
assessed as thickening is a marker of estrogen excess.
A definitive diagnosis of the type of adnexal mass can be made only with histologic
evaluation, not with imaging. However, simple ovarian cysts, hemorrhagic cysts,
endometriomas, and teratomas often have characteristic ultrasound features that are highly
predictive of the histologic diagnosis.
●Magnetic resonance imaging (MRI) – MRI is used as a secondary imaging study to
determine if surgical evaluation is needed in patients with ovarian masses that have an
indeterminant appearance on ultrasound (eg, hemorrhagic masses in which mural clot can
appear solid on ultrasound, mature teratomas with an atypical appearance, solid ovarian
neoplasms) [15].
●Computed tomography (CT) – CT is not a primary modality for evaluation of adnexal
masses. If an adnexal mass is incidentally detected on CT, further imaging with high-
resolution transvaginal ultrasound is often needed to better characterize the mass. CT or
MRI is used as part of noninvasive staging of patients with suspected ovarian cancer..)
Laboratory evaluation — Laboratory evaluation depends upon the clinical scenario:
●Pregnancy testing with a urine or serum human beta chorionic gonadotropin should be
performed in any reproductive-age patient who presents with an adnexal mass.
●A complete blood count should be drawn if anemia is suspected due to bleeding in the
setting of an ectopic pregnancy, ruptured or hemorrhagic ovarian cyst, or to assess for
leukocytosis in patients with a tubo-ovarian abscess.
●Laboratory testing to evaluate for malignancy or hormonal activity is discussed below. (

EVALUATION FOR URGENT CONDITIONS

Patients who present with an abrupt onset of severe pain, first trimester bleeding, or fever require
evaluation in an emergency department or other urgent care setting.
First trimester bleeding or pain — Adnexal masses found in early pregnancy include ectopic
pregnancy or corpus luteum cyst. A corpus luteum is a normal finding, and is not associated with
vaginal bleeding or pain. These two masses are usually easily differentiated on pelvic ultrasound.
(.)
Ectopic pregnancy — The finding of an adnexal mass (which is not consistent on ultrasound
with a corpus luteum) in a pregnant patient with no confirmed intrauterine pregnancy,
particularly if accompanied by pelvic pain or vaginal bleeding should be considered an ectopic
pregnancy until proven otherwise. Immediate evaluation and treatment are required for this
potentially life-threatening condition. The fallopian tube is the most common site of an ectopic
pregnancy, although ovarian pregnancy may also occur.
The diagnosis and management of ectopic pregnancy are discussed in detail separately.
Acute pelvic or abdominal pain — The abrupt onset of severe pain in a patient with an adnexal
mass may be associated with adnexal torsion, rupture of an ovarian cyst, or a ruptured ectopic
pregnancy.
Adnexal torsion — Adnexal torsion typically presents with an abrupt onset of severe pelvic
pain, and is often accompanied by nausea and vomiting. Urgent surgical treatment is required to
avoid ischemic injury and loss of ovarian and tubal function.
The diagnosis and management of adnexal torsion are discussed in detail separately.
Ruptured or hemorrhagic ovarian cyst — The classic presentation of a ruptured ovarian cyst
is an abrupt onset of severe pain in the mid-menstrual cycle immediately following sexual
intercourse. In ovulatory patients, a follicular cyst forms mid-cycle, followed by a corpus luteum.
These are typically physiologic cysts. The cysts are more likely to rupture in the luteal phase and
this may be spontaneous or triggered by activity like sexual intercourse. A cyst may also become
hemorrhagic without rupture. Immediate surgical intervention is required only if there is concern
that brisk bleeding from the cyst may cause anemia or hemodynamic instability. Other patients
may be managed with pain management and follow-up for resolution of the pain and the mass.
The diagnosis and management of a ruptured ovarian cyst are discussed in detail separately.
Fever — Patients with an adnexal mass and fever should be evaluated for a tubo-ovarian
abscess. Alternatively, this presentation may represent a periappendiceal abscess or diverticular
abscess. Infrequently, fever is associated with adnexal torsion.
Tubo-ovarian abscess — The classic presentation of a tubo-ovarian 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 ovaries and fallopian tubes. It is important to note that many patients with tubo-
ovarian abscess, particularly the elderly, are asymptomatic.
The diagnosis and management of a tubo-ovarian abscess are discussed in detail separately.

EVALUATION FOR MALIGNANCY

One of the principal goals of the evaluation of an adnexal mass is to determine whether it is
benign or malignant.
The types of malignant adnexal masses include
●Ovarian cancer – The most common histologic type is epithelial ovarian carcinoma
(EOC). Other types of ovarian cancer include germ cell tumors and sex cord-stromal
tumors.
●Fallopian tube or peritoneal carcinoma – Patients with peritoneal carcinoma may
present with or without an adnexal mass. High grade serous EOC, fallopian tube, and
peritoneal carcinomas are considered a single clinical entity to their shared clinical behavior
and treatment and there is accumulating evidence of a common pathogenesis. We will use
the term EOC to refer to this group of malignancies in the discussion that follows.
●Metastatic disease from another primary cancer – Gastric and breast cancer are the
most common malignancies that metastasize to the ovaries.

Excluding malignancy is typically a two-phase process. An initial evaluation is performed to

establish the degree of clinical suspicion that a mass is malignant. If malignancy is suspected,
surgical exploration is performed to make a definitive diagnosis.
The likelihood that an adnexal mass is malignant depends mainly upon one or more of the
following factors:

●Imaging study findings that are consistent with malignancy

●Age or menopausal status
●Risk factors
●Laboratory results
If malignancy is suspected based upon these factors, surgical exploration is required to obtain a
specimen for histologic diagnosis. Unfortunately, there is no minimally invasive biopsy
technique for ovarian cancer. This is because patients with early stage disease (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 4)
[16,17]. Thus, image-guided ovarian biopsy is not performed and, unfortunately, many patients
undergo surgical procedures to identify the few who have a malignancy. As an example, in a
large ovarian cancer screening randomized trial, among 570 patients who underwent surgical
evaluation for suspected ovarian cancer, 20 cases of malignancy were found (3.5 percent)
If the mass can be successfully removed without disruption via a minimally invasive technique,
this is preferred.
Decisions regarding surgical evaluation are discussed in detail separately.
Screening for ovarian cancer in patients who are asymptomatic and have no adnexal mass is
discussed in detail separately.
Initial evaluation — The goal of the initial evaluation is to determine the degree of clinical
suspicion of malignancy.
Medical history — The age and menopausal status of the patient help to guide the process of
evaluation, with the highest proportion of malignancy found in an adnexal mass in a
postmenopausal patient or a child or adolescent, as discussed above.
Patients with an adnexal mass should be asked about symptoms associated with ovarian cancer.
Patients with ovarian cancer may present with symptoms of pelvic or abdominal pain or
pressure, bloating, or gastrointestinal or urinary tract symptoms (table 5). These symptoms are
typically mild to moderate and develop over a period of weeks or months.

Alternatively, it is common for ovarian cancer to be asymptomatic or to present at an advanced

stage with an acute condition and associated symptoms (eg, bowel obstruction, pleural effusion).
Infrequently, a malignant mass may rupture or torse and present with acute pain.

Ovarian tumors that secrete hormones may present with symptoms related to estrogen excess
(abnormal uterine bleeding) or androgen excess (virilization or hirsutism)

The presence of risk factors for EOC or other histologic types of ovarian cancer is a key
determinant of clinical suspicion of the disease (table 3). Patients with an adnexal mass should be
asked about a family history of ovarian, breast, uterine, or colon cancer. Those with a family
history suggestive of a hereditary ovarian cancer syndrome (BRCA gene mutation or Lynch
syndrome) should be counseled about genetic testing. Patients with a hereditary ovarian cancer
syndrome are at a greatly increased risk of ovarian cancer (table 6 and table 7) and should
undergo surgical evaluation if any suspicious adnexal mass is found. 
Physical examination — Physical examination findings that are associated with malignancy are
discussed above.
Imaging studies — Pelvic ultrasound is the first line imaging study for the evaluation of an
adnexal mass [19].
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 [14]. Use of a
second imaging study after ultrasound is reasonable if a clinician cannot determine whether
surgical evaluation is warranted based upon the results of ultrasound and the other components
of the initial evaluation. The diagnostic performance of ultrasound compared with other imaging
modalities is discussed in detail separately.
Sonographic features suggestive of a malignant adnexal mass [20] are discussed in detail
separately.
Additional imaging studies may be necessary to evaluate the abdomen or other sites in patients
with suspected metastatic ovarian cancer.
Laboratory studies — Serum biomarkers contribute to the evaluation of an adnexal mass for
malignancy; however, their utility is limited.
Preoperative measurement of biomarkers in patients with possible ovarian cancer has several
additional functions. A baseline level is established for use for further monitoring during and
after treatment [11,21]. In addition, biomarkers may play a role in predicting whether optimal
cytoreduction is feasible

Serum markers for epithelial ovarian carcinoma — Serum CA 125 is the most commonly
used laboratory test for the evaluation of adnexal masses for EOC. In our practice, we measure
CA 125 in all postmenopausal patients with an adnexal mass. In premenopausal patients, 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. Biomarkers that are used to
decide whether to refer a patient with suspected EOC to a gynecologic oncologist are OVA1 and
the Risk of Malignancy Algorithm.

Serum markers for other histologic types — Germ cell and sex cord-stromal tumors may
secrete hormones or other substances that can be detected preoperatively to contribute to the
diagnostic evaluation. In many cases, however, the diagnosis of these histologic types is made
only upon postoperative pathology evaluation of the ovary. Serum markers associated with these
histologic types are shown in the table (table 8).

Clinical scenarios in which markers for these tumors should be drawn include:

●A child or adolescent who presents with an adnexal mass since the most likely histology of
an ovarian neoplasm is a germ cell tumor in this population. We check markers associated
with germ cell tumors, including human chorionic gonadotropin, lactate dehydrogenase, and
alpha-fetoprotein, and add total testosterone and dehydroepiandrosterone if the child has
virilization and estradiol, and luteinizing hormone and follicle-stimulating hormone if the
child has precocious puberty. Very high concentrations of estradiol, with associated
suppression of gonadotropins, are generally indicative of peripheral precocity, such as from
an ovarian tumor.
●Patients with an adnexal mass who present with symptoms or signs of estrogen excess
(abnormal uterine bleeding) or androgen excess (virilization or hirsutism) may have a germ
cell or sex cord-stromal tumor. In patients with symptoms of endocrine effects, appropriate
hormonal testing (estradiol, total testosterone) should be performed.
Surgical exploration — Surgical exploration is performed if the initial evaluation results in
sufficient suspicion of a malignant adnexal mass. Surgical evaluation allows a definitive
histologic diagnosis. If a malignancy is present, the surgeon may proceed with staging and
cytoreduction. The steps of this procedure are discussed in detail separately.
Continued surveillance — Patients 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. One approach is presented is detail separately.

REFERRAL TO A SPECIALIST

Patients with a complex adnexal mass, findings suggestive of metastatic epithelial ovarian cancer
(EOC), fallopian tube or peritoneal carcinoma, or laboratory testing suggestive of ovarian cancer
(eg, elevated serum CA 125) should be referred to a gynecologic oncologist for further
evaluation.
Patients in whom there is a high suspicion of EOC should be referred to a gynecologic
oncologist. There is evidence that prognosis is improved when EOC staging and cytoreduction is
performed by a gynecologic oncologist.

SOCIETY GUIDELINE LINKS

Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately.

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SUMMARY AND RECOMMENDATIONS

●An adnexal mass (mass of the ovary, fallopian tube, or surrounding connective tissue) is a
common gynecologic problem. An adnexal mass may be found in females of all ages,
fetuses to the elderly, and there is a wide variety of etiologies (table 1).
(See 'Introduction' above.)
●Some patients with an adnexal mass present with symptoms or physical examination
findings. Pelvic pain or pressure is the most common symptom of an adnexal mass. Other
potential symptoms or signs include abnormal genital tract bleeding, abdominal distension,
ascites, or hirsutism. Many adnexal masses are asymptomatic and the mass is discovered as
an incidental finding on pelvic imaging. (See 'Medical history' above.)
●The goal of the evaluation of a patient with an adnexal mass is to determine the most likely
etiology of the mass. The process of evaluation includes:
•A general evaluation to confirm the presence and anatomic location of the mass and to
identify any associated symptoms or physical findings. (See 'General
evaluation' above.)
•A focused evaluation for conditions that require immediate treatment for patients who
present with first trimester bleeding, acute pain, or fever. (See 'Evaluation for urgent
conditions' above.)
•A focused evaluation to exclude malignancy if the results of the general evaluation
raise the suspicion that the adnexal mass is malignant.
●The medical history includes questions regarding symptoms associated with an adnexal
mass and risk factors for ovarian or fallopian tube cancer (table 3). A thorough pelvic
examination is performed to assess for an adnexal mass and determine its characteristics.
Features that are suggestive of malignancy include a solid mass that is irregular or fixed or
is associated with posterior cul-de-sac nodularity. On the other hand, some benign lesions
may have these features.
●Pelvic ultrasound is the first line imaging study for the evaluation of an adnexal mass.
Ultrasound is relatively less expensive than other imaging modalities and its diagnostic
performance is similar. Use of a second imaging study after ultrasound is reasonable if a
clinician cannot determine whether surgical evaluation is warranted based upon the results
of ultrasound and the other components of the initial evaluation.
●Laboratory evaluation includes a pregnancy test in patients of reproductive-age and tests to
evaluate for malignancy or other conditions.