gynecology and obstetrics
Female Pelvic Mass
Evaluation of Pelvic Mass
General medical and complete obstetric and gynecologic histories are obtained. Symptoms or findings may suggest a cause for the pelvic mass: Vaginal bleeding and pelvic pain with a positive pregnancy test: Ectopic Pregnancy or, rarely, Dysmenorrhea: Endometriosis , adenomyosis, or Fever and pelvic pain: Tubo-ovarian abscess Postmenopausal bleeding: Increased suspicion of uterine cancer Hormonal effects, such as precocious puberty, virilization, or abnormal uterine bleeding: A masculinizing or feminizing ovarian tumor During the general examination, the examiner should look for signs of nongynecologic (eg, gastrointestinal, urologic, endocrine) disorders and for ascites. If malignancy is suspected, evaluation for groin or supraclavicular lymphadenopathy is indicated. A complete gynecologic examination is done. Distinguishing uterine from adnexal masses may be difficult. If ectopic pregnancy is suspected, excess pressure during examination is avoided to prevent rupture. Advanced endometriosis can manifest as nonmobile cul-de-sac masses. Cervical motion tenderness occurs in pelvic infection (and appendicitis). Nonmobile masses may be inflammatory (eg, due to endometrioma, hydrosalpinx, or tubo-ovarian abscess) or malignant. Hydrosalpinges are usually fluctuant, tender, nonmobile, and sometimes bilateral. In early pregnancy or in young girls, pelvic organ masses may be palpable in the abdomen because the space in the pelvis is too small to contain a large mass. If women of reproductive age have a pelvic mass, a pregnancy test should be done regardless of menstrual or sexual history. If a pregnancy test is positive, Ultrasonography or another imaging test is not always necessary; imaging is necessary when pelvic pain or vaginal bleeding is present. If a suspected mass is not detected during examination or the cause cannot be determined, an imaging test is done. Usually, pelvic ultrasonography is done first. 3 menstrual cycles or are accompanied by moderate to severe pain ( Evaluation references ). The International Ovarian Tumor Analysis (IOTA) group developed the Simple Rules to preoperatively assess risk of cancer in women who have ovarian or other adnexal tumors that are thought to require surgery. Classification is based on the presence or absence of 10 ultrasound features and has a higher sensitivity and specificity than other classification scores. In 2016, the IOTA Simple Rules were updated to include a risk calculation tool (SRrisk), which can be used on mobile devices ( Evaluation references ). If ultrasonography does not clearly delineate size, location, and consistency of the mass, another imaging test may do so. MRI is typically used for further evaluation of the mass; CT is useful for evaluating suspected metastases. Radiographic characteristics that suggest cancer include a solid component (particularly those with a blood supply), thick septations, surface excrescences, ascites, and additional intraabdominal masses. Suspected adnexal masses are evaluated with surgical exploration because biopsy may spread malignant cells. Tumor markers may help in the Tumor Immunodiagnosis . Suspected uterine masses may be evaluated with endometrial biopsy and/or surgical exploration. 