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Benign Disorders of the Ovaries

When disorders of the ovaries are detected, the characteristics of the mass, the age at presentation, and the patient's desire for preservation of fertility help to determine the diagnosis and subsequent therapy. A pelvic mass must be differentiated as genital or extragenital in origin. Most genital masses, especially in reproductive-age women, are benign; however, malignancy should always be excluded.

PREMENARCHAL FEMALE

Malignancies and ovarian masses are rare in childhood, but when a pelvic or ovarian mass occurs in a young girl, it should be evaluated for malignancy. Although older studies reported that approximately 80% of tumors in girls younger than 9 years old and 35% of all tumors in children and adolescents were malignant (60% of which were germ cell tumors), more recent studies have shown that functional masses may occur in both fetuses and young girls. In one study of girls younger than age 10, only 60% of the masses proved to be neoplasms, and two thirds of those were benign. Imaging studies may be helpful in assessing a mass.

In children, a pelvic mass quickly becomes abdominal in location due to the small size of the pelvis. The child most commonly presents with acute abdominal pain. A pelvic examination often is difficult in this age group.

Transabdominal ultrasonography is probably the most useful diagnostic tool in this age group. As in postmenopausal women, simple unilocular cysts of small size are almost always benign and do not require surgical intervention. Observation over a period of 2-3 months is appropriate. However, these cysts tend to float in the abdominal cavity and may subsequently undergo torsion, giving rise to acute abdominal pain. In some cases, imaging with Doppler flow may aid in the diagnosis, although the advantages of this technique remain somewhat unclear.

POSTMENARCHAL/ADOLESCENT

In general, the postmenarchal/adolescent woman is subject to the same variety of pelvic masses as the older reproductive-age woman, including uterine, adnexal, and extragenital masses. The ratio of functional adnexal masses to malignancy in the postmenarchal/adolescent woman is greater than that in the premenarchal girl. Also, at the time of the initial onset of menses some genital anomalies may become apparent, such as the appearance of a pelvic mass.

Functional occur frequently. They may be found incidentally, present as acute abdominal pain due to torsion and ischemia, or rupture with peritoneal irritation.

Adolescents have the highest rate of pelvic inflammatory disease. Therefore, the possibility of a sexually transmissible infection and an inflammatory adnexal mass should be considered in the adolescent female presenting with pelvic pain or a mass. The classic findings of cervical motion tenderness and uterine, adnexal, and lower abdominal pain, coupled with an elevated temperature.

Pregnancy in a postmenarchal female should be a primary consideration in any patient presenting with a pelvic mass. This group is also at risk for ectopic pregnancy, which may present as a pelvic mass accompanied by pain.

In the postmenarchal/adolescent female, as in the premenarchal female, unilateral, unilocular cystic masses of small size may be managed conservatively because the tumors are not likely to be malignant. However, large, growing, solid, or multilocular masses require surgical evaluation. Management should emphasize conservation of the ovary if at all possible. Even the presence of an apparent malignancy may be managed by unilateral oophorectomy in selected cases. Likewise, the management of inflammatory masses may be conservative, using aggressive antibiotic therapy. Surgical management may include unilateral removal of an abscess with irrigation and drainage in an attempt to preserve childbearing potential.