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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

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; therefore, abdominal examination and supplementary studies are the mainstay of diagnosis ovary, mass, ovarian mass, enlarged, tumor, adnexal mass, overy.

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

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. This presentation includes a wide range of anomalies including imperforate hymen and noncommunicating upper müllerian systems.

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

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

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

REPRODUCTIVE-AGE WOMEN

The woman of reproductive age is subject to the widest range of pelvic masses. In this age group, the frequency of pelvic masses is difficult to determine since many patients never undergo surgery. Early reproductive-age women are at low risk for malignancy from pelvic masses, comprising only 10% of one group studied at laparotomy. Most adnexal masses in women less than 30 years old are functional cysts, benign cystic teratomas, or endometriomas.

While most ovarian tumors are asymptomatic, when symptoms are present they may include bloating or non-specific pain that mimics gastrointestinal colic. The same generalizations that apply to masses in adolescents remain true in reproductive-age women. Those masses that are less than 6 cm, unilocular,

Functional ovarian tumors comprise the largest group of adnexal and ovarian masses in reproductive-age women. They may be found accidentally or may be associated with acute abdominal pain due to torsion. Follicular cysts are usually thin walled with clear fluid, have a maximum diameter of 5-6 cm, and regress spontaneously within 1-3 months. Surgical intervention is necessary for persistent large cysts or rupture that causes acute symptoms. Microscopically, these cysts are lined by a single layer of granulosa or theca cells.

In the past, a trial of oral contraceptives has been suggested to suppress ovarian function while these functional cysts are observed for regression. More recent studies have questioned this philosophy. No

Polycystic ovaries are the most common cause of bilateral follicular cysts. Individuals with this condition commonly present with dysfunctional bleeding secondary to infrequent ovulation. Corpus luteum cysts are less common, but may give rise to significant symptoms because of their larger size or intraperitoneal

Theca lutein cysts are the least common of the functional cysts, although they are almost always bilateral and may attain large size. The histologic picture reflects hyperstimulation by hCG. Iatrogenic stimulation of

Most benign neoplastic adnexal masses in this age group are of three varieties (Table 2). Benign cystic teratomas comprise the most common neoplasm in the reproductive years, accounting for 62% of ovarian neoplasms in one series of women under 40 years of age undergoing a laparotomy for a pelvic mass. Of these cysts, 80% occur pre-menopausally. Malignant dermoid transformation is rare (<2%) and is usually squamous in origin. Patients with dermoids may present with acute abdominal pain more frequently than

Epithelial tumors are the other major group of benign tumors in the reproductive-age group. Serous cystadenomas comprise 20% of all ovarian neoplasms and probably arise from invagination of the surface epithelium. They are usually large and unilocular, with a cyst wall comprised of a single layer of cuboidal epithelium. About 80% are benign.

Mucinous tumors are usually larger than serous tumors and less often bilateral. The cyst lining is usually smooth, although papillary projections may be seen. Cell types resembling endocervix and gastrointestinal

Uncommon benign ovarian masses include varieties of endometrioid tumors, mesonephroid tumors, Brenner tumors, and benign tumors of stromal origin. The diagnosis of an ovarian mass in a woman in this age group

Uterine leiomyomata are the most common uterine masses and are usually recognized on pelvic examination. Submucosal and intramural fibroids may distort the external contours of the uterus. Pedunculated, subserosal, broad-ligament, and parasitic fibroids may simulate adnexal masses. They often present asymptomatically but on occasion cause acute pain. Inflammatory masses comprise the other common nonneoplastic adnexal masses. Included in this group are tuboovarian abscesses.

Surgical intervention for benign neoplasms should include preservation of fertility and techniques to decrease the potential for postoperative adhesions. An elliptical incision can be made over the most dependent area of

POSTMENOPAUSAL ADNEXAL MASS

Proper identification and therapy of the adnexal mass in the postmenopausal female remains a challenge. The overall risk of malignancy in an ovarian cyst is 13% in a premenopausal woman and 45% in a postmenopausal woman. A benign serous cystadenoma is the most common post-menopausal adnexal mass.

With the development of sensitive ultrasonography, the discovery of an incidental small ovarian mass proves to be a diagnostic and therapeutic problem. Many years ago, the concept was proposed that any ovary that is palpable in the postmenopausal woman is abnormal and should be removed. Unfortunately, body habitus

There is controversy concerning the use of tumor markers such as CA 125 as either screening tools or routinely preoperatively. CA 125 is a monoclonal antibody raised as an immunogen to an ovarian cancer cell line. It is expressed by normal tissues of müllerian origin in the pre-menopausal female, which limits its usefulness in that age group. The antibody is detectable in 80% of serous tumors, but less often in mucinous tumors. However, only 50% of patients with stage I disease test positive for CA 125; therefore, the test often fails to detect treatable cases. Only about 2% of women with an elevated CA 125 level have ovarian cancer when the CA 125 marker is used as a screening tool. Currently, its usefulness is limited to follow-up of those tumors found to have an elevated CA 125 level before surgery.

Initial exploration with the laparoscope is appropriate in those women with masses that have benign screening characteristics. Intraoperatively, the mass should be carefully inspected for adhesions and su