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Psoriasis: Recognition and Management Strategies
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Adnexal Masses: Diagnosis and Management

Vernon Wheeler, MD
Blade Umstead, DO
Christina Chadwick, DO, MS

American Family Physician. 2023;108(6):580-587.

Author disclosure: No relevant financial relationships.

Pelvic masses occur in up to 20% of women throughout their lifetime. These masses represent a spectrum of gynecologic and nongynecologic conditions. Adnexal masses—found in the fallopian tubes, ovaries, and surrounding areas—are mostly benign. Evaluation includes assessment for symptoms that may suggest malignancy, such as abdominal pain, abdominal bloating, and early satiety. A family history of ovarian, breast, or certain heritable syndromes increases the risk of malignancy. For women of reproductive age, ectopic pregnancies must be considered; a beta human chorionic gonadotropin level should be obtained. Transvaginal ultrasonography is the imaging test of choice for evaluating adnexal masses for size and complexity. Adnexal cysts that are greater than 10 cm, contain solid components, or have high color flow on Doppler ultrasonography are high risk for malignancy. Further imaging, if warranted, should be completed with computed tomography or magnetic resonance imaging, particularly if there is concern for disease outside the ovary. Multimodal assessment tools that use ultrasonography and biomarkers, such as the risk of malignancy index, are useful in the diagnosis and exclusion of malignant causes. Asymptomatic masses that are determined to be benign may be observed and managed expectantly. In symptomatic or emergent cases, such as ectopic pregnancy or ovarian torsion, a gynecologist should be consulted. In any adnexal mass with high risk for malignancy, a consultation with gynecologic oncology is indicated.

Pelvic masses occur in up to 20% of women during their lifetime and can arise from gynecologic or nongynecologic etiologies.1,2 The adnexa are a group of structures adjacent to the uterus, which includes the ovaries and fallopian tubes. Although the most common sources of adnexal masses are benign, such as luteal cysts and polycystic ovaries, masses can also have malignant causes, such as epithelial ovarian carcinoma or other cancers metastatic to the ovary. Potentially fatal adnexal masses include ectopic pregnancies, pelvic inflammatory disease, and tubo-ovarian abscesses3–6 (Table 14–7 ). This article reviews the evaluation and management of adnexal masses in women and other people assigned female sex at birth.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating Comments
Screening for ovarian cancer is not recommended in asymptomatic women who are not at high risk.14 A U.S. Preventive Services Task Force recommendation statement based on consistent, large randomized controlled trials showing no mortality benefit and harm from frequent false-positive results
Transvaginal pelvic ultrasonography is the imaging test of choice for evaluation of adnexal masses.2 C Consensus statement based on equivalent sensitivity to computed tomography and magnetic resonance imaging
Patients with an adnexal mass who have an elevated cancer antigen 125 level, high-risk ultrasound findings, or any other concern for ovarian malignancy should be referred to a gynecologic oncologist.2 C Consensus, expert opinion
Asymptomatic and nonsuspicious adnexal masses found during pregnancy can be safely managed through observation because most of the masses self-resolve or regress and have low risk of malignancy.42,46 C Consensus, expert opinion and limited patient-oriented data

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

Vernon Wheeler, MD, FAAFP, BCFMO, is co-director for the family medicine obstetrics faculty and research in the Carl R. Darnall Army Medical Center Family Medicine Residency Program, Fort Hood, Tex.; an assistant professor in the Department of Family and Community Medicine at the Uniformed Services University of the Health Sciences, Bethesda, Md.; and a clinical assistant professor at Texas A&M University Health Science Center College of Medicine, Temple, Tex.

BLADE UMSTEAD, DO, is a resident in the Carl R. Darnall Army Medical Center Family Medicine Residency Program.

CHRISTINA CHADWICK, DO, MS, RDMS, is family medicine faculty and the Point of Care Ultrasound (POCUS) Director in the Carl R. Darnall Army Medical Center Family Medicine Residency Program.

Address correspondence to Vernon Wheeler, MD, Carl R Darnall Army Medical Center, 36065 Santa Fe Ave., Fort Hood, TX 76544 (vernon.l.wheeler8.civ@health.mil). Reprints are not available from the authors.

Author disclosure: No relevant financial relationships.

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