According to Researchers, about twenty percent of women will experience a pelvic mass in their lifetime. Most masses present doctors with challenges in diagnosis as well as management. If you have a pelvic mass, your doctor should first check if your mass is gynecological, whether it’s malignant or benign before coming up with the management option. All Women’s Care has shared the article below that seeks to assist you in understanding how different types of masses are diagnosed and managed. For many years, we have served and empowered women of all religions, races, ages, backgrounds, and sexual orientations in Los Angeles.

What are Pelvic Masses?

A pelvic mass is also known as an adnexal mass. It is a growth that happens near or in the fallopian tubes, ovaries, uterus, and connecting tissues. While they are often benign, they can be cancerous.

While some have fluid, others are solid. Usually, medical experts are more concerned about solid masses. Most of the pelvic masses do not require treatment. It is because they resolve on their own after a couple of menstrual cycles.

An adnexal mass can happen to any woman irrespective of age.

Common Symptoms of Adnexal Masses

Often adnexal masses patients experience no signs and symptoms. These symptoms are discovered by pelvic examination. However, a pelvic mass can occasionally lead to the following symptoms:

  • Painful periods
  • Abnormal bleeding from your uterus
  • Abnormally heavy bleeding during periods
  • Severe pelvic or abdominal pain which is on one side
  • Abdominal symptoms such as loss of appetite, constipation, nausea, vomiting, increased abdominal size, fullness feeling, bloating
  • Urinary or incontinence frequency and urgency
  • Loss of energy
  • Weight loss
  • Fever
  • Fatigue
  • Vaginal discharge

The question of whether the symptoms manifest depends mainly on the size of your pelvic mass. Because the above symptoms appear due to different conditions, it is essential to seek medical attention.

What Causes Pelvic Masses

Adnexal masses have numerous conditions that vary in seriousness from benign growths to malignant tumors. The causes can be either non-gynecological or gynecological. Common causes include:

  • Ovarian cysts- An ovarian cyst is a fluid-filled sac that develops on an ovary. They are painless, and patients do not experience symptoms.
  • Ovarian cancer- Ovarian cancer occurs when abnormal cells in an ovary multiply, forming a tumor. The tumor can grow and spread to other body parts. Some of the symptoms of ovarian cancer include fatigue, heartburn, back pain, constipation, painful sexual intercourse, irregular periods, and indigestion.
  • Benign ovarian tumor- Ovarian tumors are the abnormal growth of cell or lump. Unlike the cysts, they have fluid. If the cells in the ovarian tumor are not cancerous, the tumor is a benign tumor. That means the tumor will not spread to or invade surrounding tissues. Based on the tumor's size, you may or not experience symptoms.
  • Ectopic Pregnancy- This type of pregnancy occurs when fertilized eggs are implanted in the oviduct instead of the uterus. Normally, ectopic pregnancies do not grow to maturity. If the fertilized ovum continues growing in your fallopian tube, your tube will rupture and result in heavy bleeding. It can also lead to internal bleeding and severe and sudden pain. If left untreated, an ectopic pregnancy might be fatal.
  • Pelvic inflammatory disease- It happens due to an infection. It is an inflammation of the upper genital tract that includes ovaries, uterus, and oviduct.
  • Ovarian torsion- It is an emergency that involves a partial or complete rotation of tissues that support your ovary, which stops blood flow to the ovary.
  • Tubo-ovarian abscess- It is an infectious mass that forms due to pelvic inflammatory ailment.
  • Fibroid
  • Paratubal cyst

Risk Factors

Risk factors hinge on what caused the mass. Patients with ovarian masses are more likely to suffer from ovarian torsion. According to research conducted by Ci Huang, Dah-Ching Ding, and Mun-Kun Hong, approximately eighty percent of ovarian torsion patients have pelvic masses at least 5 cm.

According to Ashley M. Florence and Mary Fatehi, medical experts detect fibroids in around seventy percent and eighty percent of white women and black women, respectively, before they are fifty years of age. Other factors that can increase the risk of suffering from fibroids include:

  • A high BMI (body mass index)
  • Taking contraceptives before attaining sixteen years
  • Starting periods early in life

Ovarian cancer is hereditary. That means if you have a family history of ovarian cancer, you are more likely to develop ovarian cancer. Other risk factors are:

  • Obesity
  • Endometriosis
  • Inherited genetic changes
  • Tall height
  • Hereditary nonpolyposis colorectal cancer
  • Postmenopausal hormonal therapy

Additionally, according to the National Cancer Institute, the risk of suffering from cancer increases with age.

Management of Pelvic Masses

Your doctor will decide the best treatment and management option depending on the cause of your mass. The management of masses also depends on the:

  • Mass etiology
  • Mass location
  • Patient's characteristic

Generally, there are three management options:

  • Surgery- It is done when your mass is symptomatic, or malignancy is a concern (there are numerous risks related to the mass like infection and torsion). If you have an ovarian mass, your doctor will perform an ovarian cystectomy or oophorectomy. When it comes to other types of pelvic masses, the mass could be resected or biopsied.
  • Expectant management- Expectant management is used when the pelvic mass is benign, and there is no need for surveillance, surgery, or further follow-up.
  • Continued surveillance- It is used when the suspicion of malignancy is low, but it hasn't been excluded. Usually, it involves the measurement of serum tumor markers and consecutive pelvic ultrasounds.

Adnexal Mass Management in Pregnancy

A pelvic mass should be discovered and treated before a woman becomes expectant. That way, the mother does not experience complications. However, pelvic masses are sometimes discovered during pregnancy when having a pelvic examination or routine ultrasound.

Usually, a pelvic examination, ultrasound, and laparoscopy diagnose adnexal masses. If a patient is not showing symptoms, the growth is discovered at the routine exams.

A laparoscopy is a slim, telescope-like gadget that is inserted through a tiny incision below or in the navel. It permits your doctor to view the pelvic organs. During an ultrasound, an electronic gadget is put in the patient's vagina or moved on the abdomen, creating echoes that are transformed into organs' images for viewing.

After the diagnosis, the specialist will determine if the condition is an emergency. In most cases, if it is not, the doctor will investigate the cause of your mass and the most effective cause of action.

Laboratory tests and imaging could be used to tell the cause of the mass. Moreover, the doctor will conduct a pregnancy test to dismiss an ectopic pregnancy. It is because it will require immediate medical attention.

The differential adrenal mass diagnosis is extensive and include:

  • Endometrioma
  • Cystadenoma
  • Luteoma
  • Pedunculated leiomyoma
  • Mature teratoma
  • Germ cell
  • Sex cord
  • Follicular cysts

While most masses are benign, a few are malignancies.

Additionally, if you experience pain diagnoses like heterotopic pregnancy, torsion, ectopic pregnancy, and degenerating fibroid should be put into account.

Management

As previously mentioned, most of the pelvic masses experienced by expectant mothers are benign. Usually, they are five cm in diameter.  Masses detected during the first-trimester resolve by the second trimester.

Generally, masses experienced following the first trimester and which are:

  • above 10 cm in diameter,
  • solid or have cystic and solid areas or have papillary parts,

are managed surgically.

It is because these characteristics increase the danger of complications like labor dystocia, adnexal torsion, or rupture or malignancy.

An adnexal mass without the above characteristics often resolves during the pregnancy.

The ideal time for surgery is after your first trimester because organogenesis is complete. Consequently, lowering the danger of teratogenesis and necessary oophorectomy or cystectomy will not interfere with progesterone production of corpus luteum.

Preoperative Assessment

Often, imaging using ultrasound is enough for preoperative assessment. However, more imaging is sometimes required for mass characterization. Imaging with magnetic resonance imaging (MRI) is the preferred option because it doesn't expose the fetus and the mother to ionizing radiation and has a good resolution.

If malignancy during pregnancy is a concern, drawing a serum tumor marker before surgery isn't recommended. Oncofetal antigens like CA 125 (cancer antigen 125), human chorionic gonadotropin, and carcinoembryonic antigen are elevated at the time of gestation hence becoming poor malignancy markers. In case malignancy is diagnosed, then a tumor marker can be acquired postoperatively.

Surgery and Prognosis

In case there is low malignancy suspicion, a laparoscopic technique is the most reasonable and preferable approach at different stages of your pregnancy. However, the early second trimester is the best. To reduce the risk of uterine hurt, entry at Palmers' point should be in the left quadrant.

If malignancy is present, maximum exposure must be acquired using a midline vertical incision. A peritoneal washing can be acquitted after entering your peritoneal cavity. Also, contralateral ovary must be examined alongside an abdominopelvic surgery. If your mass shows concerning characteristics like the existence of ascites, your specimen ought to be sent for intraoperative frozen pathology. If the malignancy exists, a full staging technique is performed, and an OBGYN consulted.

In a study with 101 participants, thirty-one percent of pelvic masses in expectant mothers greater than fourteen weeks gestation were teratomas. In the study, while roughly half of the patients had invasive surgery, the other half underwent surgery through laparotomy. Women who underwent laparotomy had more complications, and there weren't any variations between the two groups concerning neonatal and pregnancy results. 

For patients with simple-appearing pelvic masses on ultrasound, reimaging might happen during the postpartum period. You should be given rupture and torsion precautions during your pregnancy. Be sure to consult a gynecologist if you have more concerning characteristics of ultrasound.

Ovarian Masses

Discussed below is ovarian mass management according to the possibility of malignancy and clinical presentation.

Uncertain Etiology or an Alleged Malignancy

Excluding the possibility of malignancy is the primary goal of a pelvic mass evaluation. If you have a mass that is alleged to be malignancy after your initial evaluation, surgical exploration is necessary.

Surgical evaluation is the standard approach to pelvic masses evaluation. It is because there are no non-invasive techniques for ovarian cancer diagnosis. However, this technique causes most patients to undergo surgery. For instance, an ovarian cancer screening trial conducted by Ryan A, Menon U, Jacobs IJ, et al. discovered that for every peritoneal or ovarian cancer detected using an ultrasound, an additional ten patients underwent surgery for benign or normal pathology. Nevertheless, ovarian cancer prognosis is poor unless the condition is treated early.

Assessing the Risk

One of the essential factors used to determine the suspicion of malignancy of a mass is the mass' appearance on imaging.

Ultrasound morphology related to malignancy includes thick septations and nodularity or solid components. Based on ultrasound morphology, masses can be classified into the risk groups below:

  • High risk
  • Low risk
  • Intermediate risk

Previously, the size of a pelvic mass was deemed useful, with large masses considered to be malignant. Although most ovarian malignancies are big, this relationship is yet to be confirmed. According to Brown DL, Doubilet PM, Miller FH, et al. there isn't a significant variation in size between benign and malignant masses.

Also, the size of a mass does matter for the risk of development of torsion, rupture, and symptoms. The larger the mass, the less sure the doctor is about the mass' content.

Other factors that increase the extent of suspicion include risk factors, symptoms, elevated tumor marker, and menopausal status.

Please remember this discussion provides a general framework of surgery indications. A patient's management depends on the clinical judgment and clinical characteristics of the patients. If you are not sure about the best management option, a gynecologist ought to be consulted.

Patients with a family history of ovarian cancer are managed differently from the general population. Adnexal mass in these women is a sign of surgery.

Management Options

Surgical procedures for pelvic masses could be performed using either:

  • Laparotomy
  • Laparoscopically (robotic or conventionally)

The surgical technique used depends on the surgeon, your preference, and the extent of suspicion of malignancy. While ovarian cancer screening could be performed with laparoscopic, most surgeons prefer laparotomy. Typically, if the suspicion level of malignancy is moderate or low, a laparoscopic technique is employed.

When selecting the surgical technique for malignancy, it's essential to understand that it's unclear if laparoscopy is as sensitive as laparotomy as far as detection of a tiny metastatic implant in the epigastrium and bowel mesentery is concerned.

The surgical method used should reduce the possibility of tumor disruption. In the event malignancy is alleged, oophorectomy is needed. Women with early-stage ovarian cancer benefit from the pelvic mass intact removal. It is because opening the pelvic mass affects prognosis negatively and leads to an advanced stage. Additionally, each attempt should offer your doctor with a specimen with your intact cortex.

In case the laparoscopic technique is employed, your ovary will be put in a tissue recovery bag. In case your specimen is huge to be removed through an existing incision, the incision could be enlarged, or cyst fluid could be aspirated.

Morcellating your ovarian mass in a bag is not recommended since it can compromise pathology analysis. Generally, cyst contents aspiration is not recommended as the primary surgical intervention. It is because there is a high likelihood of recurrence, cyst fluid cytology is unreliable for malignancy exclusion, and no tissue is acquired for histopathology.

For premenopausal patients, ovarian cystectomy is advisable. However, it is only possible if the malignancy suspicion is low, there is no proof of metastatic ailment, and the mass is benign.

Surveillance

If your potential for ovarian cancer is low but hasn't been excluded, surveillance with consecutive serum tumor markers and pelvic ultrasounds can be the most effective management option.

It is paramount to inquire from your doctor of what size or morphologic changes will lead to surgery and if surveillance will be discontinued if there aren't substantial changes. Throughout the surveillance period, if your mass size increases to above ten cm, develops malignancy features, or the CA 125 is above 35 U/ml, your doctor will stop surveillance. If the mass reduces to size or remains unchanged, surveillance goes on until the anticipated stopping point is attained.

For postmenopausal patients:

  • Low-risk pelvic masses- Your doctor will conduct a CA 125 and ultrasound in 3 (three) months and after six months.
  • Intermediate risk pelvic mass- The doctor will conduct a CA 125 and transvaginal ultrasound in six weeks and then conduct other tests every three months for one year. Then a final test is conducted a year later.

For premenopausal patients:

If the patient has a low-risk mass, the doctor will conduct ultrasounds in three months and then after six months.

When it comes to intermediate-risk pelvic masses, an ultrasound is repeated after six weeks. It permits visualization of the pelvic mass at different points of your menstrual cycle. Then the test is repeated in 3 months and then after 6 (six) months. A final test is done after a year.

Management of Masses Caused by Pelvic Inflammatory Disease

The main treatment of the condition in question is antibiotics. Since more than one organism causes pelvic inflammatory disease, at least two antibiotics could be essential.

The antibiotics could be taken through veins (intravenously) or oral. If you take oral antibiotics, be sure to finish your medication, even when the symptoms disappear. It is because the infection may still be present after the symptoms go away.

Make sure you tell your physician about your progress, three days after starting the treatment. If the condition isn't improving, revisit the medical expert, and have another examination. The doctor may choose to conduct a computed tomography scan or an ultrasound to check if you have an abscess. If it exists, surgery could be an option.

Treatment and Management of Masses Due to Ovarian Torsion

Surgery is the most effective treatment option. Moreover, your doctor could prescribe medication to reduce nausea and pain before the procedure.

More often than not, the doctor will recommend undergoing the procedure as soon as possible. If the condition prevents blood flow for long, the ovarian tissue can die, and the ovary should be removed.

The doctor will perform the surgery with a laparoscopy (it involves making tiny incisions in your abdomen). Your specialist will insert numerous medical instruments like video cameras into your pelvic and abdomen and try to untwist your ovary.

If the doctor can't see your ovary clearly, they will perform an open procedure. In other words, the doctor will make a big incision under your navel, exposing your ovary and untwisting it.

You can go back to your home the same day following the procedure. Nevertheless, the specialist will monitor your ovary to make sure that it has adequate blood flow. If the ovary shows tissue death signs, it will be removed later.

The medical expert may also recommend follow-up care like avoiding physical activity or heavy lifting for a couple of weeks.

You should contact your doctor immediately you experience complications or one of the following signs of infections:

  • Fever
  • Inflammation and redness at the incision areas
  • Foul-smelling discharge
  • Severe pelvic pain
  • A wound that doesn't heal

Paratubal Cyst Management

Also called a Paraovarian cyst, a Paratubal cyst is a fluid-filled sac. It forms near the fallopian tube or ovary and does not adhere to internal organs.

These cysts are tiny and range from two to twenty millimeters in diameter. They are usually discovered during unrelated surgery or gynecological examinations.

A ruptured, twisted or large Paratubal cyst can lead to abdominal or pelvic pain.

If the cyst is tiny and asymptomatic, the doctor might recommend a surveillance approach. You will be required to undergo periodic checkups to monitor any changes.

If the cyst is bigger than ten cm, the doctor will recommend removal irrespective of whether you are experiencing symptoms or not. The procedure is known as a cystectomy. The OBGYN can use either laparoscopy or laparotomy. The doctor will consider the cyst's location, size, or condition before recommending the best procedure.

Find an Experienced OBGYN Near Me

The above discussion on the management of pelvic mass is purposed to trigger a conversation with an experienced gynecologist in Los Angeles. The specialist will be in a position to explain to you the different management options depending on the root cause. If you want to speak to an OBGYN, All Women’s Care is ready to answer all your questions and address your concerns. Call us today at 213-250-9461 to book your initial consultation.