How to Apply New Guidelines for Evaluating Adnexal Masses

Andrew M. Kaunitz, MD


November 30, 2016

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Hello. I'm Andrew Kaunitz, professor and associate chair in the department of obstetrics and gynecology at the University of Florida College of Medicine in Jacksonville. Today, I'd like to discuss new guidance from the American College of Obstetricians and Gynecologists (ACOG) regarding evaluation of adnexal masses.

As more women undergo imaging of the abdomen and pelvis, we increasingly encounter patients with a diagnosis of adnexal mass. In this video, I highlight several points made by a new practice bulletin from the ACOG[1]:

  • Vaginal ultrasound, rather than computed tomography or magnetic resonance imaging, should be chosen as the first approach for imaging adnexal masses. An abdominal approach should be used when vaginal imaging is not appropriate, such as for virginal patients, those with severe atrophic changes, and masses that extend beyond the pelvis. Assessment of vascular flow with Doppler often provides useful information. Red flags for malignancy include papillary or solid projections within a cyst, irregularity, substantial flow with Doppler, and ascites.

  • When a mass is identified, serum testing can provide information that helps assess risk for ovarian malignancy. Because CA-125 assessment is associated with a high prevalence of false-positives in premenopausal women, measuring this serum marker in premenopausal women is often not useful. However, in postmenopausal patients with an adnexal mass, an elevated CA-125 level should prompt referral to a gynecologic oncologist. In pre- and postmenopausal women with adnexal masses, a multivariate index assay as well as the Risk of Ovarian Malignancy Algorithm can identify malignancies with greater sensitivity and specificity than CA-125 alone. A positive score with either of these risk assessment panels should, again, prompt referral to a gynecologic oncologist.

  • Simple cysts, hydrosalpinges, endometriomas, and mature cystic teratomas or dermoids represent benign cystic adnexal masses commonly imaged in premenopausal women. These types of masses often can be definitively diagnosed via ultrasound. When asymptomatic, these masses can be managed expectantly with serial sonographic follow-up. In premenopausal women, dominant follicles are 3 cm or less in diameter, whereas simple ovarian cysts are larger than 3 cm. In postmenopausal women, this threshold is 1 cm.[2] Simple cysts, which often regress, have thin, smooth walls and no septations, solid component, or flow noted with Doppler. In women with dermoids or endometriomas, surgery should be considered if the masses are large, grow during sonographic follow-up, or are symptomatic.[1]

Fortunately, the great majority of adnexal masses found with imaging are benign, and most are asymptomatic. Our challenge as women's health clinicians is to not overreact to imaging findings and facilitate appropriate surgery for the relatively small number of patients for whom it is indicated. This new guidance from ACOG will help us achieve these goals.

Thank you for taking the time to view this video. I am Andrew Kaunitz.


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