Adnexal Masses in Adolescents
The prevalence of adnexal masses in adolescents is unknown. Of those adnexal masses requiring surgical intervention in specialty care centers, 7-25% are malignant in pediatric and adolescent ages combined, with germ cell tumors being the most common.
The differential diagnosis includes:
- Ovary: functional cysts (follicular, corpus luteum); endometriosis; benign neoplasms (teratomas, serous and mucinous cystadenoma); malignant neoplasms (germ cell, sex-cord or stromal tumor, epithelial carcinoma); torsion
- Tube: tubo-ovarian abscess, hydrosalpinx, ectopic pregnancy, paratubal cyst, torsion.
- Vagina/Uterus: Anomalies (obstructing longitudinal vaginal septum, Mullerian anomalies, imperforate hymen)
- Gastrointestinal: appendiceal abscess
- Other: Peritoneal inclusion cysts, pelvic kidney
Adolescents with adnexal masses can present with symptoms, although even large masses may be asymptomatic. Acute pain may suggest a ruptured or hemorrhagic ovarian cyst, ovarian torsion, ectopic pregnancy, or tubo-ovarian or appendiceal abscess. Nausea and vomiting with acute or intermittent pain may occur with torsion. Other symptoms of adnexal masses may include abdominal distention or endocrine manifestations such as precocious puberty, uterine bleeding, amenorrhea, or virilization. Menstrual cycle, sexual activity, contraceptive practices and potential exposure to sexually transmitted infections should be confidentially discussed.
Pelvic examination may not be appropriate in adolescents who are not sexually active or in those with severe pain. The adnexa may be palpated on bimanual exam via the rectum. Initial laboratory testing must include βhCG. Other relevant laboratory testing may include CBC, gonorrhea and chlamydia, and tumor markers (CA 125, βhCG, alpha fetoprotein, and lactate dehydrogenase). Imaging would typically start with ultrasound; MRI or CT may be required. Ultrasound can be transvaginal or transabdominal, with the latter preferred in patients who are prepubertal or not sexually active. Morphologic scoring systems to assess malignant potential may be used, but have not been validated in adolescents. Ultrasound findings of a sonolucent cyst with smooth walls and the absence of thick septations or solid components indicate a low risk of malignancy. MRI is the preferred imaging modality after an initial ultrasound for suspected vaginal and uterine anomalies.
Management of asymptomatic functional cysts up to 10 cm may be expectant with serial ultrasound imaging. Oral contraceptives do not hasten resolution of existing cysts but may prevent new ones from forming. Patients with suspected hemorrhagic cysts should be followed expectantly if clinically stable and the pain can be managed medically. Torsion requires prompt surgical intervention for reduction of the torsion with concomitant ovarian cystectomy for identified pathology to preserve ovarian function. Additional adnexal pathology is found in over half of patients with the diagnosis of torsion. A gynecologic oncologist should be involved when imaging and laboratory testing suggests malignancy. A hydrosalpinx may be managed expectantly if it has the characteristic ultrasound appearance of a sonolucent, elongated, extraovarian structure. Paratubal and inclusion cysts appearing as extraovarian, sonolucent structures may also be followed with serial ultrasound imaging. If surgical intervention is needed, attempt should be made to use minimally invasive techniques and preserve ovarian function if possible. Anomalies resulting in menstrual outflow obstruction are managed surgically.
American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins—Gynecology. Practice Bulletin No. 174: Evaluation and Management of Adnexal Masses. Obstet Gynecol. 2016 Nov;128(5):e210-e226. doi: 10.1097/AOG.0000000000001768. PMID: 27776072.
Levine D, Brown DL, Andreotti RF, et al.; Society of Radiologists in Ultrasound. Management of asymptomatic ovarian and other adnexal cysts imaged at US Society of Radiologists in Ultrasound consensus conference statement. Ultrasound Q. 2010 Sep;26(3):121-31. doi: 10.1097/RUQ.0b013e3181f09099. PMID: 20823748.
Kelleher CM, Goldstein AM. Adnexal masses in children and adolescents. Clin Obstet Gynecol. 2015 Mar;58(1):76-92. doi: 10.1097/GRF.0000000000000084. PMID: 25551698.
Initial approval May 2009; Revised 2/2015; Reaffirmed 7/2016, Revised November 2017; Reaffirmed May 2019, Revised March 2022
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