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5/1/2009

Adnexal Masses in Adolescents

Author: Robert S. Schenken, MD

Editor: Eduardo Lara-Torre, MD

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The prevalence of adnexal masses in adolescents is unknown.  While the diagnosis of a “ruptured ovarian cyst” is common for adolescents presenting with abdominal and pelvic pain, often this default diagnosis represents only the ultrasound findings of a normal cystic follicle and does not truly explain the pain.  Less than 25% of ovarian neoplasms in adolescents are malignant.

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.  Abdominal pain may be due to torsion, cyst rupture, or hemorrhage into a cyst and/or abdominal cavity.  Other symptoms may include abdominal distention or endocrine manifestations such as precocious puberty, uterine bleeding, amenorrhea, or virilization. Cyclic pain could suggest other conditions and should be investigated based on presentation.  Nausea and vomiting with acute or intermittent pain may occur with torsion.  Acute pain may suggest a ruptured or hemorrhagic ovarian cyst, ectopic pregnancy, or tubo-ovarian or appendiceal abscess.  Their menstrual cycle, sexual activity, contraceptive practices and sexually transmitted infections exposure should be discussed and confidentiality obtained.

Pelvic examination may not be appropriate or revealing in adolescents who are not sexually active or those with severe pain.  It may be possible to palpate the adnexa on rectal examination.  Initial laboratory testing must include βhCG, as adolescents may not acknowledge consensual or non-consensual sexual activity.  Other relevant laboratory testing may include CBC, gonorrhea and chlamydia, and tumor markers.  Imaging is critical in the evaluation and 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 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 to preserve ovarian function. Additional adnexal pathology is found in over half of patients with the diagnosis of torsion. Certain neoplasms may require surgical intervention, and 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. 

Further Reading:

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.

Levine D, Brown DL, Andreotti RF, et al. Management of asymptomatic ovarian and other adnexal cysts imaged at US Society of Radiologists.; Ultrasound Q. 2010 Sep;26(3):121-31. doi: 10.1097/RUQ.0b013e3181f09099.

Kelleher CM, Goldstein AM. Adnexal masses in children and adolescents. Clin Obstet Gynecol. 2015 Mar;58(1):76-92. doi: 10.1097/GRF.0000000000000084.v

Initial approval May 2009; Revised 2/2015; Reaffirmed 7/2016, Revised November 2017; Reaffirmed May 2019

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