Evaluation of the Adnexal Mass in an Older Woman
Editor: Martin E. Olsen, MD
The evaluation and management of an adnexal mass in an older woman is an important clinical challenge. Adnexal masses arise in gynecologic and non-gynecologic sites. Primary ovarian lesions include functional cysts and neoplastic cysts and masses (benign, borderline, and malignant). Ovarian cysts are not unusual during perimenopause and menopause. Most are benign. Age is the most significant risk factor for ovarian cancer, with a lifetime risk for ovarian cancer of 1 in 70. Adnexal masses can be found in the course of evaluation for symptoms or incidentally on exam or imaging. The use of tumor markers and imaging for early detection of cancer in asymptomatic women has not been shown to reduce mortality. Given the risks associated with surgery for false-positive results of screening, the screening of asymptomatic women is not recommended.
The goal is to identify malignancy while minimizing unnecessary intervention. Ultrasound is the imaging modality of choice. It offers the ability to characterize the ovarian mass, whether simple, multilocular, cystic/solid or solid. MRI may be used in addition to ultrasound in the differentiation of benign versus malignant lesions, but the additional cost may not be justifiable. CT and or PET-CT imaging is useful for preoperative imaging of lesions highly suspicious for ovarian cancer to optimize surgical planning, but have a limited role in the initial evaluation of adnexal masses.
Serum markers such as Cancer Antigen 125 (CA 125), Human Epididymis 4 (HE4) and newer Multivariate Index Assays (OVA1) are added tools to evaluate adnexal masses. CA 125 can be elevated in both benign and malignant conditions. CA125 and HE4 together may have improved diagnostic value. The clinical significance of OVA1 is not clear. Measuring LDH, Β-HCG, and AFP is of limited value in older women as most cancers in this age group are epithelial in origin.
Primary management of ovarian cancer by a gynecologic oncologist has improved survival rates. Currently ACOG and Society of Gynecologic Oncology recommend that patients presenting with the following be referred to a gynecologic oncologist:
- Evidence of metastasis
- First degree relative with breast or ovarian cancer
- Premenopausal patient with CA 125 > 200
- Postmenopausal patient with CA 125 > 35
- Fixed / nodular pelvic mass
Asymptomatic simple unilocular cysts up to 10cm in size have less than 1% risk of malignancy and should be followed with ultrasound imaging in 4 to 6 months. Resolution will occur in up to two thirds of patients. Multilocular and solid/cystic masses are seen in up to 3.2% of postmenopausal woman. Women with asymptomatic multilocular or solid/cystic lesions less than 5cm and a normal CA 125 can undergo repeat imaging and CA 125 in 4 weeks. If the size of the mass or CA 125 increases, surgery is appropriate. If the mass shrinks, CA 125 falls, or if the clinical picture is unchanged, the patient can be followed conservatively with ultrasound at 3-6 months. Although evidence based guidance is lacking, if all parameters have been stable for 18 to 24 months, repeat scans and marker levels can be discontinued. If the tumor is ≥ 5cm or there is any evidence of papillary projections or ascites, the patient should be referred to a gynecologic oncologist.
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.
Rauh-Hain JA, Melamed A, Buskwofie, A, et al, Adnexal mass in the postmenopausal patient. Clin Obstet Gynecol. 2015 Mar;58(1):53-65. doi: 10.1097/GRF.0000000000000085.
Committee on Gynecologic Practice, Society of Gynecologic Oncology., Committee Opinion #716: The role of the obstetrician–gynecologist in the early detection of epithelial ovarian cancer in women at average risk. Obstet Gynecol. 2017 Sep;130(3):e146-e149. doi: 10.1097/AOG.0000000000002299.
Initial Approval October 2015; Reviewed January 2017, Revised May 2018
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This document is designed to aid practitioners in providing appropriate obstetric and gynecologic care. Recommendations are derived from major society guidelines and high quality evidence when available, supplemented by the opinion of the author and editorial board when necessary. It should not be construed as dictating an exclusive course of treatment or procedure to be followed.
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Rauh-Hain JA, Melamed A, Buskwofie, A, Schorge JO. Adnexal mass in the postmenopausal patient. Clin Obstet Gynecol. 2015;58:53-65.
Initial Approval October 2015; Updated January 2017
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