A 22-year-old woman comes to the office for routine annual examination. The patient has regular menses typically lasting 4 or 5 days with minimal cramping on the first day. Her last menstrual period was 3 weeks ago. She normally has no midcycle pain, but for 2 days she has had a mild, sharp pain in her left lower abdomen. The patient has had no nausea, vomiting, dysuria, or changes in bowel movements. She has no chronic medical conditions or previous surgeries. The patient is sexually active and uses a copper-containing intrauterine device (IUD) for contraception. She does not use tobacco, alcohol, or illicit drugs. Vital signs are normal. BMI is 22 kg/m2. The abdomen is mildly tender over the left lower quadrant. On speculum examination, the cervix appears normal and without lesions. The IUD strings are visualized at the external cervical os. The uterus is small and mobile, and a 4-cm nontender mass is palpable in the left adnexa. Pelvic ultrasonography reveals a 4-cm simple left ovarian cyst with normal Doppler flow. Urine pregnancy test is negative. Which of the following is the best next step in management of this patient?
Show Explanatory Sources
Adnexal masses are common and typically benign in women of reproductive age. However, patients with a new adnexal mass require assessment for emergency gynecologic conditions (eg, ectopic pregnancy, torsion) or possible malignancy (eg, epithelial ovarian cancer). Clinical features concerning for malignancy include postmenopausal age, chronic or worsening pelvic pain, and mass symptoms (eg, bloating, constipation).
Initial evaluation of an adnexal mass is with a pregnancy test and a pelvic ultrasound. Pelvic ultrasound visualizes ovarian blood flow (ie, Doppler flow), mass size, and internal mass features. On ultrasound, malignant masses typically appear complex (ie, solid and cystic) with irregular, thickened internal septations.
In contrast, this patient's midcycle, mild abdominal pain (ie, mittelschmerz) is most likely caused by a physiologic corpus luteum cyst related to recent ovulation. The diagnosis can be confirmed by ultrasound, which typically reveals a simple-appearing ovarian cyst with normal Doppler flow. Because physiologic ovarian cysts resolve spontaneously, the best next step in management is observation and repeat examination in 6 weeks.
(Choice A) Aspiration of ovarian cyst fluid is rarely indicated because cyst fluid cytology is typically not diagnostic for malignancy; in addition, spillage of cyst contents can increase cancer staging if the mass is malignant.
(Choice B) CA-125 can be measured in postmenopausal women with ovarian cancer to monitor disease progression or response to chemotherapy. However, in premenopausal women, CA-125 testing has low sensitivity and specificity, and is not indicated in this patient with a benign-appearing ovarian cyst.
(Choice C) In contrast to this patient with a physiologic corpus luteum cyst, those with malignant adnexal masses (eg, complex appearance, thick septations) typically undergo a CT scan of the abdomen and pelvis to assess for metastases. CT scan findings can guide the use of adjuvant chemotherapy in patients prior to surgical staging.
(Choice E) An ovarian cystectomy may be indicated if this patient's symptoms worsen or the cyst increases in size; however, physiologic ovarian cysts, such as this one, typically resolve without treatment.
Educational objective:
In premenopausal women, adnexal masses are typically benign, are related to ovulation, and resolve spontaneously. Therefore, premenopausal patients with simple-appearing ovarian cysts are managed with observation and repeat examination.