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Adnexal Tumors Treatment & Management

  • Author: Nelson Teng, MD, MBA, MS, PhD; Chief Editor: Michel E Rivlin, MD  more...
Updated: Mar 02, 2016

Medical Therapy

Asymptomatic, small, well-characterized adnexal masses may be observed with regular pelvic examinations and radiologic evaluations. A surgical approach should be used if growth occurs in these masses, if the patient becomes symptomatic, or if the cyst develops more concerning features, such as solid components. As indicated previously, the suspicion for a malignancy is increased in prepubescent and postmenopausal women.

Some controversy exists regarding the use of combined hormonal contraceptives in the prevention and treatment of ovarian cysts. Observational studies in women taking higher-dose, “early-generation” oral contraceptive pills (OCPs) suggested a lower incidence of functional and benign epithelial ovarian cysts. However, more recent data have shown that contemporary oral contraceptive formulations have minimal effects on the incidence of ovarian cysts and that treatment with OCPs does not appear to expedite cyst resolution.[42]

Cyst aspiration is contraindicated, especially in postmenopausal patients.  In benign cysts, cyst wall removal is necessary to prevent recurrence and aspiration has little therapeutic benefit.  In malignancy, cytology only has a sensitivity of 25-82% for detection of cancer.  Spillage of cyst fluid may induce peritoneal seeding of malignancy.  Intraoperative cyst rupture is known to decrease overall survival in stage 1 ovarian cancer patients in comparison to intact tumors.  Additionally, there are case reports of recurrence of malignancy along the aspiration needle tract.[1]  


Surgical Therapy

All adnexal masses that are symptomatic or have characteristics of a malignancy should be considered for surgical evaluation. The extensive differential diagnosis and possible surgical procedures should be discussed with the patient.

Obvious benign masses can be treated with resection of the mass alone or removal of the adnexal structure.

In those cases in which the presence of malignancy is questionable, one should limit the resection to the structures involved unless a preoperative decision has been made that a more aggressive approach should be taken.

When an obvious epithelial ovarian malignancy is encountered, a complete staging protocol must be performed. This generally includes complete exploration of the abdomen, total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy, pelvic and para-aortic lymph node dissections, biopsies of the undersurface of the right and left diaphragms, and biopsies of the colic gutters followed by a maximal resection of the intra-abdominal tumor.[43] In select cases involving women with limited, early stage, low-grade ovarian cancers, a fertility sparing procedure may be considered.[44] In some cases, resecting portions of the small bowel or colon may be necessary; therefore, preoperative bowel preparation may be warranted, as is a discussion about possible colostomy or other bowel changes.

Among women undergoing laparoscopic resection of adnexal masses, a transvaginal approach for specimen removal is associated with less postoperative pain than a transumbilical approach.[45]


Preoperative Details

Preoperative preparation is vital to the proper care of a woman with an adnexal mass. This should include the following:

  • A complete discussion of the possible procedures and the long-term results
  • A complete bowel preparation in selected cases
  • A careful evaluation of any associated medical problems or past surgeries
  • An evaluation of the woman's nutritional status, particularly when ascites is present
  • Consideration of referral to a gynecologic oncologist

Given the limitations of preoperative diagnostic testing in accurately determining the risk of malignancy (see Workup), the American College of Obstetricians and Gynecologists and the Society of Gynecologic Oncologists have established referral guidelines for a newly diagnosed pelvic mass.[1, 46] Women who meet the following criteria would benefit from preoperative consultation with a gynecologic oncologist:

Premenopausal (younger than 50 y)

See the list below:

  • CA-125 level greater than 200 units/mL
  • Ascites
  • Evidence of abdominal or distant metastasis (by results of examination or imaging study)
  • Family history of breast or ovarian cancer (in a first-degree relative)

Postmenopausal (older than 50 y)

See the list below:

  • Elevated CA-125 levels (any degree of elevation)
  • Ascites
  • Nodular or fixed pelvic mass
  • Evidence of abdominal or distant metastasis (by results of examination or imaging study)
  • Family history of breast or ovarian cancer (in a first-degree relative)

Intraoperative Details

During the procedure, several factors must be kept in mind, including the following:

  • The dissection depends on the preoperative discussion concerning the nature and extent of the procedure.
  • The dissection must be tailored to the woman's desire regarding future fertility. In many cases with benign disease, the dissection should not block future reproductive abilities.
  • The presence of extensive disease as seen with cancer or endometriosis alters normal anatomical relations, which can result in a greater chance for injury to surrounding structures such as the ureters or bowel. Such dissections are best performed with the assistance of a gynecologic oncologist.

Intraoperative frozen section analysis should be considered based on a number of factors, as follows[47] :

  • Physical characteristics of the mass (eg, tumor lobularity, visible excrescences, combined solid and cystic components)
  • Presence of adhesions noted during surgery (associated with increased risk of malignancy)
  • Logistical considerations such as the on-call availability of gynecologic oncologist backup if malignancy is identified

A retrospective analysis of 748 Turkish patients who underwent exploratory laparotomy for adnexal masses found that intraoperative frozen section evaluation was highly accurate in evaluating the tumors when compared to permanent section pathology.[48] However, factors that were associated with misdiagnosis included masses larger than 10 cm and a borderline histology. On the basis of multivariate analysis, borderline history was an independent predicted for misdiagnosis during frozen examination.[48]


Postoperative Details

Most adnexal masses can be removed with relative ease and are associated with little postoperative complexity; however, in women with significant preexisting medical problems and/or cancer, major postoperative problems can be encountered. When indicated, intensive care unit admission with close monitoring of fluid balance, electrolyte balance, coagulation status, and cardiopulmonary function may be required.



Most adnexal masses require little more than the normal annual gynecologic examination for follow-up because they rarely recur. On the other hand, women found to have a malignancy require additional therapy, such as chemotherapy or radiation therapy. Their follow-up care should include frequent reexaminations to determine the disease status.

For patient education resources, see Women's Health Center, as well as Ovarian Cysts.



The major adverse outcomes in the treatment of adnexal masses are related to complications resulting from surgical therapy. These may include the following:

  • Infections of the urinary tract, wound, or lungs
  • Blood loss with the resulting need for transfusion and associated blood-borne infections
  • Injury to surrounding organs such as the urinary bladder, large or small bowel, ureters, or sidewall blood vessels and nerves
  • Pelvic vein thrombosis with associated pulmonary embolism

Outcome and Prognosis

Most adnexal masses are benign; outcome and prognosis are very good. Generally, no impact on life span or quality of life is noted. In fact, most women treated for adnexal masses have no interruption in their reproductive abilities.

Those women who are found to have malignant adnexal masses fall into 3 groups, as follows:

  • Women ranging in age from the late teens (y) to early 20s (y): Germ cell tumors are seen in these women. The tumors are generally confined to the ovary and are cured in 90% of women after chemotherapy.
  • Women aged 40-60 years: Epithelial tumors are the most common ovarian cancer in these women. These tumors are advanced (stage III-IV) in more than 50% of women. Even after the use of chemotherapy, only 10-40% of patients survive their disease. [43]
  • Women older than 60 years: Ovarian epithelial malignancies are common in this group of patients. Metastatic malignancies are also common. The incidence of sex-cord stromal tumors also increases in incidence in this age group, although it still accounts for only 5% of tumors. Stromal tumors are often early stage and may have an indolent course.

Future and Controversies


The future holds several interesting possibilities. First, the rapid expansion of new laparoscopic equipment, including the robotic surgery platform, makes minimally invasive surgery an area that is gaining increasing importance in the treatment of adnexal masses. Second, the development of new radiologic techniques or expansion of the present techniques will allow the clinician to gain additional characterization of adnexal masses without entering the surgical suite. Third, new molecular, genetic, and biologic markers and therapies should become available that will assist in the diagnosis and treatment of adnexal masses, both benign and malignant.


The major controversy surrounding adnexal masses is when and how to treat them. While some adnexal masses can be clearly stratified into low- or high-risk for malignancy based on clinical, laboratory, and clinical findings, currently, there are no definitive means of preoperative diagnosis with imaging or laboratory findings.

Contributor Information and Disclosures

Nelson Teng, MD, MBA, MS, PhD Associate Professor, Department of Gynecology and Obstetrics, Division of Gynecologic Oncology, Stanford University School of Medicine

Disclosure: Nothing to disclose.


Gillian Lee Hsieh, MD Fellow in Gynecologic Oncology, Stanford University School of Medicine and University of California, San Francisco, School of Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

A David Barnes, MD, MPH, PhD, FACOG Consulting Staff, Department of Obstetrics and Gynecology, Mammoth Hospital (Mammoth Lakes, CA), Pioneer Valley Hospital (Salt Lake City, UT), Warren General Hospital (Warren, PA), and Mountain West Hospital (Tooele, UT)

A David Barnes, MD, MPH, PhD, FACOG is a member of the following medical societies: American College of Forensic Examiners Institute, American College of Obstetricians and Gynecologists, Association of Military Surgeons of the US, American Medical Association, Utah Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Michel E Rivlin, MD Former Professor, Department of Obstetrics and Gynecology, University of Mississippi School of Medicine

Michel E Rivlin, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, Mississippi State Medical Association, Royal College of Surgeons of Edinburgh, Royal College of Obstetricians and Gynaecologists

Disclosure: Nothing to disclose.

Additional Contributors

John J Kavanagh, Jr, MD Chief, Professor, Department of Internal Medicine, Section of Gynecological and Medical Therapeutics, MD Anderson Cancer Center, University of Texas Medical School at Houston

John J Kavanagh, Jr, MD is a member of the following medical societies: American Association for the Advancement of Science, Society of Gynecologic Oncology, American Association for Cancer Research, American Association for the History of Medicine, American College of Physicians, American Federation for Medical Research, American Medical Association, Southern Medical Association, Texas Medical Association

Disclosure: Nothing to disclose.

Elise J Simons, MD Clinical Instructor, Department of Obstetrics and Gynecology, Stanford University School of Medicine

Elise J Simons, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Obstetricians and Gynecologists

Disclosure: Nothing to disclose.


The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author, Margrit Juretzka, MD, to the development and writing of this article.

  1. ACOG Practice Bulletin. Management of adnexal masses. Obstet Gynecol. 2007 Jul. 110(1):201-14. [Medline].

  2. Drake J. Diagnosis and management of the adnexal mass. Am Fam Physician. 1998 May 15. 57(10):2471-6, 2479-80. [Medline].

  3. Gallup DG, Talledo E. Management of the adnexal mass in the 1990s. South Med J. 1997 Oct. 90(10):972-81. [Medline].

  4. Sayasneh A, Ekechi C, Ferrara L, et al. The characteristic ultrasound features of specific types of ovarian pathology (Review). Int J Oncol. 2015 Feb. 46(2):445-58. [Medline].

  5. Hricak H, Chen M, Coakley FV, et al. Complex adnexal masses: detection and characterization with MR imaging--multivariate analysis. Radiology. 2000 Jan. 214(1):39-46. [Medline].

  6. Alcazar JL, Ruiz-Perez ML, Errasti T. Transvaginal color Doppler sonography in adnexal masses: which parameter performs best?. Ultrasound Obstet Gynecol. 1996 Aug. 8(2):114-9. [Medline].

  7. Castillo G, Alcázar JL, Jurado M. Natural history of sonographically detected simple unilocular adnexal cysts in asymptomatic postmenopausal women. Gynecol Oncol. 2004 Mar. 92(3):965-9. [Medline].

  8. Modesitt SC, Pavlik EJ, Ueland FR, DePriest PD, Kryscio RJ, van Nagell JR Jr. Risk of malignancy in unilocular ovarian cystic tumors less than 10 centimeters in diameter. Obstet Gynecol. 2003 Sep. 102(3):594-9. [Medline].

  9. Zalel Y, Piura B, Elchalal U, Czernobilsky B, Antebi S, Dgani R. Diagnosis and management of malignant germ cell ovarian tumors in young females. Int J Gynaecol Obstet. 1996 Oct. 55(1):1-10. [Medline].

  10. Barber HR, Graber EA. Gynecological tumors in childhood and adolescence. Obstet Gynecol Surv. 1973 May. 28(5):suppl:357-81. [Medline].

  11. Pfeifer SM, Gosman GG. Evaluation of adnexal masses in adolescents. Pediatr Clin North Am. 1999 Jun. 46(3):573-92. [Medline].

  12. Slap GB, Forke CM, Cnaan A, et al. Recognition of tubo-ovarian abscess in adolescents with pelvic inflammatory disease. J Adolesc Health. 1996 Jun. 18(6):397-403. [Medline].

  13. Kinkel K, Lu Y, Mehdizade A, Pelte MF, Hricak H. Indeterminate ovarian mass at US: incremental value of second imaging test for characterization--meta-analysis and Bayesian analysis. Radiology. 2005 Jul. 236(1):85-94. [Medline].

  14. Russo A, Calò V, Bruno L, Rizzo S, Bazan V, Di Fede G. Hereditary ovarian cancer. Crit Rev Oncol Hematol. 2008 Jul 23. [Medline].

  15. Lancaster JM, Powell CB, Chen LM, Richardson DL, SGO Clinical Practice Committee. Society of Gynecologic Oncology statement on risk assessment for inherited gynecologic cancer predispositions. Gynecol Oncol. 2015 Jan. 136 (1):3-7. [Medline].

  16. Plon SE, Cooper HP, Parks B, Dhar SU, Kelly PA, Weinberg AD, et al. Genetic testing and cancer risk management recommendations by physicians for at-risk relatives. Genet Med. 2011 Feb. 13 (2):148-54. [Medline].

  17. NCCN. Genetic/Familial High-Risk Assessment: Breast and Ovarian. NCCN Clinical Practice Guidelines in Oncology. Version 2.2015. NCCN; 2015.

  18. Risch HA, McLaughlin JR, Cole DE, Rosen B, Bradley L, Kwan E. Prevalence and penetrance of germline BRCA1 and BRCA2 mutations in a population series of 649 women with ovarian cancer. Am J Hum Genet. 2001 Mar. 68(3):700-10. [Medline].

  19. Pal T, Permuth-Wey J, Betts JA, Krischer JP, Fiorica J, Arango H. BRCA1 and BRCA2 mutations account for a large proportion of ovarian carcinoma cases. Cancer. 2005 Dec 15. 104(12):2807-16. [Medline].

  20. Press JZ, De Luca A, Boyd N, Young S, Troussard A, Ridge Y. Ovarian carcinomas with genetic and epigenetic BRCA1 loss have distinct molecular abnormalities. BMC Cancer. 2008. 8:17. [Medline].

  21. Clement PB. Tumor-like lesions of the ovary associated with pregnancy. Int J Gynecol Pathol. 1993 Apr. 12(2):108-15. [Medline].

  22. Chiang G, Levine D. Imaging of adnexal masses in pregnancy. J Ultrasound Med. 2004 Jun. 23(6):805-19. [Medline].

  23. Padilla LA, Radosevich DM, Milad MP. Limitations of the pelvic examination for evaluation of the female pelvic organs. Int J Gynaecol Obstet. 2005 Jan. 88(1):84-8. [Medline].

  24. Buys SS, Partridge E, Black A, Johnson CC, Lamerato L, Isaacs C, et al. Effect of screening on ovarian cancer mortality: the Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Randomized Controlled Trial. JAMA. 2011 Jun 8. 305(22):2295-303. [Medline].

  25. Mol BW, Bayram N, Lijmer JG, Wiegerinck MA, Bongers MY, van der Veen F, et al. The performance of CA-125 measurement in the detection of endometriosis: a meta-analysis. Fertil Steril. 1998 Dec. 70(6):1101-8. [Medline].

  26. Devarbhavi H, Kaese D, Williams AW, Rakela J, Klee GG, Kamath PS. Cancer antigen 125 in patients with chronic liver disease. Mayo Clin Proc. 2002 Jun. 77(6):538-41. [Medline].

  27. Topalak O, Saygili U, Soyturk M, Karaca N, Batur Y, Uslu T, et al. Serum, pleural effusion, and ascites CA-125 levels in ovarian cancer and nonovarian benign and malignant diseases: a comparative study. Gynecol Oncol. 2002 Apr. 85(1):108-13. [Medline].

  28. Alcazar JL, Guerriero S, Minguez JA, et al. Adding cancer antigen 125 screening to gray scale sonography for predicting specific diagnosis of benign adnexal masses in premenopausal women: is it worthwhile?. J Ultrasound Med. 2011 Oct. 30(10):1381-6. [Medline].

  29. Canis M, Pouly JL, Wattiez A, et al. Laparoscopic management of adnexal masses suspicious at ultrasound. Obstet Gynecol. 1997 May. 89(5 Pt 1):679-83. [Medline].

  30. Carlson KJ, Skates SJ, Singer DE. Screening for ovarian cancer. Ann Intern Med. 1994 Jul 15. 121(2):124-32. [Medline].

  31. The role of the generalist obstetrician-gynecologist in the early detection of ovarian cancer. Gynecol Oncol. 2002 Dec. 87(3):237-9. [Medline].

  32. Kadan Y, Fiascone S, McCourt C, et al. Predictive factors for the presence of malignant transformation of pelvic endometriosis. Eur J Obstet Gynecol Reprod Biol. 2014 Dec 2. 185C:23-27. [Medline].

  33. Montagnana M, Danese E, Ruzzenente O, Bresciani V, Nuzzo T, Gelati M, et al. The ROMA (Risk of Ovarian Malignancy Algorithm) for estimating the risk of epithelial ovarian cancer in women presenting with pelvic mass: is it really useful?. Clin Chem Lab Med. 2011 Mar. 49 (3):521-5. [Medline].

  34. Karimi-Zarchi M, Mojaver SP, Rouhi M, Hekmatimoghaddam SH, Moghaddam RN, Yazdian-Anari P, et al. Diagnostic Value of the Risk of Malignancy Index (RMI) for Detection of Pelvic Malignancies Compared with Pathology. Electron Physician. 2015 Nov. 7 (7):1505-10. [Medline].

  35. Karlsen MA, Høgdall EV, Christensen IJ, Borgfeldt C, Kalapotharakos G, Zdrazilova-Dubska L, et al. A novel diagnostic index combining HE4, CA125 and age may improve triage of women with suspected ovarian cancer - An international multicenter study in women with an ovarian mass. Gynecol Oncol. 2015 Sep. 138 (3):640-6. [Medline].

  36. Yoshida A, Derchain SF, Pitta DR, De Angelo Andrade LA, Sarian LO. Comparing the Copenhagen Index (CPH-I) and Risk of Ovarian Malignancy Algorithm (ROMA): Two equivalent ways to differentiate malignant from benign ovarian tumors before surgery?. Gynecol Oncol. 2016 Mar. 140 (3):481-5. [Medline].

  37. Ware Miller R, Smith A, DeSimone CP, Seamon L, Goodrich S, Podzielinski I, et al. Performance of the American College of Obstetricians and Gynecologists' ovarian tumor referral guidelines with a multivariate index assay. Obstet Gynecol. 2011 Jun. 117 (6):1298-306. [Medline].

  38. Committee Opinion No. 477: the role of the obstetrician-gynecologist in the early detection of epithelial ovarian cancer. Obstet Gynecol. 2011 Mar. 117(3):742-6. [Medline].

  39. Ueland FR, Desimone CP, Seamon LG, Miller RA, Goodrich S, Podzielinski I. Effectiveness of a multivariate index assay in the preoperative assessment of ovarian tumors. Obstet Gynecol. 2011 Jun. 117(6):1289-97. [Medline].

  40. Twickler DM, Forte TB, Santos-Ramos R, et al. The Ovarian Tumor Index predicts risk for malignancy. Cancer. 1999 Dec 1. 86(11):2280-90. [Medline].

  41. DePriest PD, Gallion HH, Pavlik EJ, et al. Transvaginal sonography as a screening method for the detection of early ovarian cancer. Gynecol Oncol. 1997 Jun. 65(3):408-14. [Medline].

  42. ESHRE Capri Workshop Group. Ovarian and endometrial function during hormonal contraception. Hum Reprod. 2001 Jul. 16(7):1527-35. [Medline].

  43. Einhorn N. Ovarian cancer. Acta Oncol. 1996. 35 Suppl 7:86-92. [Medline].

  44. Schilder JM, Thompson AM, DePriest PD, Ueland FR, Cibull ML, Kryscio RJ, et al. Outcome of reproductive age women with stage IA or IC invasive epithelial ovarian cancer treated with fertility-sparing therapy. Gynecol Oncol. 2002 Oct. 87(1):1-7. [Medline].

  45. Ghezzi F, Cromi A, Uccella S, Bogani G, Serati M, Bolis P. Transumbilical versus transvaginal retrieval of surgical specimens at laparoscopy: a randomized trial. Am J Obstet Gynecol. 2012 Aug. 207(2):112.e1-6. [Medline].

  46. Im SS, Gordon AN, Buttin BM, Leath CA 3rd, Gostout BS, Shah C. Validation of referral guidelines for women with pelvic masses. Obstet Gynecol. 2005 Jan. 105(1):35-41. [Medline].

  47. van den Akker PA, Kluivers KB, Aalders AL, Snijders MP, Samlal RA, Vollebergh JH. Factors influencing the use of frozen section analysis in adnexal masses. Obstet Gynecol. 2011 Jul. 118(1):57-62. [Medline].

  48. Basaran D, Salman MC, Boyraz G, et al. Accuracy of intraoperative frozen section in the evaluation of patients with adnexal mass: retrospective analysis of 748 cases with multivariate regression analysis. Pathol Oncol Res. 2015 Jan. 21(1):113-8. [Medline].

  49. ACOG Practice Bulletin No. 103: Hereditary breast and ovarian cancer syndrome. Obstet Gynecol. 2009 Apr. 113(4):957-66. [Medline].

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