ADNEXAL MASSES

What does adnexal masses mean?

Adnexal masses are usually discovered due to symptoms (e.g., pain or pressure symptoms) or during a routine gynecological examination (e.g. using transvaginal ultrasound). The most common adnexal masses are cysts of the ovary (i.e. cavities filled with fluid). More rarely, solid tumours or a mixture of cystic and solid changes can be found. An ectopic pregnancy (e.g., tubal pregnancy) can also present itself as an adnexal mass.

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Adnexal masses are common in premenopausal women (i.e., childbearing age) and are usually the result of hormonal changes related to the menstrual cycle and the production of follicles in the ovary. The resulting cysts are called “functional cysts” and usually disappear spontaneously after a few menstrual cycles. If adnexal masses persist, cause pain or show specific characteristics on transvaginal ultrasound, further clarification is often needed. 

In post-menopausal women, adnexal masses are significantly less frequent and a «functional cyst» is less likely due to the inactivity of the ovary. Therefore, any adnexal mass in a post-menopausal women requires further diagnostic steps.

THERAPY PLANNING

Depending on the symptom of the patients, the age and the appearance of the adnexal mass on transvaginal ultrasound, a diagnosis can often quickly be established. Many cystic adnexal masses, such as endometriosis cysts, dermoid cysts, corpus luteum cysts or hemorrhagic cysts show a typical ultrasound image, which, with the appropriate expertise, allows fast and accurate diagnosis». In other cases, further examinations, such as a blood test (e.g., tumor markers), a urine sample or further imaging (e.g. MRI or CT examination) are required.

In many cases a wait-and-see approach can safely be pursued, consisting of regular transvaginal ultrasound examinations. Surgical treatment is necessary in case of pain not responding to treatment or suspicious findings on transvaginal ultrasound examination.

WHAT SURGICAL TREATMENT OPTIONS ARE AVAILABLE?

If surgical therapy is required, this can usually be done by means of laparoscopy. The type of adnexal mass and the age of the patient are the decisive factors in determining whether an operation to preserve the ovary (e.g. cyst removal) can be performed or whether the ovary and the tube (adnexa) must be removed.

In post-menopausal women where the ovary is no longer active, an adnexectomy (removal of the ovary and fallopian tube) is usually performed. In women of childbearing age, the aim is to only remove the cyst and preserve the ovary. Preservation of ovarian hormonal function and fertility is the highest priority in adolescents and women of childbearing age. Endometriosis cysts, also known as chocolate cysts, play a special role here, as their surgical removal is often challenging and, in the absence of expertise, the ovaries can be excessively damaged. In addition, if the cysts are not removed completely, the risk of recurrence increases significantly, which sometimes leads to further operations, which in turn further damage the ovary and potentially decrease fertility.

Therefore, when a treatment plan is established for endometriosis cysts, it is of utmost importance to take into account the patients age and fertility planning.

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