**Unveiling the Mystery of Pelvic Masses**
When it comes to pelvic masses, the journey of diagnosis can begin in various ways. Sometimes a patient experiences symptoms linked to a pelvic mass, while in other cases, it's serendipitously stumbled upon during a routine pelvic exam or ultrasound for different concerns. These masses can take residence in the uterus, ovaries, or even non-gynecologic areas of the pelvis.
The first crucial step in this detective work is to delve into the patient's age, medical history, and risk factors. These details act as clues in the diagnostic puzzle. For instance, if we're dealing with a younger woman, an ovarian cyst might be a functional one—harmless. But in postmenopausal women, it's essential to consider the possibility of ovarian cancer. We're also interested in menopausal status, menstrual history, family medical history, the risk of sexually transmitted infections (STIs), signs of excess androgens (hormones like testosterone), and painful menstruation, known as dysmenorrhea.
Pelvic examinations, although not foolproof, can offer valuable insights into the diagnosis. However, they become less reliable as body mass index (BMI) increases. Nonetheless, they provide additional information such as the mass's location, its mobility, tenderness when the cervix is moved, pelvic tenderness, and any unusual vaginal discharge.
The next logical step in our investigation involves pelvic ultrasonography. Depending on the mass's size and location, this can be done either transabdominally or transvaginally. It's also essential to rule out pregnancy in premenopausal women. For postmenopausal women with adnexal masses (masses near the ovaries), we utilize Doppler ultrasonography, evaluate cyst appearance, and perform CA-125 testing to assess the risk of ovarian cancer.
Let's pause here to address some jargon:
- **Adnexal mass**: A mass located near the uterus and ovaries.
- **CA-125**: A blood test that measures a protein often elevated in ovarian cancer.
- **Doppler ultrasonography**: A special ultrasound technique to assess blood flow in the mass.
- **Transabdominal**: An ultrasound where the probe is moved across the abdomen.
- **Transvaginal**: An ultrasound where a probe is placed into the vagina for a closer look.
Now, let's explore specific types of pelvic masses:
**Uterine Fibroids:** These pesky growths can be found in about one-third of women of reproductive age. While some don't cause trouble, others lead to pelvic pain, pressure, and heavy or irregular bleeding. They even top the list of reasons for hysterectomies in the United States. Treatment options include watchful waiting, as fibroids often shrink after menopause. However, a hysterectomy, although definitive, involves major surgery with risks. Uterine-sparing procedures, such as myomectomy, are an option but may lead to symptom recurrence. Fibroids can also affect fertility, but their removal doesn't always improve it.
**Ovarian Cysts and Carcinoma:** Here, transvaginal ultrasonography comes to the rescue again. We find that simple cysts are usually benign, but complex cysts or those larger than 10 cm carry a higher malignancy risk. Malignant cysts tend to display increased blood flow when examined with Doppler ultrasonography. So when should we raise the red flag and refer to a specialist? Well, premenopausal women should be referred if their CA-125 levels are high, they have ascites (abnormal fluid accumulation), signs of metastasis, or a close relative with breast or ovarian cancer. Postmenopausal women should also seek specialized care if they have elevated CA-125 levels, ascites, a fixed pelvic mass, signs of ascites, or a family history of breast or ovarian cancer among first-degree relatives.
In the realm of treatment, oral contraceptives (OCs) are not typically used for functional ovarian cysts, although they can reduce their occurrence. We're still navigating the best treatments for ovarian cysts, as medical options remain relatively uncharted territory.
So, the world of pelvic masses is indeed a complex one, filled with various challenges, risks, and treatment options. It's a realm where early detection and proper evaluation play a pivotal role in ensuring the best outcome for our patients.
This chart summarizes the possible causes of a pelvic mass based on different organs:
1. Uterus:
- Uterine fibroid: Symptoms include pelvic pressure and heavy vaginal bleeding.
- Intrauterine pregnancy: Recognized by a positive pregnancy test and absence of menstruation (amenorrhea).
2. Fallopian Tubes:
- Ectopic pregnancy: Indicated by a positive pregnancy test, adnexal (near the ovaries) pain, or tenderness, and hemodynamic instability.
- Tubo-ovarian abscess: Associated with STI risk, pelvic pain, cervical motion tenderness, vaginal discharge, and fever.
3. Ovaries:
- Simple cysts: More common in premenopausal women, causing sharp pelvic pain and pressure.
- Endometriomas: Typically linked to dysmenorrhea (painful menstruation).
- Dermoid cysts (teratomas): May cause pelvic pressure.
- Ovarian carcinoma: Typically found in postmenopausal women.
- Polycystic ovarian syndrome: Characterized by hyperandrogenism, irregular menstrual cycles, and multiple cysts on ultrasound.
- Germ cell tumors: Associated with pelvic pressure, chromosomal abnormalities, and common in younger women (teens and 20s).
4. Intestines:
- Appendicitis: Presents with anorexia, right lower quadrant pain or tenderness, elevated white blood cell count, and fever.
- Diverticulitis: Features left lower quadrant pain or tenderness, cramping, constipation, more common in older individuals, and fever.
5. Urinary Tract:
- Bladder tumor: Often identified by hematuria (blood in urine).
- Pelvic kidney: Typically asymptomatic.