QuizMe 26

Adnexal mass

A healthy 60 yr old lady is visiting for follow up for an asymptomatic right adnexal masspicked up 4 months ago on a routine visit. TVS performed at the time revealed a 4-cm simple cyst, with a CA-125 of 9 IU/mL. The patient today remains asymptomatic, with no
tiredness, change in appetite, or bowel symptoms. She is without personal or family history of any malignancy.

  • Bimanual examination: right adnexal mass; non-tender, mobile.
  • TVS: 4-cm, simple, right ovarian cyst
  • Ca-125: 4 IU/mL
  •  Postmenopausal woman
  • Asymptomatic
  •  No alarming physical signs
  • No change on TVS
  • Image-guided cyst aspiration
  •  Laparoscopic salpingo-oophorectomy
  •  Open salpingo-oophorectomy
  •  Review in 6-12 m
  •  CT scan pelvis

Review in 6-12 m

It is recommended that an adnexal mass in a postmenopausal lady should be initially assessed by CA 125 levels and TVS.

A CT scan would be indicated if the clinical picture or investigations yielded suspicion of a malignancy. Since the CA 125 and the TVS are reassuring, a CT scan is not appropriate.

Asymptomatic, simple, unilateral ovarian cysts of less than 5-cm in diameter have a low risk of malignancy. In the presence of
normal serum CA125, such cysts can be managed conservatively with repeat evaluation in 4-6 m. If the cyst remains asymptomatic, unchanged or reduces in size, with normal CA125, offering review within 6- 12m to ensure stability would be most fitting.

Aspiration of ovarian cysts in postmenopausal women is not recommended, unless it is for symptom control in advanced malignancy unfit for surgery or further intervention. Surgical management is often reserved for cases with concerning qualities; such as
bilateral cysts, presence of symptoms, non-simple features on ultrasonography, or a cyst diameter of more than 5 cm. The approach
for surgery would then be governed by the risk of malignancy index (RMI) calculated. Women with low risk of malignancy (RMI
<200) are suitable for laparoscopic surgery, while cysts suspicious of malignancy (RMI >200) require a full laparotomy and stagingprocedure.


  • Ovarian Cysts in Postmenopausal Women (Green-top Guideline No. 34) Available from:https://www.rcog.org.uk/en/guidelines-research-services/guidelinesgtg34/
  • Practice Bulletin No. 174: Evaluation and Management of Adnexal Masses. Obstet Gynecol [2016]. Available from:https://pubmed.ncbi.nlm.nih.gov/27776072/
  • WS B, ST M. Diagnosis and Management of Adnexal Masses. AmFam Physician [2016]. Available from:https://pubmed.ncbi.nlm.nih.gov/27175840/