Although many ovarian masses are discovered incidentally, patients should be asked about any potential symptoms that might be associated with ovarian malignancy, such as persistent abdominal bloating, anorexia, early satiety, pelvic or abdominal pain, or increased urinary urgency and frequency. Clinicians should also assess the patient's underlying risk by obtaining a thorough family history, especially with regard to diagnoses of breast, uterine, colon, or ovarian cancers.
Although the physical examination is relatively insensitive for the diagnoses of ovarian masses, it is important to examine for any associated findings, such as lymphadenopathy. Palpable pelvic masses that are irregular, solid, fixed, nodular, or associated with ascites are particularly concerning for malignancy and should prompt urgent referral to a gynecologic oncologist.
B. Diagnostic Tests and Imaging
Transvaginal ultrasound is the diagnostic test of choice in any premenopausal or postmenopausal woman presenting with an ovarian mass. Ultrasonography should be performed by clinicians with expertise in gynecologic imaging who can provide a thorough description of the morphology and ultrasonographic features of the mass.
Ultrasound detection of a simple cyst is associated with a benign process in 95–99% of postmenopausal women. Simple cysts are characterized by a round or oval shape, a thin wall, posterior acoustic enhancement, anechoic fluid, and an absence of septations or nodules. Complex cysts may have solid components, septations, and papillary projections.
Ovarian masses may be characterized according to the International Ovarian Tumor Analysis (IOTA) "rules" (https://www.iotagroup.org/), which help differentiate benign from malignant ovarian mass processes (sensitivity 95%, specificity 91%). According to the IOTA classification, an ovarian mass is suspicious of being malignant when any of the following features are present: irregular solid tumor, irregular multilocular solid tumor with largest diameter greater than 1 cm, four or more papillary structures, ascites, and prominent blood flow on color Doppler. If an ovarian mass is suspected of being malignant, the patient should be urgently referred to a gynecologic oncologist.
Serum CA-125 is a biomarker that is expressed by the majority of epithelial ovarian cancers. However, in premenopausal women, its serum level can also be elevated in benign conditions, such as endometriosis, pelvic inflammatory disease, and adenomyosis making it unreliable in the assessment of the risk of ovarian cancer (sensitivity 50–74%, specificity 26–92%). In contrast, in postmenopausal women, serum CA-125 does have utility in differentiating benign conditions from ovarian cancer. A CA-125 value above 35 units/mL is considered abnormal in postmenopausal women, though rising levels on serial determinations are more helpful than a single value.
Serum lactate dehydrogenase (LD), alpha-fetoprotein (AFP), and human chorionic gonadotropin (hCG) may be elevated in germ cell tumors, and these markers should be ordered in premenopausal women (under age 40 years) who have complex ovarian mass on ultrasound imaging.
Although measuring CA-125 can be useful in the evaluation of an ovarian mass, evidence does not support the use of serum CA-125 in routine screening for ovarian cancer in asymptomatic women.