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  • Transvaginal ultrasound is the preferred test for evaluating an ovarian mass in both premenopausal and postmenopausal women.

  • CA-125 is a useful tumor marker for the evaluation of ovarian masses in postmenopausal women but has limited utility in premenopausal women.

  • The Risk for Malignancy Index is a helpful tool for assessing the risk of malignancy in an ovarian mass.


Ovarian masses are common, affecting up to 20% of women. Many of these masses are found incidentally, often as part of a radiologic workup for another symptom, such as abdominal pain. Although the vast majority of ovarian masses in premenopausal women are benign, the incidence of ovarian cancer increases with age. Additionally, up to 10% of suspected ovarian masses may be related to nonovarian disease (see eTable 18–3 found in Chapter 18-21: Ovarian Cancer & Ovarian Tumors for more details). The role of the primary care clinician is to provide prompt referral to a gynecologist or gynecologic oncologist based on the likelihood of malignancy and the need for potential surgical management.


A. Symptoms and Signs

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 regarding 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 initial diagnostic test of choice in any premenopausal or postmenopausal woman presenting with an ovarian mass. Transvaginal ultrasound has a reported sensitivity of 93.5% and specificity of 91.5% in separating masses that are likely benign from those that are concerning for malignancy and require further evaluation.

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" (, which ...

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