Ovarian Masses in Adolescents Many studies of ovarian tumors in the pediatric and adolescent age group do not distinguish between prepubertal or premenarchal girls and menarchal adolescents. The findings of some reports are based on age group, although this is less helpful than a distinction by pubertal development. In evaluating a pelvic or abdominal mass, the clinician must take into consideration the patient’s pubertal status because the likelihood of functional masses increases after menarche (Table 14.4). The risk of malignant neoplasms is lower among adolescents than among younger children. Germ cell tumors are the most common tumors of the first decade of life but occur less frequently during adolescence (see Chapter 37). Mature cystic teratoma is the most frequent neoplastic tumor of children and adolescents, accounting for more than one-half of ovarian neoplasms in women younger than 20 years of age (112). Epithelial neoplasms occur with increasing frequency beyond adolescence.
It is well established that neoplasia can arise in dysgenetic gonads. The risk of malignant tumors in dysgenetic gonads of patients with a Y chromosome depends on the nature of the disorder of sex development, the presence of the gonadoblastoma region of the Y chromosome, and other factors—both established and as yet unknown (113). A number of genes involved in gonadal differentiation were described. In the past, it was stated that the risk of malignant tumors is approximately 25%, and thus gonadectomy was recommended (114). Other perspectives suggest that a gonadal biopsy may allow the estimation of individual risk and permit a more conservative approach to gonadectomy. A multidisciplinary approach to diagnosis of disorders of sex development with attention to biological, genetic, and psychological factors is advocated (115). Functional ovarian cysts occur frequently in adolescence. They may be an incidental finding on examination or may be associated with pain caused by torsion, leakage, or rupture. Paratubal cysts represent embryologic remnants that may be confused with an ovarian mass; they are typically asymptomatic, but can be associated with adnexal torsion (Fig. 14.14). Adnexal or ovarian torsion is a challenging diagnosis to make in prepubertal girls or adolescents; torsion of a mass is more likely to occur than is torsion of normal adnexa, although this can occur. Doppler ultrasound examination may not predict the presence of torsion, although discrepancy in ovarian volume and large volume of the torsed adnexa may be helpful in making the diagnosis (116,117). Management should consist of detorsion rather than oophorectomy, even if the mass appears to have no blood ﬂow, as recovery of ovarian function is likely (118).
Endometriosis is less common during adolescence than in adulthood, although it can occur during adolescence. In one study of adolescents referred with chronic pain, 50% to 65% had endometriosis (119). Although endometriosis can occur in young women with obstructive genital anomalies (presumably as a result of retrograde menstruation), most adolescents with endometriosis do not have associated obstructive anomalies. In young women, endometriosis may have an atypical appearance characterized by nonpigmented or vesicular lesions, peritoneal windows, and puckering (120).
Other causes of pelvic masses, such as uterine abnormalities, are rare in adolescence.