Other Studies Endometrial sampling with an endometrial biopsy or hysteroscopy is mandatory when both pelvic mass and abnormal bleeding are present. An endometrial lesion—carcinoma or hyperplasia—may coexist with a benign mass such as a leiomyoma. In
Figure 14.23 Transvaginal pelvic ultrasound demonstrating multiple uterine leiomyomas.
a woman with leiomyomas, abnormal bleeding cannot be assumed to be caused solely by the fibroids. Clinicians differ in recommendations about the need for endometrial biopsy when the diagnosis is leiomyomas with regular menses.
If urinary symptoms are prominent, studies of the urinary tract may be necessary, including urodynamic testing, if incontinence or symptoms of pelvic pressure are present. Cystoscopy may be necessary or appropriate to rule out intrinsic bladder lesions.
Laboratory Studies Laboratory studies that are indicated for women of reproductive age with a pelvic mass include pregnancy test, cervical cytology, and complete blood count. The value of tumor markers, such as CA125 in distinguishing malignant from benign adnexal masses in premenopausal women with a pelvic mass, is questioned. A number of benign conditions, including uterine leiomyomas, PID, pregnancy, and endometriosis can cause elevated CA125 levels in premenopausal women; thus, measurement of CA125 levels is not useful in premenopausal women with adnexal masses, because it may lead to unnecessary surgical intervention. Ultrasonographic characteristics are more helpful than CA125 in suggesting risks of malignancy in premenopausal women (219).
Imaging Studies Other studies may be necessary or appropriate. The most commonly indicated study is pelvic ultrasonography, which will help document the origin of the mass to determine whether it is uterine, adnexal, bowel, or gastrointestinal. The ultrasonographic examination provides information about the size of the mass and its consistency—unilocular cyst, mixed echogenicity, multiloculated cyst, or solid mass—which can help determine management (Figs.
14.24 and 14.25). Solid components, mural nodules, papillary excrescences, and ascites increase the suspicion of malignancy (220). A number of different ultrasound scoring systems were developed in an effort to quantify risks of malignancy.
Transvaginal and transabdominal ultrasonography are complementary in the diagnosis of pelvic masses, particularly those that have an abdominal component. Transvaginal ultrasonography has the advantage of providing additional information about the internal architecture or anatomy of the mass. Heterogeneous pelvic masses, described as tubo-ovarian abscesses on transabdominal ultrasonography, can be differentiated as pyosalpinx, hydrosalpinx, tubo-ovarian complex, and tubo-ovarian abscess with transvaginal ultrasonography (Fig. 14.26).
The diagnostic accuracy of transvaginal ultrasonography in diagnosing endometrioma can be quite high (Fig. 14.27). Endometriomas can have a variety of ultrasonographic appearances, from purely cystic to varying degrees of complexity with septation or debris to a solid appearance. A variety of scoring systems were developed with the intent of predicting benign versus malignant adnexal masses using ultrasound; the ultrasonographic morphologic characteristics used in many types of scoring systems are listed in Table 14.13 (220). Color ﬂow Doppler was added to other sonographic characteristics to predict risk of malignancy; ultrasound techniques are comparable to CT and MRI in differentiating benign from malignant masses (221,222). Although an analysis of such features may be helpful, histologic confirmation of surgically removed persistent masses remains the standard of care.
Figure 14.24 Transvaginal ultrasound of a unilocular ovarian cyst.