Figure 14.34 Management of endometrial hyperplasia. (Reproduced with permission from Berek & Hacker’s Gynecologic Oncology, 5th edition, Lippincott Williams & Wilkins, 2010, p 410.) a woman who is entirely asymptomatic and whose ultrasonographic examination was performed for indications unrelated to pelvic pathology. It is suggested that when the cyst is asymptomatic, small (<5–10 cm in diameter), unilocular, and thin walled, with a normal CA125 level, the risk of malignancy is extremely low and these masses can be followed conservatively, without surgery (220,264,265). Surgery may be indicated in some women with a strong family history of ovarian, breast, endometrial, or colon cancer, or with a mass that appears to be enlarging (see Chapter 37). The addition of color ﬂow Doppler examination and other ultrasonographic characteristics may be helpful in distinguishing benign from malignant masses, although the role of Doppler ultrasonography remains somewhat controversial (Tables 14.4 and 14.13) (220).
Uterine and Other Masses Many postmenopausal women have not had regular gynecologic care, and the discovery of a pelvic mass may reﬂect the persistence of a uterine leiomyoma that previously was not discovered. The possibility of transient ovarian cysts is noted above, and it may be difficult to distinguish an ovarian from a uterine mass. Some women may not remember having been told they had a pelvic mass. Thus, a review of medical records may be helpful in determining the preexistence of a benign pelvic mass. Uterine leiomyomas are hormonally responsive and typically decrease in size or resolve after menopause (see Chapter 15).
Diagnosis A personal and family medical history is helpful in detecting individuals at increased risk for the development of ovarian cancer. Several hereditary family cancer syndromes involve ovarian neoplasms (see Chapter 37). However, patients with hereditary forms of epithelial ovarian cancer account for only a small percentage of all cases; 90% to 95% of cases of ovarian cancer are sporadic and without identifiable heritable risk.
In postmenopausal women with a pelvic mass, a CA125 measurement may be helpful in predicting a higher likelihood of a malignancy, which may guide decisions regarding management, consultation, or referral. A high index of suspicion by both women and their clinicians represents the best way to detect early ovarian cancer. Persistent symptoms such as an increase in abdominal size, bloating, fatigue, abdominal pain, indigestion, inability to eat normally, urinary frequency, pelvic pain, constipation, back pain, new onset of urinary incontinence, or unexplained weight loss require evaluation and consideration of the possibility of ovarian cancer. A physical examination, transvaginal ultrasonography, and CA125 measurement are appropriate.
A normal CA125 level does not rule out ovarian cancer; up to 50% of early-stage ovarian malignancies and 20% to 25% of advanced cancers have normal values of CA125 (266).
Management The use of improved imaging techniques may allow the nonoperative management of ovarian masses that are probably benign (Table 14.13). A suspicious or persistent complex mass requires surgical evaluation. A physician trained to appropriately stage and debulk ovarian cancer, such as a gynecologic oncologist, should perform the surgery in a hospital with the necessary support and consultative services to optimize the patient’s outcome (266). When a malignant ovarian mass is discovered and the appropriate surgical staging and debulking procedure cannot be performed by the generalist obstetrician-gynecologist, a gynecologic oncologist should be consulted. Comprehensive surgical staging facilitates appropriate therapy and optimizes prognosis.