Table 14.12 Conditions Diagnosed as a Pelvic Mass in Women of Reproductive Age
Less common conditions that must be excluded:
Carcinoma of the colon, rectum, appendix
Carcinoma of the fallopian tube
Reproductive-Age Conditions diagnosed as a pelvic mass in women of reproductive age are presented in Pelvic Masses Table 14.12.
Differential Diagnosis It is difficult to determine the frequency of diagnoses of pelvic mass in women of reproductive age because many pelvic masses are not treated with surgery. Nonovarian or nongynecologic conditions may be confused with an ovarian or uterine mass (Table 14.12). The frequency of masses found at laparotomy was studied, although the percentages are affected by varying indications for surgery, indications for referral, type of practice (gynecologic oncology vs. general gynecology), and patient populations (a higher percentage of African Americans with uterine leiomyomas, for example). Benign masses, such as functional ovarian cysts or asymptomatic uterine leiomyoma, typically do not require or warrant surgery (Table 14.4).
Age is an important determinant of the likelihood of malignancy. In one study of women who underwent laparotomy for pelvic mass, malignancy was seen in only 10% of those younger than 30 years of age, and most of these tumors had low malignancy potential (194). The most common tumors found during laparotomy for pelvic mass are mature cystic teratomas or dermoids (seen in one-third of women younger than 30 years of age) and endometriomas (approximately one-fourth of women 31 to 49 years of age) (194,195).
Uterine leiomyomas, commonly termed uterine fibroids, are by far the most common benign uterine tumors and are usually asymptomatic (195). Other benign uterine growths, such as uterine vascular tumors, are rare. See Chapter 15 for discussion of diagnosis, types and locations of fibroids, incidence, symptoms, causes, natural history, pathology, and management.
During the reproductive years, the most common ovarian masses are benign. Ovarian masses can be functional or neoplastic, and neoplastic tumors can be benign or malignant. Functional ovarian masses include follicular and corpus luteal cysts. About two-thirds of ovarian tumors are encountered during the reproductive years. Most ovarian tumors (80% to 85%) are benign, and two-thirds of these occur in women between 20 and 44 years of age. The chance that a primary ovarian tumor is malignant in a patient younger than 45 years of age is less than 1 in 15. Most tumors produce few or only mild, nonspecific symptoms. The most common symptoms include abdominal distension, abdominal pain or discomfort, lower abdominal pressure sensation, and urinary or gastrointestinal symptoms. If the tumor is hormonally active, symptoms of hormonal imbalance, such as vaginal bleeding related to estrogen production, may be present. Acute pain may occur with adnexal torsion, cyst rupture, or bleeding into a cyst. Pelvic findings in patients with benign and malignant tumors may differ. Masses that are unilateral, cystic, mobile, and smooth are most likely to be benign, whereas those that are bilateral, solid, fixed, irregular, and associated with ascites, cul-de-sac nodules, and a rapid rate of growth are more likely to be malignant (196).
In assessing ovarian masses, the distribution of primary ovarian neoplasms by decade of life can be helpful (197). Ovarian masses in women of reproductive age are most likely benign, but the possibility of malignancy must be considered (Fig. 14.20) (196).