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INTRODUCTION

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Uterine adnexae are defined as the areas adjacent to the uterus that are occupied by the fallopian tubes and ovaries. The embryologic origin of the fallopian tubes and ovaries are 2 distinct events in the development of a female embryo. Development of the ovaries begins before the development of the remainder of the genital tract. The origin of the male and female gonads are similar up until the seventh week of gestation, at which time the primitive sex cords begin to break up in the female embryo. The developing ovary eventually has 3 layers: the surface epithelium, primitive germ cells, and sex cord epithelium. These layers give rise to the 3 main types of ovarian tumors: (1) epithelial tumors, which comprise approximately 70% of all ovarian neoplasms; (2) germ cell tumors, which comprise 15% to 20% of ovarian tumors; and (3) sex cord–stromal tumors, which account for 5% to 10% of ovarian tumors. The remainder of the masses are a result of metastatic or secondary involvement to the ovary.1

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It is estimated that 289,000 women will undergo surgical intervention for an adnexal mass in the United States every year.2 This represents one of the most common indications for gynecologic surgery.3 The determination of whether a mass represents a condition that requires immediate surgical intervention, or is likely to be malignant or benign, is of paramount

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importance. A patient's demographics, presenting symp-toms, physical examination, imaging, laboratory studies, and family history can provide invaluable insights in determining the appropriate treatment plan. Given this information, a physician can form an accurate differential diagnosis and establish an appropriate management plan.

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DIAGNOSIS

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Key Points

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  1. Ultrasound characteristics of malignant adnexal masses include presence of complex or solid components, presence of ascites, bilaterality, and size greater than 10 cm.

  2. Serum tumor markers useful in the evaluation of adnexal masses include CA125, alpha-fetoprotein, lactate dehydrogenase, human chorionic gonadotropin, and inhibin A and B.

  3. Novel markers, including human epididymis 4 pro-tein (HE4), transthyretin, transferrin, β-microglobulin, and apolipoprotein A1 may improve preoperative assessment of the risk of malignancy in adnexal masses.

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Symptoms

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Not all patients with an adnexal mass initially present with symptoms. Some masses are found incidentally on imaging ordered for the evaluation of unrelated conditions. However, when patients do present with symptoms, detailed evaluation and characterization of the reporting signs can provide insight into the etiology of the mass. Physicians should question patients regarding the duration, intensity, location, and radiation of their pain to determine whether immediate surgical intervention is needed for conditions such as ovarian torsion or ectopic pregnancy. Physicians should also perform a complete review of systems focusing on symptoms that can help elucidate the etiology of an adnexal mass such as the following: fevers, chills, vaginal discharge, vaginal bleeding, weight loss, abdominal bloating, changes in bowel or bladder function, and ...

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