Ovarian masses in premenopausal women

ovarian massThis Guideline outlines the management of ovarian masses in premenopausal women.

If a cyst is suspected or found, take a full history, including family history and other malignancy risk factors. Ask for features that could indicate endometriosis or malignancy (early satiety or altered appetite, abdominal discomfort or urinary frequency or urgency).

Examine the person, including doing a vaginal examination.

Organise an ultrasound scan.

Simple cysts – most of these are functional

  • If it is less than 30mm, it doesn’t count as a cyst.
  • If it is less than 50mm, no further investigation is needed.
  • If it is 50 to 70mm, do annual USS. If the cyst persists or grows, refer to gynae.
  • If it is over 70mm, refer to gynae as may well be removed (as chance of becoming symptomatic is higher).

Complex cysts – try to evaluate risk of being malignant

  • Do CA125
  • If woman under 40, also do LDH, aFP, hCG (looking for germ cell tumours).
  • Calculate the RMI (Risk of Malignancy Index). It doesn’t give a cut-off for referral, but levels over 200 definitely need referral
    • RMI = U x M x CA125
    • U = Ultrasound features. U = 0 for 0 features. U = 1 for 1 feature. U = 3 for 2-5 features. Features include multi-locular cyst, solid areas, metastases, ascites, and bilateral lesions.
    • M = Menopausal status. 1 = premenopausal. 3 = postmenopausal.
    • CA125 measured in IU/ml
  • If any ‘malignant’ features on USS – refer to gynae oncology service:
    • Irregular solid tumour
    • Ascites
    • At least 4 papillary structures
    • Irregular, multi-locular tumour with largest diameter > 100mm
    • Very strong Blood Flow

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