From the Guidelines
The finding that requires further investigation is a palpable, non-tender right ovary in a 62-year-old slender patient. In postmenopausal women, the ovaries typically atrophy and become smaller, making them difficult to palpate during a bimanual examination. When an ovary is palpable in a postmenopausal woman, it raises concern for possible ovarian pathology, including ovarian malignancy, as supported by the guidelines from the American College of Radiology 1 and the National Comprehensive Cancer Network 1. This is true even if the ovary is non-tender, as ovarian cancers often develop without pain in early stages. The other findings described are normal variations:
- mild tenderness during ovarian palpation in slender women is common due to normal sensitivity;
- non-palpable ovaries in obese patients occur because adipose tissue makes palpation difficult;
- and non-palpable ovaries in a young woman with normal BMI during her first exam may be due to patient tension or anatomical variation. Any palpable adnexal mass in a postmenopausal woman warrants further evaluation with pelvic ultrasound and possibly CA-125 testing to rule out malignancy, as recommended by the European Society for Medical Oncology 1. The use of ultrasound-based diagnostic models, such as the International Ovarian Tumor Analysis (IOTA) Simple Rules risk model or the IOTA Assessment of Different NEoplasias in the adneXa (ADNEX) model, is preferable to CA-125 or other biomarkers for distinguishing between benign and malignant ovarian tumors 1.
From the Research
Findings Requiring Further Investigation
The following findings may require further investigation during a GYN exam:
- A palpable, non-tender right ovary in a 62-year-old slender patient 2
Rationale
This is because a postmenopausal palpable ovary can be a sign of potential ovarian cancer risk, and further evaluation using ultrasound (US) examination is necessary to assess the risk of malignancy 2.
Comparison of Other Options
In contrast:
- Mild tenderness when palpating the ovaries of a slender woman may not necessarily require further investigation, as it could be a normal finding in some cases
- Non-palpable ovaries of a 35-year-old obese patient or a 21-year-old patient with normal BMI during her first pelvic exam are not typically considered abnormal findings that require further investigation 3
Diagnostic Tools
Ultrasound (US) is the first-line imaging investigation for suspected adnexal masses, and can be used to evaluate ovarian tumors and differentiate between benign and malignant lesions 4, 5, 6. Magnetic Resonance Imaging (MRI) can also be used to characterize ovarian masses and provide accurate information about hemorrhage, fat, and collagen 4, 6.