What is the best next step in managing a 17-year-old nulligravid (never having been pregnant) girl with a tender left adnexal mass, an 8-cm left ovarian cyst with calcifications and hyperechoic nodules, and intermittent left lower quadrant pain, worsened by intercourse and exercise?

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From the Guidelines

The best next step in management for this patient is surgical intervention, specifically laparoscopic cystectomy with preservation of normal ovarian tissue. This 17-year-old patient presents with symptoms and imaging findings highly suggestive of an endometrioma (chocolate cyst) or possibly a dermoid cyst. The large size (8 cm), presence of calcifications and hyperechoic nodules on ultrasound, along with the clinical presentation of cyclic pain worsening with intercourse and exercise, point toward these diagnoses. Additionally, her family history of endometriosis in her sister increases the likelihood of endometriosis. Conservative surgical management is preferred in this young nulligravid patient to preserve fertility while removing the pathology. During surgery, tissue should be sent for histopathological examination to confirm the diagnosis. Following surgery, hormonal therapy such as combined oral contraceptives may be recommended to suppress recurrence if endometriosis is confirmed. The patient should be counseled about the potential impact on future fertility and the possible need for follow-up imaging to monitor for recurrence. Medical management alone would be insufficient for a cyst of this size with concerning ultrasound features that require histological evaluation.

Key Considerations

  • The patient's symptoms and ultrasound findings are concerning for an endometrioma or dermoid cyst, which require histological evaluation to confirm the diagnosis.
  • The large size of the cyst (8 cm) and presence of calcifications and hyperechoic nodules increase the likelihood of a complex cyst that requires surgical intervention.
  • Conservative surgical management is preferred in this young nulligravid patient to preserve fertility while removing the pathology.
  • The patient's family history of endometriosis in her sister increases the likelihood of endometriosis, which requires surgical intervention to confirm the diagnosis and prevent future complications.

Management Recommendations

  • Surgical intervention, specifically laparoscopic cystectomy with preservation of normal ovarian tissue, is the recommended management approach for this patient.
  • Tissue should be sent for histopathological examination to confirm the diagnosis during surgery.
  • Hormonal therapy, such as combined oral contraceptives, may be recommended to suppress recurrence if endometriosis is confirmed.
  • The patient should be counseled about the potential impact on future fertility and the possible need for follow-up imaging to monitor for recurrence, as supported by recent studies 1.

From the Research

Diagnosis and Management

  • The patient's symptoms, such as colicky left lower quadrant pain that worsens with intercourse and exercise, and the presence of a tender left adnexal mass, suggest a possible diagnosis of ovarian torsion or an ovarian cyst 2, 3.
  • The ultrasonography results showing an 8-cm left ovarian cyst with calcifications and hyperechoic nodules support this diagnosis 2, 3.
  • The patient's family history of endometriosis, which can increase the risk of ovarian torsion, is also relevant 3.

Risk Factors and Treatment

  • The patient's age, symptoms, and ovarian mass size (>5 cm) increase her likelihood of ovarian torsion 3.
  • The study by 3 found that patients with a mass >5 cm had two times the odds of torsion, and that imaging was not reliable at identifying torsion.
  • The management of ovarian torsion typically involves surgery or detorsion, with the goal of preserving ovarian function 2, 3, 4.
  • The study by 4 found that surgery at the time of ovarian detorsion, such as cystectomy, does not appear to impact ovarian function when compared with detorsion alone.

Next Steps

  • Given the patient's symptoms, diagnosis, and risk factors, the best next step in management would be to proceed with surgical evaluation and possible detorsion or cystectomy 2, 3, 4.
  • The goal of treatment should be to preserve ovarian function and prevent further complications, such as infertility or malignancy 3, 4.

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

2
Research

A review of ovary torsion.

Tzu chi medical journal, 2017

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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