Management of Elderly Woman with Abdominal Pain and Adnexal Mass
An elderly (postmenopausal) woman with abdominal pain and an adnexal mass requires immediate comprehensive ultrasound evaluation (transvaginal, transabdominal, and color Doppler) to risk-stratify the mass, followed by gynecologic oncology referral if suspicious features are present, or MRI with contrast if indeterminate. 1, 2
Initial Diagnostic Approach
Perform comprehensive ultrasound evaluation as the essential first-line imaging:
Transvaginal ultrasound combined with transabdominal and color/power Doppler imaging is the mandatory initial imaging modality for all postmenopausal women with adnexal masses, achieving >90% sensitivity for detecting adnexal pathology 3, 1, 2
Color Doppler evaluation is critical to assess vascularity within solid components and identify flow patterns that distinguish benign from malignant masses 3, 1
The ultrasound report must document: mass size, laterality, septation thickness, presence of solid components/papillary projections/excrescences, vascular flow patterns, and ascites 4
Risk Stratification Based on Ultrasound Features
Classify the mass into one of three categories to guide management:
Benign Features (No Further Workup Needed)
Simple cysts <3 cm (unilocular, no internal echoes, thin walls, no solid components, no vascularity) carry extremely low malignancy risk (0.3-0.4%) and require no follow-up 1, 2
Simple cysts >3 cm warrant single follow-up ultrasound in 3-6 months to confirm stability, as 53% spontaneously resolve and 28% remain stable 3, 2
Specific benign diagnoses can be established for dermoids (echogenic attenuating component with fat), endometriomas (low-level internal echoes), and pedunculated fibroids (connection to uterus via bridging vessel) 3, 1
Indeterminate Features (Requires MRI)
Masses with multiple septations, solid components without clear malignant features, or papillary projections carry only 3.6-10.7% malignancy risk 1
MRI pelvis with and without IV contrast is the problem-solving modality of choice, achieving 100% sensitivity and 77.7-85.1% specificity, with no malignancies misclassified as benign 3, 1, 2
MRI identifies vascular vegetations in cystic masses and enhancement patterns of solid tissue, which are the best indicators of malignancy 3, 1
Suspicious Features (Requires Oncology Referral)
Large mass size, complexity, irregular projections, thick septations, solid components with vascularity, or ascites indicate high malignancy risk 5, 6, 7
Immediate referral to gynecologic oncologist is mandatory, as this is the second most important prognostic factor after stage, yet only 33% of women with ovarian cancer receive appropriate subspecialty referral 1
CT abdomen and pelvis with IV contrast should be obtained for staging evaluation once malignancy is suspected 3, 1, 2
Role of Tumor Markers
CA-125 has limited utility and should not guide initial management:
CA-125 alone performs worse than ultrasound in distinguishing benign from malignant masses and should not be used as a standalone test 3, 1
When combined with Doppler showing resistive index <0.5 and CA-125 cutoff of 65 U/mL (not the standard 35 U/mL), specificity reaches 100%, but only for masses already suspected malignant on ultrasound 3, 1
CA-125 may assist in evaluation but should be interpreted alongside imaging findings, not in isolation 5, 4
Critical Management Pitfalls to Avoid
Never obtain CT for initial mass characterization, as CT has poor soft-tissue discrimination in the adnexal region and wastes resources while exposing patients to radiation without diagnostic benefit 3, 1
Do not skip color Doppler evaluation, as vascularity patterns are critical for risk assessment and cannot be determined by grayscale ultrasound alone 3, 1
Avoid over-surveillance of simple cysts, as large studies show simple cysts carry 0-0.5 cases per 10,000 women 3-year cancer risk, equivalent to women with normal ovaries 1
Recognize that surgical exploration of benign lesions carries 2-15% complication rates, making accurate preoperative characterization essential to prevent unnecessary surgery 1
Ensure masses >6 cm or persisting >12 weeks are referred to gynecology or gynecologic oncology, as delayed referral worsens outcomes 5, 6, 7
Addressing the Abdominal Pain
The presence of abdominal pain in this elderly woman raises concern for malignancy:
Persistent pelvic/abdominal pain, increased abdominal size/bloating, urinary urgency/frequency, and difficulty eating occurring >12 times per month are symptoms suggestive of ovarian cancer and warrant thorough evaluation 5, 4
Pain may also indicate complications such as torsion, rupture, or hemorrhage, which require urgent surgical evaluation if acute 6, 7
The combination of pain and an adnexal mass in a postmenopausal woman should prompt expedited workup rather than watchful waiting 4, 7