What is the next step in managing an incompletely assessed left ovarian lesion in a patient who refuses a pelvic ultrasound?

From the Guidelines

For a patient with an incompletely assessed left ovarian lesion who refuses pelvic ultrasound, I recommend scheduling an MRI of the pelvis with contrast as the next step. This imaging modality can provide detailed characterization of the 24 x 19 x 21mm left ovarian lesion without requiring a transvaginal approach, as suggested by the most recent guidelines 1. The MRI can help differentiate between an endometrioma, hemorrhagic cyst, or other pathology that was not fully assessed on the transabdominal ultrasound.

While waiting for the MRI, the patient should be monitored for symptoms such as increasing pelvic pain, changes in menstrual pattern, or other concerning symptoms that might indicate complications. The importance of further imaging should be emphasized to the patient, as proper characterization of ovarian lesions is essential for appropriate management, with indeterminate lesions being typically benign but carrying a risk of malignancy ranging from 3.6% to 10.7% 1.

If the patient continues to refuse all pelvic imaging, a discussion about the risks of inadequate assessment, including delayed diagnosis of potential malignancy, should be documented. The MRI is particularly valuable in this case because the ultrasound report indicates a slightly lobulated echogenic lesion that requires further evaluation to rule out more serious pathology, and MRI can assign a specific benign diagnosis or stratify for risk of malignancy, thus potentially altering further imaging follow-up intervals 1.

Key points to consider include:

• The patient's refusal of pelvic ultrasound necessitates an alternative imaging approach.
• MRI with contrast is the recommended next step for characterizing the left ovarian lesion.
• Monitoring for symptoms and emphasizing the importance of further imaging are crucial for patient management.
• The risk of malignancy in indeterminate lesions, although generally low, warrants thorough evaluation.
• Recent guidelines support the use of MRI for further assessment of adnexal masses when initial ultrasound findings are indeterminate or inconclusive 1.

From the Research

Next Steps for Patient with Ovarian Cyst

Given the patient's ultrasound report and their reluctance to undergo a pelvic ultrasound, the following considerations should be taken into account:

• The patient's ultrasound report indicates an ongoing echogenic lesion in the left ovary, which could be an endometrioma, hemorrhagic cyst, or other lesion 2, 3.
• The report also mentions that further detailed assessment is not possible due to the transabdominal nature of the study, suggesting that a transvaginal ultrasound might provide more accurate information 3.
• Studies have shown that transvaginal ultrasound is a cost-effective method for diagnosing most cystic ovarian lesions in premenopausal women 3.
• However, the patient's reluctance to undergo a pelvic ultrasound should be respected, and alternative approaches should be considered.

Alternative Approaches

• The patient's medical history and symptoms should be taken into account to determine the best course of action 4.
• If the patient is asymptomatic and not at increased risk of any specific gynecologic condition, a routine screening pelvic examination may not be necessary 4.
• The decision to perform a pelvic examination or further imaging should be a shared decision between the patient and their healthcare provider 4.

Considerations for Ovarian Cysts

• Ovarian cysts are common in asymptomatic women, and most are benign 5.
• The prevalence of ovarian lesions increases with age, and benign ovarian lesions are found in about 1 in 25 gynecologically asymptomatic women aged 20-39 years 5.
• The natural history of ovarian cysts needs to be elucidated in a large prospective observational study to inform management decisions 5.