Description

• The ovaries are a source of many tumor types because they have complex histologies and embryonic origins.
• Adnexal masses have a wide differential diagnosis, including malignant or benign tumors, infectious processes, and ectopic pregnancy.
• Tumors are often clinically silent until well-developed.
• Tumors may have a mixture of solid or cystic components and may produce hormones.

Pediatric Considerations

• Ovarian masses are rare in the neonatal period.
• Malignancy must be ruled out in premenarchal patients.
• Management of tumors in pediatric patients must prioritize preservation of normal ovarian tissue.

Pregnancy Considerations

• Most cysts discovered during pregnancy are corpus luteum or follicular cysts.
• Large, bilateral theca lutein cysts in early pregnancy, in conjunction with an elevated hCG, should raise suspicion for a molar pregnancy.
• The most commonly encountered tumors during pregnancy are cystadenomas (serous/mucinous) and dermoid cysts.
• The ideal time for surgical management is the 2nd trimester.

Geriatric Considerations
The risk of malignancy is greatly increased in women age >50 years. Postmenopausal patients warrant comprehensive evaluation and follow-up.

Epidemiology

Incidence

• Premenarchal
  • 2–5% in prepubertal girls
  • Premenarchal girls have a 6–11% risk of malignancy in an ovarian tumor.
• Premenopausal
  • 30% in women with regular menses and 50% in women without regular menses
• Postmenopausal
  • Prevalence of ovarian tumor (benign or malignant) in postmenopausal women is 7%.
  • The risk of malignancy in an ovarian tumor in postmenopausal women is 29–35%.

Etiology and Pathophysiology

• Functional cyst
  • Results from dysregulation of ovarian follicles during the menstrual cycle
  • Bleeding into a functional cyst will result in a hemorrhagic cyst.
  • These cysts do not appear to be precursor lesions to epithelial ovarian malignancies.
• Endometrioma
  • Endometriosis causes localized, repeated ovarian hemorrhage.
  • May arise from retrograde menstruation
• Hormone mediated
  • Theca lutein cysts develop in response to β-hCG.

Risk Factors

• Benign ovarian tumors
  • Early menarche, obesity, infertility, and hypothyroidism
  • Cigarette smoking doubles the relative risk for developing functional ovarian cysts.
  • Risk factors for endometriomas and mature teratomas are not well-defined.
  • Tamoxifen increases the risk of ovarian cyst formation (15–30%).
  • Hormone replacement therapy increases the frequency of unilocular ovarian cysts in women age >50 years (1)[B].
• Malignant ovarian tumors
  • Lifetime risk of ovarian cancer is 1.3%, and the average age of diagnosis is 63 years.
  • In children up to 14 years old, 78% of malignant ovarian tumors are germ cell tumors (2)[B].
  • Risk factors for ovarian cancer include age >60 years, early menarche, late menopause, nulligravidity, infertility, endometriosis, polycystic ovary syndrome, family history of ovarian/breast/colon cancer, a personal history of breast/colon cancer, or a deleterious BRCA mutation.
  • Risk for ovarian cancer is decreased in women who have used oral contraceptive pills (OCPs) for at least 5 years, are multiparous, have a history of a tubal ligation or salpingectomy, or who have breastfed.
  • Limited studies show no clear evidence that fertility treatment increases the risk of a woman developing invasive ovarian cancer.

General Prevention

• OCPs do not increase rates of cyst resolution, but they do decrease the risk of forming new ovarian cysts.
• Continuous or cyclic use of oral contraceptives can reduce or delay recurrence of endometriomas following surgical excision (3)[B].