A 17-year-old nulligravid girl comes to the office due to 2 months of colicky left lower quadrant pain. The pain worsens with intercourse and exercise but resolves spontaneously. She has had no diarrhea, constipation, or urinary symptoms. Her last menstrual period was 3 weeks ago. Menses occur monthly and last 5-6 days with 2 days of heavy bleeding. The patient is sexually active with a new partner and uses condoms for contraception. She has no chronic medical conditions and has had no surgeries. She does not use tobacco, alcohol, or illicit drugs. Her older sister recently had in vitro fertilization due to infertility from endometriosis. Vital signs are normal. Pelvic examination shows a tender left adnexal mass and small, mobile uterus. Urine pregnancy test is negative. Neisseria gonorrhoeae and Chlamydia trachomatis testing is negative. Ultrasonography reveals an 8-cm left ovarian cyst with calcifications and hyperechoic nodules. Which of the following is the best next step in management of this patient?

Question

A 17-year-old nulligravid girl comes to the office due to 2 months of colicky left lower quadrant pain.  The pain worsens with intercourse and exercise but resolves spontaneously.  She has had no diarrhea, constipation, or urinary symptoms.  Her last menstrual period was 3 weeks ago.  Menses occur monthly and last 5-6 days with 2 days of heavy bleeding.  The patient is sexually active with a new partner and uses condoms for contraception.  She has no chronic medical conditions and has had no surgeries.  She does not use tobacco, alcohol, or illicit drugs.  Her older sister recently had in vitro fertilization due to infertility from endometriosis.  Vital signs are normal.  Pelvic examination shows a tender left adnexal mass and small, mobile uterus.  Urine pregnancy test is negative.  Neisseria gonorrhoeae and Chlamydia trachomatis testing is negative.  Ultrasonography reveals an 8-cm left ovarian cyst with calcifications and hyperechoic nodules.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d9d8_7070_bc81_4d0d67f2ca13_MD0003_00 This patient has a mature cystic teratoma (dermoid cyst), a benign ovarian germ cell tumor common in premenopausal women. Dermoid cyst contents include sebaceous fluid, hair, and teeth, creating ultrasound findings of hyperechoic nodules and calcifications. Although many dermoid cysts are asymptomatic, the heterogeneous solid and fluid components of varying density create an inherently unbalanced tumor that predisposes some patients to develop partial adnexal rotation (ie, intermittent torsion). This torsion results in an intermittent, colicky pelvic pain, often triggered by physical activity (eg, intercourse, exercise) impeding ovarian blood flow. The pain resolves spontaneously once the adnexa untwists and blood flow returns. However, some patients develop persistent ovarian torsion, which is a gynecologic surgical emergency because persistent torsion results in ischemia and eventual necrosis of the ovary. Therefore, dermoid cysts are surgically removed with either a laparoscopic ovarian cystectomy or oophorectomy to reduce the risk of ovarian torsion and prevent complications (eg, infertility, hemorrhage, sepsis) associated with ovarian necrosis. (Choice A) Broad-spectrum intravenous antibiotics are indicated for suspected tubo-ovarian abscess, a purulent polymicrobial fluid collection with a sonographic appearance of a multiloculated, cystic adnexal mass. Unlike this patient, there are typically no echogenic nodules or calcifications. (Choice B) CA-125 and CEA are tumor markers that can be increased in patients with epithelial ovarian cancer and are used in monitoring cancer progression or recurrence. Testing for either is not indicated in initial evaluation of adnexal masses in premenopausal women due to low sensitivity and specificity. (Choice C) GnRH agonists (eg, leuprolide) treat endometriosis through estrogen suppression, which induces regression of implants and reduction of chronic pelvic pain. Ovarian endometriomas appear on ultrasound as homogeneous cystic masses with a diffuse "ground-glass" appearance rather than hyperechoic nodules or calcifications. (Choice E) Physiologic follicular cysts are managed with observation and repeat ultrasound in 6 weeks because these typically resolve spontaneously. Follicular cysts occur in the first half of the menstrual cycle (follicular phase) and resolve after ovulation (luteal phase); they appear simple and thin-walled. Educational objective: Mature cystic teratomas are benign germ cell tumors common in premenopausal women. These heterogeneous tumors (eg, hair, teeth) appear on sonogram as complex ovarian cysts with calcified, hyperechoic areas. Treatment is with surgical removal to reduce the risk of ovarian torsion. References: Dermoid cysts in adolescents. (http://www.ncbi.nlm.nih.gov/pubmed/26308203) Surgical treatment of mature cystic teratomas: a comparison of emergent and elective surgeries. (http://www.ncbi.nlm.nih.gov/pubmed/27935160) Torsed ovarian dermoid. (http://www.ncbi.nlm.nih.gov/pubmed/27054654)

A 17-Year-Old Nulligravid Girl Comes to the Office Due to 2