A 34-year-old woman comes to the office for a routine examination. The patient has regular menses every 28 days that last 5 days; the first 2 days are accompanied by crampy abdominal pain that is relieved with ibuprofen. Her last menstrual period was 2 weeks ago. She is sexually active with her husband, who has had a vasectomy. On review of systems, the patient reports intermittent dull pelvic pain that started 2 days ago; the pain is worse with physical activity. Similar pain episodes occasionally occur about a week before menses. The patient has had no abdominal swelling or bloating, nausea, vomiting, or changes in bowel or bladder habits. Vital signs are normal. The abdomen is nontender and nondistended and has normal bowel sounds. Speculum examination shows a normal-appearing cervix. Bimanual examination reveals a 4-cm, nontender, right adnexal mass. The remainder of the physical examination is unremarkable. Urine pregnancy test is negative. Which of the following is the best next step in management for this patient?

Question

A 34-year-old woman comes to the office for a routine examination.  The patient has regular menses every 28 days that last 5 days; the first 2 days are accompanied by crampy abdominal pain that is relieved with ibuprofen.  Her last menstrual period was 2 weeks ago.  She is sexually active with her husband, who has had a vasectomy.  On review of systems, the patient reports intermittent dull pelvic pain that started 2 days ago; the pain is worse with physical activity.  Similar pain episodes occasionally occur about a week before menses.  The patient has had no abdominal swelling or bloating, nausea, vomiting, or changes in bowel or bladder habits.  Vital signs are normal.  The abdomen is nontender and nondistended and has normal bowel sounds.  Speculum examination shows a normal-appearing cervix.  Bimanual examination reveals a 4-cm, nontender, right adnexal mass.  The remainder of the physical examination is unremarkable.  Urine pregnancy test is negative.  Which of the following is the best next step in management for this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d9cf_48a4_bc81_41acfd1ac72e_MD0003_00 This premenopausal patient has recurrent midcycle pelvic pain and a small, nontender adnexal mass that is likely due to recurrent physiologic cysts (or Mittelschmerz) secondary to ovulation. Recurrent physiologic cysts are benign; however, because a variety of gynecologic conditions can present with an adnexal mass, further evaluation is indicated. Initial evaluation of all adnexal masses in premenopausal women is with a pregnancy test and pelvic ultrasound, which helps further identify the masses: Location, with the adnexal mass originating from the fallopian tube (eg, hydrosalpinx), ovary (eg, endometrioma), or uterus (eg, pedunculated uterine fibroid) Emergent nature by evaluating for a fetal heartbeat, blood flow to the ovary, and free fluid in the pelvis (eg, ectopic pregnancy, ovarian torsion) Internal features, which can help determine whether the mass is a benign (eg, simple, thin-walled, mobile) or malignant (eg, thick septations, solid components, immobile) process Pelvic ultrasound is the preferred imaging modality for evaluation of the female reproductive tract because of its ease of use, high specificity for determining a disease process (particularly in distinguishing from benign and malignant conditions), and fetal safety profile. (Choice A) FSH levels are typically used to evaluate disorders of the hypothalamic-pituitary-ovarian axis that present with amenorrhea or abnormal uterine bleeding. LH levels can be used to track ovulation in patients with infertility. Neither is used in the evaluation of adnexal masses. (Choices C, D, and E) Although this patient's history is suggestive of recurrent physiologic/functional cysts (based on midcycle pain that resolves around menses), the adnexal mass still requires evaluation with pelvic ultrasound. If the ultrasound shows a benign cyst, a repeat ultrasound in 6 weeks is performed to evaluate for cyst resolution. Benign cysts can be managed with reassurance and routine follow up; patients with recurrent pain symptoms can be treated with continuous oral contraceptives. (Choice F) A CA-125 level, a nonspecific marker for epithelial ovarian cancer, is used in the evaluation of adnexal masses; however, it is more specific for ovarian cancer in postmenopausal women who no longer have benign reasons for CA-125 elevation (eg, fibroids, endometriosis). Educational objective: Premenopausal women with an adnexal mass on pelvic examination require further evaluation with a pregnancy test and pelvic ultrasound, which helps identify the mass location, emergent nature, and internal features (eg, benign vs malignant). References: Adnexal masses: characterization and imaging strategies. (http://www.ncbi.nlm.nih.gov/pubmed/20974354)

A 34-Year-Old Woman Comes to the Office for a Routine