Adnexal masses are uncommon occurrences in the adolescent population. However, when they occur, they are anxiety-provoking for both the patient and her family. Many practitioners are unfamiliar with the proper management of these adnexal masses and are quick to proceed with surgical intervention that is often unnecessary. The estimated incidence of adnexal masses in the adolescent population is approximately 2.6 per 100,000 girls younger than 18 years of age [1]. An estimated ten percent of pediatric ovarian masses are found to be malignant [2,3]. Ovarian malignancies account for only one percent of all malignancies found in female patients less than 15 years of age [4]. While the discovery of an ovarian mass in an adolescent patient is concerned, conservative management is warranted due to the fact that the majority of these tumors are benign [5]. It is important to be aware of the presentation, evaluation, and treatment of benign ovarian cysts in order to conserve ovarian function.

Ovarian masses are categorized as functional cysts, benign neoplasms, or malignant neoplasms. In a review of females under the age of 21 undergoing surgery for an adnexal mass, 57.9% of the cases were diagnosed with an ovarian cyst [5]. The prepubertal adolescent is at risk of developing functional cysts due to the failure of involution of follicles [6]. Prepubertal cysts are commonly caused by gonadotropin stimulation of the ovary by the immature hypothalamic-pituitary axis [7]. Millar, et al. found ovarian cysts in 2% - 5% of prepubertal females undergoing ultrasound [7]. These cysts are mostly small (<1 cm) and insignificant. In the postpubertal adolescent, cysts result from failure of ovulation or persistence of ovarian follicles [6].

Ovarian masses present in many ways including abdominal pain, palpable abdominal mass, nausea, vomiting, increasing abdominal girth, and precocious puberty [2,8]. A review by Kanizsai, et al. demonstrated that in the adolescent population, cysts are most likely to be associated with irregular menstrual cycles [9]. In prepubertal females, an ovarian cyst most commonly presents as a palpable abdominal mass [2]. Ovarian torsion should be suspected for patients who present with a sudden onset of severe abdominal pain, fever, nausea, and vomiting [10].

Clinical symptoms have not shown to be reliable in the prediction of ovarian malignancy, although increased index of suspicion is warranted for patient who present with an asymptomatic palpable abdominal mass or signs and symptoms of precocious puberty [2,3,5,8]. Age at presentation may also pose a significant risk factor for malignancy, as Oltmann, et al. found a 3-fold greater odds ratio for malignancy in females aged 1- to 8-year compared to the 15- to 19-year-old group [2]. This study involved 424 patients with pediatric ovarian masses and found that 22% of patients aged 1 to 8 years were found to have a malignancy compared to 10% of patients aged 9 to 15 years [2].

A thorough history and physical should be obtained and diseases of the genitourinary and gastrointestinal tracts should be ruled out when patients present with abdominal pain or a palpable mass. It is important to discuss menstrual cycle, sexual history, and contraceptive methods to help elucidate the cause of symptoms. A pregnancy test and a complete blood count should be ordered immediately in patients who present with abdominal pain to identify the presence of pregnancy, leukocytosis, anemia, and hemorrhage. Ovarian torsion should be suspected if fever, severe pain, and leukocytosis are present [11]. Surgical emergencies including ectopic pregnancy, appendicitis, and ovarian torsion should be managed appropriately.

The diagnostic study of choice for an adnexal mass in the adolescent is ultrasonography. Transvaginal ultrasound is preferred if the patient is mature enough to tolerate exam. If not, a transabdominal image will suffice. A common finding on ultrasound is a functional cyst. Functional cysts form when a follicle fails to involute after ovulation and continues to enlarge [6]. Functional cysts are radiologically described as anechoic thin-walled cysts with distal acoustic enhancement [12]. Corpus luteum cysts are distinguished from “simple” or follicular cysts since they often display internal echoes [6]. If hemorrhage within the cyst occurs, the cyst may appear complex or solid [12]. A hemorrhagic cyst will first appear with a homogenous increase in echogenicity and fluid debris within the cyst [13]. The cyst will steadily decrease as the clot lyses [14]. In addition, evaluation of the fluid in pelvis can further correlate pathology, as blood appears echogenic and simple cystic fluid will appear anechoic [15]. A teratoma is visualized as a heterogeneous cysticsolid ovarian mass less than 8 cm on ultrasound [16]. An enlarged ovary and increased volume ratio in comparison to the contralateral ovary is indicative of an ovarian torsion [17]. In children, the presence of Doppler flow does not exclude torsion [14].

While cystic lesions are reassuring for a benign process, heterogeneous masses raise concern for malignancy [2]. Ultrasound findings consistent with malignancy include a solid lesion, increased vascular flow, septations of 3 mm or greater, and presence of ascites [18]. Size of tumor have not been shown to be a predictor of malignancy, although persistent or enlarging cysts are concerning for a malignant process [9,19].

If masses are complex, solid, or concerning for a malignant process, tumor markers are indicated. Unlike adult females, germ cell tumors are the most prevalent malignant ovarian tumor in adolescents and children [5]. Appropriate tumor markers include CA-125, alpha-fetoprotein, serum beta-hCG, estradiol, inhibin B, and lactate dehydrogenase levels [6]. Tumor markers may aid in diagnosis of a germ cell tumor but they have been reported to be elevated in only 54% of ovarian malignancies and 6.5% of benign lesions [2].

Simple cysts greater than 3 cm should be managed conservatively with monthly ultrasounds to confirm regression [20]. Ovarian cysts typically resolve spontaneously through 3 menstrual cycles [9]. For postpubertal females, timing of the ultrasound during the follicular phase of the cycle immediately after the menstrual cycle will avoid confusion between a follicle, corpus luteum, and persistent cyst [10]. Large ovarian cysts, defined as greater than 5 cm, require weekly ultrasounds [13]. Warner, et al. successfully managed 90% of children with large ovarian cysts without surgical intervention [13]. Hemorrhagic functional cysts may be confused with a malignant process due to its solid or complex characteristics but should regress in 2 to 8 weeks [21].

In conclusion, adolescents and children benefit from conservative management of ovarian cysts due to the fact that the majority of cysts are benign. If surgical intervention is necessary, the goal should be to preservation ovarian tissue in order to allow normal pubertal development and preserve fertility. Children and adolescent patients should be referred to a pediatric gynecologist or gynecologic surgeon with knowledge and experience in this topic in order to achieve the best possible outcome.