# Clinical Cases: Pelvic Masses and Ovarian Disease

## Case 1: Ovarian Torsion

### Patient Demographics
- **Age:** 25 years
- **Sex:** Female
- **Occupation:** Graduate student

### Chief Complaint
"I woke up with the worst pain in my right side. I'm going to throw up."

### History of Present Illness
The patient presents to the emergency department with sudden onset of severe right lower quadrant pain that woke her from sleep 4 hours ago. The pain is constant, rated 10/10, and has not responded to ibuprofen. She has vomited 3 times since the pain started. She denies fever, diarrhea, dysuria, or vaginal bleeding. Her last menstrual period was 2 weeks ago. She has had similar but less severe episodes of right-sided pain twice in the past month that resolved spontaneously.

### Gynecologic History
- Menarche: Age 12
- Cycles: Regular, 28 days
- LMP: 14 days ago
- Sexually active: Yes, one partner
- Contraception: Combined oral contraceptive pills
- Prior pregnancies: G0
- No prior surgeries

### Past Medical History
- Ovarian cyst found incidentally on ultrasound 3 months ago during evaluation for pelvic pain (5 cm, described as dermoid)
- Recommended observation at that time

### Physical Examination
- **Vital Signs:** BP 118/72, HR 108 (tachycardic), RR 20, Temp 98.6F
- **General:** Appears in significant distress, diaphoretic, crying in pain
- **Abdomen:** Soft, severe tenderness to palpation in right lower quadrant, guarding but no rebound, decreased bowel sounds
- **Pelvic:** Cervix normal, uterus normal size, right adnexa extremely tender with palpable fullness, left adnexa non-tender

### Differential Diagnosis
1. **Ovarian torsion** (most likely given known cyst and sudden onset)
2. Ruptured ovarian cyst
3. Appendicitis
4. Ectopic pregnancy
5. Tubo-ovarian abscess

### Diagnostic Workup

**Laboratory Studies:**
| Test | Result | Interpretation |
|------|--------|----------------|
| Urine hCG | Negative | Rules out ectopic pregnancy |
| WBC | 12,500 | Mild leukocytosis (stress response) |
| Hemoglobin | 13.2 g/dL | Normal (no significant bleeding) |

**Transvaginal Ultrasound:**
- Right ovary: Enlarged (8 cm), heterogeneous appearance, edematous stroma
- 6 cm mature cystic teratoma (dermoid) within right ovary
- Follicles displaced to periphery
- **Doppler:** Absent arterial and venous flow to right ovary
- Left ovary: Normal
- No free fluid

### Diagnosis
**Right Ovarian Torsion**
- Sudden severe pain with nausea/vomiting
- Known ovarian mass (risk factor)
- Enlarged, edematous ovary with absent Doppler flow
- Previous intermittent episodes (likely intermittent torsion)

### Emergency Surgical Consultation

**Indications for Urgent Surgery:**
- Clinical presentation strongly suggestive of torsion
- Absent Doppler flow (though normal flow does not exclude torsion)
- Do not delay for additional imaging

### Surgical Management: Laparoscopic Detorsion

**Operative Findings:**
- Right adnexa twisted 720 degrees (2 complete turns)
- Ovary appears dusky purple/blue
- Dermoid cyst (6 cm) visible within ovary

**Procedure:**
1. Detorsion performed by untwisting counterclockwise
2. Observed for reperfusion for 10 minutes
3. Ovary gradually regained pink color (viable!)
4. Ovarian cystectomy performed to remove dermoid
5. Ovary preserved
6. Oophoropexy (plication to shorten utero-ovarian ligament) to prevent recurrence

**Post-Detorsion Appearance:**
- Ovary pink with good perfusion
- Capsule intact
- No necrotic areas

### Pathology
- Mature cystic teratoma (dermoid cyst)
- Contains hair, sebaceous material, tooth
- Benign

### Postoperative Course
- Pain significantly improved
- Started on PO intake evening of surgery
- Discharged POD 1

### Patient Counseling
- Ovary was saved despite dusky appearance
- Most ovaries recover function after detorsion (even if they look "dead")
- Oophoropexy reduces but does not eliminate recurrence risk
- Monitor for any return of symptoms
- Fertility should be preserved

### Teaching Points
- Ovarian torsion is a surgical emergency - time to intervention matters
- Risk factors: Ovarian mass 5-8 cm (most significant), pregnancy, ovulation induction
- Classic presentation: Sudden severe unilateral pain with nausea/vomiting
- Intermittent torsion: Waxing and waning pain from twisting and untwisting
- Doppler findings can be normal in early or intermittent torsion
- Clinical suspicion should drive decision to operate
- Always attempt detorsion first - do NOT remove ovary based on appearance alone
- Even dusky/blue ovaries frequently recover after detorsion

### Clinical Image
![Ovarian Torsion](case_01_image.jpg)

**Image Description:** Laparoscopic image demonstrating a torsed right ovary with dusky purple discoloration. The adnexa is twisted on its vascular pedicle. After detorsion, the ovary gradually regained normal pink coloration indicating restoration of blood flow.

**Attribution:** Educational illustration. Used for medical education purposes.

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## Case 2: Complex Ovarian Mass in a Postmenopausal Woman

### Patient Demographics
- **Age:** 62 years
- **Sex:** Female
- **Occupation:** Retired schoolteacher

### Chief Complaint
"I've been feeling bloated and my pants don't fit anymore."

### History of Present Illness
The patient reports 3 months of progressive abdominal bloating, early satiety, and a 10-pound unintentional weight loss. She initially attributed symptoms to digestive issues but they have progressively worsened. She now feels full after eating only small amounts and has noticed her abdomen is larger despite losing weight. She denies vaginal bleeding, pelvic pain, or changes in bowel or bladder function. She has not seen a gynecologist in 5 years.

### Gynecologic History
- Menarche: Age 11
- Menopause: Age 52
- No hormone replacement therapy
- Prior pregnancies: G2P2
- Last Pap smear: 5 years ago (normal)
- No history of abnormal Pap smears

### Past Medical History
- Hypertension (on lisinopril)
- Hyperlipidemia (on atorvastatin)
- Prior cholecystectomy

### Family History
- Mother: Breast cancer at age 68
- Sister: Ovarian cancer at age 58 (deceased)
- Maternal aunt: Breast cancer at age 55

### Physical Examination
- **Vital Signs:** BP 138/82, HR 78, Weight 155 lbs (down from 165 lbs 3 months ago)
- **General:** Thin-appearing woman in no acute distress
- **Abdomen:** Distended, firm, palpable mass extending from pelvis to umbilicus, shifting dullness present (ascites), non-tender
- **Pelvic:** Cervix atrophic, uterus obscured by mass, large pelvic mass filling pelvis and extending into abdomen, fixed

### Concerning Features
- Postmenopausal with new pelvic mass
- Symptoms classic for ovarian cancer (bloating, early satiety, weight loss)
- Ascites present
- Fixed, large mass
- Strong family history of breast and ovarian cancer

### Diagnostic Workup

**Laboratory Studies:**
| Test | Result | Interpretation |
|------|--------|----------------|
| CA-125 | 842 U/mL | Markedly elevated (normal <35) |
| CBC | Normal | |
| CMP | Albumin 3.0 g/dL | Slightly low (chronic illness) |
| HE4 | 220 pmol/L | Elevated |
| ROMA score | 85% | High probability of malignancy |

**Transvaginal and Transabdominal Ultrasound:**
- Large complex pelvic mass (12 cm) with solid and cystic components
- Thick septations (>3 mm)
- Papillary projections into cyst
- Internal vascularity on Doppler
- Moderate ascites
- Right ovary not separately visualized (mass arising from right adnexa)
- Left ovary: Atrophic, normal

**CT Abdomen/Pelvis:**
- 12 cm complex right ovarian mass
- Moderate ascites
- Omental thickening (omental caking) - suspicious for peritoneal carcinomatosis
- Enlarged para-aortic lymph nodes (up to 2 cm)
- No liver metastases
- No hydronephrosis

### Diagnosis
**Suspected Ovarian Malignancy (High-Grade Serous Carcinoma)**
- Postmenopausal with complex adnexal mass
- Markedly elevated CA-125
- Suspicious imaging features (solid components, papillary projections, ascites)
- Omental caking suggesting advanced disease
- Strong family history suggesting possible hereditary cancer syndrome

### Referral to Gynecologic Oncology

**Indication for Oncology Referral:**
- Postmenopausal patient with:
  - Elevated CA-125
  - Complex mass with solid components
  - Ascites
  - Imaging suggestive of metastatic disease

**Benefit of Subspecialty Care:**
- Gynecologic oncologists achieve better surgical outcomes
- Complete cytoreduction improves survival

### Surgical Planning

**Preoperative:**
- Genetic counseling and BRCA testing initiated
- Paracentesis for symptom relief (4 L ascitic fluid removed)
- Cytology of ascites: Positive for adenocarcinoma
- Bowel prep administered
- Discussed goal of optimal debulking

### Surgical Treatment: Exploratory Laparotomy and Tumor Debulking

**Operative Findings:**
- Moderate ascites
- 14 cm right ovarian mass with capsular rupture
- Omental carcinomatosis
- Diaphragm implants bilaterally
- Para-aortic lymphadenopathy
- No liver or splenic involvement
- Bowel serosa implants (superficial)

**Procedure Performed:**
- Total abdominal hysterectomy
- Bilateral salpingo-oophorectomy
- Total omentectomy
- Para-aortic and pelvic lymphadenectomy
- Peritoneal stripping from diaphragm
- Appendectomy

**Outcome:**
- Optimal debulking achieved (residual disease <1 cm)

### Final Pathology
- **High-grade serous carcinoma of the ovary**
- FIGO Stage IIIC (peritoneal metastases >2 cm outside pelvis + positive lymph nodes)
- Fallopian tube epithelium with STIC (serous tubal intraepithelial carcinoma) - suggesting tubal origin

### BRCA Testing Result
- **BRCA1 pathogenic mutation** detected
- Family members counseled regarding testing

### Adjuvant Treatment
- Intravenous chemotherapy: Carboplatin + Paclitaxel x 6 cycles
- Maintenance therapy: PARP inhibitor (olaparib) given BRCA1 mutation

### Prognosis
- Stage IIIC with optimal debulking: ~40% 5-year survival
- BRCA1 mutation: More favorable response to platinum chemotherapy and PARP inhibitors

### Teaching Points
- Ovarian cancer classically presents with vague symptoms (bloating, early satiety, weight loss)
- 75% of ovarian cancers are diagnosed at advanced stage
- Postmenopausal patient with elevated CA-125 and complex mass has high malignancy risk
- Referral to gynecologic oncology improves outcomes
- BRCA mutations increase ovarian cancer risk significantly
- High-grade serous carcinoma often originates from the fallopian tube

### Clinical Image
![Ovarian Cancer CT](case_02_image.jpg)

**Image Description:** Axial CT image of the abdomen/pelvis demonstrating a large complex ovarian mass with solid and cystic components, moderate ascites, and omental thickening (omental caking) consistent with peritoneal carcinomatosis in a patient with advanced ovarian cancer.

**Attribution:** Image from Radiopaedia. Educational case. Licensed under CC BY-NC-SA 3.0.

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## Case 3: Endometrioma in a Woman Desiring Fertility

### Patient Demographics
- **Age:** 32 years
- **Sex:** Female
- **Occupation:** Marketing director

### Chief Complaint
"I'm having trouble getting pregnant and my periods are very painful."

### History of Present Illness
The patient and her husband have been trying to conceive for 18 months without success. She has progressively worsening dysmenorrhea that now requires her to take time off work. The pain starts before her period and continues throughout menstruation. She also experiences pain with deep penetration during intercourse. She has been using ovulation predictor kits and timing intercourse appropriately.

### Gynecologic History
- Menarche: Age 12
- Cycles: Regular, 28 days, heavy flow x 7 days
- Severe dysmenorrhea since mid-20s, progressively worsening
- Dyspareunia with deep penetration
- LMP: 3 weeks ago
- Sexually active: Yes, married
- Prior pregnancies: G0
- Contraception: None x 18 months (trying to conceive)

### Past Medical History
- No chronic conditions
- No prior surgeries

### Physical Examination
- **Abdomen:** Soft, non-tender
- **Pelvic:**
  - Cervix: Normal
  - Uterus: Normal size, fixed, tender with manipulation
  - Right adnexa: 5 cm tender mass, minimally mobile
  - Left adnexa: Normal
  - Cul-de-sac: Nodularity palpated (concerning for deep endometriosis)

### Diagnostic Workup

**Transvaginal Ultrasound:**
- Right ovary: 5.2 cm cyst with homogeneous low-level internal echoes
- **"Ground glass" appearance** - classic for endometrioma
- No solid components
- No internal vascularity
- Left ovary: Normal, multiple antral follicles
- Uterus: Normal appearance

**Laboratory Studies:**
| Test | Result | Interpretation |
|------|--------|----------------|
| AMH | 3.2 ng/mL | Normal ovarian reserve |
| FSH | 6.5 mIU/mL | Normal |
| Estradiol | 45 pg/mL | Normal |
| CA-125 | 65 U/mL | Mildly elevated (common with endometriosis) |

### Diagnosis
**Right Ovarian Endometrioma (Chocolate Cyst)**
- Characteristic ultrasound appearance
- Associated symptoms (dysmenorrhea, dyspareunia)
- Cul-de-sac nodularity suggesting endometriosis
- Infertility

### Management Discussion

**The Dilemma:**
- Endometrioma may contribute to infertility
- Surgery (cystectomy) can reduce ovarian reserve
- Need to balance treatment benefits vs. ovarian damage

**Options:**

**1. Proceed Directly to IVF (Without Surgery):**
- Can retrieve oocytes from ovaries with endometriomas
- Avoids surgical risk to ovarian reserve
- Endometrioma <4-5 cm generally does not preclude IVF

**2. Surgical Excision (Laparoscopy):**
- Cystectomy removes endometrioma
- Also allows diagnosis and treatment of concurrent deep endometriosis
- Risk: AMH decline post-surgery (ovarian tissue removed with cyst wall)
- May improve natural conception and IVF outcomes for some patients

**3. Medical Suppression:**
- GnRH agonist or progestin
- Only suppresses symptoms; does not treat cyst or improve fertility
- Not appropriate for patient trying to conceive

### Multidisciplinary Discussion (With Reproductive Endocrinologist)

**Recommendations:**
- Given 5 cm endometrioma and cul-de-sac nodularity suggesting deep endometriosis
- Laparoscopy offers both diagnostic and therapeutic value
- Complete staging of endometriosis
- Excision of endometrioma
- Treatment of any deep infiltrating endometriosis
- May improve fertility outcomes

**Patient Counseled About:**
- Risk of reduced ovarian reserve post-surgery
- Pre-operative AMH is normal; will check post-operatively
- Surgical technique (stripping vs. ablation) - stripping provides tissue for pathology
- Recurrence rate: 20-30% within 2 years

### Surgical Management: Diagnostic Laparoscopy and Cystectomy

**Operative Findings:**
- Right ovarian endometrioma (5 cm) - chocolate-colored fluid aspirated
- Stage III endometriosis (revised ASRM classification)
- Deep infiltrating endometriosis in cul-de-sac
- Left ovary: Superficial endometriotic implants
- Bilateral fallopian tubes: Patent (chromopertubation positive)

**Procedure Performed:**
- Right ovarian cystectomy (stripping technique)
- Excision of deep infiltrating endometriosis
- Ablation of superficial implants
- Lysis of pelvic adhesions

**Pathology:**
- Endometriotic cyst confirmed
- No malignancy

### Postoperative Course
- Discharged home same day
- AMH checked at 3 months post-op: 2.4 ng/mL (slight decline, still adequate)
- Advised to attempt conception for 6-12 months
- If not pregnant: Proceed to IVF

### Follow-up (6 months post-surgery)
- Dysmenorrhea significantly improved
- Dyspareunia resolved
- Currently 8 weeks pregnant (spontaneous conception)
- Early prenatal care initiated

### Teaching Points
- Endometriomas have a characteristic "ground glass" ultrasound appearance
- Endometriosis is a common cause of infertility (30-50% of infertile women)
- Surgery for endometrioma must weigh benefits against ovarian reserve loss
- Surgical planning should involve reproductive endocrinology input
- Recurrence is common; long-term suppression or monitoring needed after treatment
- Malignancy risk is low (<1%) but endometriomas are associated with clear cell and endometrioid ovarian cancers

### Clinical Image
![Endometrioma Ultrasound](case_03_image.jpg)

**Image Description:** Transvaginal ultrasound image demonstrating an endometrioma (chocolate cyst) with the characteristic homogeneous low-level internal echoes described as a "ground glass" pattern. The cyst wall is smooth and there are no solid components or internal vascularity.

**Attribution:** Image from Radiopaedia. Case courtesy of Dr. Andrew Dixon. Licensed under CC BY-NC-SA 3.0. Source: https://radiopaedia.org/cases/endometrioma