15.3 Adnexal Masses, Malignancy Red Flags & Vulvar Disease

Benign Ovarian Masses & Malignancy Red Flags

Adnexal masses are common incidental or symptomatic findings. The midwife must differentiate physiologic functional cysts from benign neoplasms and identify malignant features requiring oncology referral.

Adnexal Mass Classification & Sonographic Features
├── 1. Physiologic Functional Ovarian Cysts (Reproductive-Aged Women)
│   ├── Follicular Cyst ──> Failure of Graafian follicle to rupture / ovulate
│   │   └── Thin-walled, unilocular, anechoic, smooth margins, 3 to 8 cm
│   │   └── NATURAL HISTORY: Spontaneous regression in 1 to 2 cycles (6-8 weeks)
│   └── Corpus Luteum Cyst ──> Failure of corpus luteum to regress after ovulation
│       └── Thick-walled, complex reticular echoes ("spiderweb"), peripheral "ring of fire"
│       └── NATURAL HISTORY: Spontaneous resolution in 1 to 2 cycles; risk of rupture
├── 2. Benign Ovarian Neoplasms
│   ├── Mature Cystic Teratoma (Dermoid Cyst) ──> Germ cell tumor (all 3 germ layers)
│   │   └── Hyperechoic Rokitansky nodule, acoustic shadowing; 15% risk of torsion
│   │   └── DOES NOT RESOLVE; Requires elective laparoscopic cystectomy
│   ├── Serous Cystadenoma ──> Thin-walled, unilocular, clear serous fluid
│   ├── Mucinous Cystadenoma ──> Large, multilocular, thick gelatinous mucin
│   └── Endometrioma ("Chocolate Cyst") ──> Ectopic endometrial tissue in ovary
│       └── Homogeneous low-level "ground-glass" echoes, absent Doppler flow
└── 3. Red Flags for Ovarian Malignancy (Urgent Gynecologic Oncology Referral)
    ├── Postmenopausal ovarian mass (any complex or solid mass)
    ├── Solid components or mural nodularity (>3 mm)
    ├── Thick, irregular septations (>2 to 3 mm) or multilocular architecture
    ├── Ascites or peritoneal implants
    └── Elevated Serum CA-125 (>35 U/mL in postmenopausal women)

Clinical Management of Functional Cysts vs. Dermoids

• Simple Follicular Cysts (<8 cm): In an asymptomatic, premenopausal woman, a thin-walled, unilocular, anechoic cyst <8 cm is almost universally a benign physiologic follicular cyst. The standard of care is expectant management with repeat transvaginal ultrasound in 6 to 8 weeks (following 1 to 2 menses) to confirm spontaneous resolution. Combined oral contraceptives do NOT hasten the resolution of an existing cyst, though they prevent future cyst formation.
• Mature Cystic Teratoma (Dermoid Cyst): Most common benign ovarian neoplasm in women <30 years old. Composed of well-differentiated ectodermal, mesodermal, and endodermal tissues (hair, sebum, teeth, calcified bone). Characterized by high lipid content, causing the ovary to float anteriorly in the pelvis, predisposing to ovarian torsion (15% risk). Dermoid cysts never resolve spontaneously; management is elective laparoscopic ovarian cystectomy with preservation of normal ovarian tissue.
• Ovarian Torsion: A surgical emergency resulting from partial or complete twisting of the ovarian vascular pedicle. Classic presentation: sudden-onset, severe, unilateral, sharp/colicky lower abdominal and pelvic pain, accompanied by nausea and vomiting (70%). Doppler ultrasound shows enlarged, edematous ovary with absent or compromised venous and arterial flow. Requires immediate surgical detorsion and cystectomy.

Evaluating Vulvar Disease

The blueprint task "evaluates for vulvar disease" is where a great many chronic, treatable conditions are missed, usually because the vulva is inspected quickly and only in the context of a speculum exam.

Examine systematically and with light: mons, labia majora and minora, clitoral hood, vestibule, hymenal ring, perineum, and perianal skin. Note color, architecture, texture, and symmetry, and ask the patient to point to where the symptom is.

[!IMPORTANT] If in doubt, biopsy. Any persistent, atypical, pigmented, ulcerated, indurated, or non-responding vulvar lesion warrants a 3–4 mm Keyes punch biopsy under local anesthetic. Empiric steroid or antifungal treatment of an undiagnosed vulvar lesion is the classic route to a delayed vulvar cancer diagnosis.

The Vulvar Dermatoses

Vulvodynia

Chronic vulvar pain lasting 3 months or longer without an identifiable cause. The most common form is localized provoked vestibulodynia, mapped with the cotton-swab (Q-tip) test at the vestibule. Management is multimodal: pelvic floor physical therapy for the near-universal accompanying hypertonicity, topical lidocaine, tricyclics or gabapentinoids, cognitive behavioral therapy, sex therapy, and vulvar care measures. Reassure the patient that the pain is real and that a normal-appearing vulva does not mean nothing is wrong.

Neoplasia

• Vulvar HSIL (usual-type VIN) is HPV-16 driven and occurs in younger patients, especially smokers.
• Differentiated VIN (dVIN) arises in a background of lichen sclerosus in older patients and carries the higher progression risk — which is why lichen sclerosus requires ongoing surveillance rather than one prescription.
• Vulvar squamous cell carcinoma presents as a persistent ulcer, plaque, or nodule, frequently with a long history of "yeast" treated repeatedly.
• A Bartholin duct cyst or abscess in a patient over 40 should be biopsied or excised rather than simply drained, to exclude carcinoma.