Ovaries, Adnexal Masses, and Doppler

Quick Answer: Simple cyst = benign pattern. Solid + papillary + ascites = malignancy workup. Dermoid = fat, Rokitansky nodule, shadowing. Hemorrhagic cyst = reticular echoes, no solid vascularity. Torsion = enlarged ovary, peripheral follicles, reduced flow.

Normal Ovarian Findings

Cyclic follicles, corpus luteum with peripheral vascularity, and in PCOS string of pearls peripherally arranged follicles (diagnosis requires clinical and lab correlation—not sonographer diagnosis alone).

Postmenopausal simple cyst <3 cm often benign surveillance; larger or complex masses need workup per ACR/O-RADS pathways.

Simple Cyst Criteria (Benign Pattern)

• Anechoic
• Thin imperceptible wall
• No septation, solid nodule, or papillary projection
• Posterior enhancement

Hemorrhagic Cyst vs Endometrioma

Short-term follow-up clarifies hemorrhagic cyst vs endometrioma when indeterminate.

Dermoid Cyst (Mature Cystic Teratoma)

Hyperechoic Rokitansky nodule (dermoid plug), fat-fluid level, echogenic lines, acoustic shadowing. Pathognomonic combination on registry images.

Rupture may cause chemical peritonitis—free fluid plus fat droplets (rare vignette).

Malignancy Features (IOTA/O-RADS Concepts)

Suspicious descriptors:

• Solid component with papillary projections ≥3 mm
• Ascites
• Peritoneal nodules
• Strong central flow in solid areas
• Size >10 cm adds concern but is not sufficient alone

Worked Scenario: Complex Adnexal Mass

Solid vascular papillary projection with ascites in postmenopausal patient—high suspicion ovarian malignancy—gynecologic oncology referral, not 6-month cyst follow-up.

Doppler in Adnexal Masses

Ovarian Torsion (Surgical Emergency)

Enlarged heterogeneous ovary, peripheral displaced follicles, whirlpool sign in twisted pedicle, decreased or absent arterial flow—but partial torsion may retain some flow early. Clinical pain and enlarged ovary still mandate surgical suspicion.

Other Adnexal Lesions

Krukenberg Tumor (Recognition)

Bilateral solid ovarian masses from GI primary—ascites and peritoneal disease may accompany.

Exam Traps

• Corpus luteum ring of fire called malignancy
• Dermoid missed when shadowing not appreciated
• Torsion dismissed because some arterial flow present
• Pedunculated fibroid reported as ovarian without stalk identification
• Simple cyst in postmenopausal patient managed like premenopausal without guideline context

Adnexa items require pattern recognition + Doppler + clinical context—describe simple rules before defaulting to cancer or benign labels.

O-RADS Ultrasound Categories (Simplified)

O-RADS stratifies malignancy risk. O-RADS 1 normal; O-RADS 2 almost certainly benign (simple cyst, dermoid, hemorrhagic cyst); O-RADS 3 low risk; O-RADS 4–5 intermediate to high risk requiring specialist management. Registry items test descriptor recognition more than memorizing category numbers.

IOTA Simple Rules (Benign vs Malignant)

Benign features: unilocular, smooth walls, maximum diameter <10 cm, no solid parts, no papillary projections, no ascites. Malignant features: solid areas, papillary projections ≥3 mm, irregular thick septa, ascites, peritoneal nodules. Apply rules before defaulting to follow-up in postmenopausal patient with solid vascular mass.

Endometrioma vs Hemorrhagic Cyst Follow-Up

Hemorrhagic cyst often resolves in 6–8 weeks—short-interval follow-up appropriate. Endometrioma persists with ground-glass echoes. Endometrioma with solid nodule is not classic endometrioma—consider endometrioid tumor and gynecologic oncology referral.

Paraovarian and Paratubal Cysts

Paraovarian cyst is simple cyst separate from ovary with normal ovarian tissue adjacent. Hydatid of Morgagni is paratubal. Mislabeling as ovarian cyst affects surgical approach—document ovary distinct from cyst on cine sweep.

Pedunculated Subserosal Fibroid vs Ovarian Mass

Pedunculated fibroid may appear separate from uterus but stalk to myometrium is key—slow sweep from mass to uterus identifies connection. Ovarian mass lacks uterine stalk. Torsion of pedunculated fibroid is possible—clinical pain with mass off uterus.

Theca Lutein Cysts and molar Pregnancy

Bilateral enlarged multicystic ovaries with markedly elevated hCG suggest complete mole with theca lutein cysts. Not malignant ovarian neoplasm—manage molar pregnancy. Registry recognition item links uterine snowstorm appearance with large ovaries.

Postmenopausal Adnexal Mass Protocol

Simple cyst <3 cm in postmenopausal patient may be followed per ACR guidelines. Any solid component, septations, or size >3 cm increases workup. CA-125 is clinical lab—not sonographer orders—but registry may ask appropriate next step: gynecologic oncology referral vs simple cyst follow-up.

Torsion Partial Flow Trap

Partial torsion may retain some arterial flow—do not exclude torsion with enlarged ovary, pain, and peripheral follicles. Dermoid shows Rokitansky nodule, fat-fluid level, and shadowing.

Simple Cyst Follow-Up

Premenopausal simple cyst <3 cm often needs no follow-up; 3–5 cm gets short-interval surveillance; solid papillary projections require oncology pathway not routine cyst follow-up.

Hemorrhagic Cyst Evolution

Hemorrhagic cyst shows reticular internal echoes without solid vascularity—often resolves in 6–8 weeks. Endometrioma persists with ground-glass echoes. O-RADS and IOTA descriptors guide benign versus malignant pathways on registry items.