Introduction: 

This case study revolves around a middle-aged woman visiting for a routine health examination who ends up with a significant finding on her physical examination. The case allows you to explore the evaluation and management of an unexpected adnexal mass.

Case Profile: A 46-year-old G3P3 woman presents for her routine health examination. She is in good health with no specific concerns. She had three normal vaginal deliveries and underwent a tubal ligation after the birth of her third child 13 years ago. She has no history of abnormal Pap smears or sexually transmitted infections. Her cycles are regular, and her last menstrual period was 20 days ago. She is not taking any medications. Her family history is significant for a maternal cousin who was diagnosed with ovarian cancer at age 58.

On examination, she has normal vital signs. Her heart, lung, and abdominal exams are normal. On pelvic examination, she has normal external genitalia, vagina, and cervix. On the bimanual exam, however, she has a slightly enlarged uterus and a palpable 7 cm mobile, non-tender left adnexal mass, which is confirmed on the rectovaginal exam.

Activity Questions:

• What is the next step in the management of this patient? 
  Hint: Consider the role of imaging and laboratory investigations in diagnosing an adnexal mass.
  

• How would your approach be different if the patient was postmenopausal at 64 years of age? 
  Hint: Discuss how menopausal status can affect the management of an adnexal mass.
  

• The ultrasound shows a 7 cm left complex ovarian cyst. What is your differential diagnosis? 
  Hint: Consider both benign and malignant possibilities based on the ultrasound findings.
  

• What risk factors does this patient have for ovarian cancer? 
  Hint: Discuss the patient-specific risk factors and also the generic risk factors for ovarian cancer.
  

• List elements of the history and physical examination that would help support the diagnosis of ovarian cancer. 
  Hint: Discuss symptoms and physical findings often associated with ovarian cancer.
  

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