Master the board step 3

Master the Boards: USMLE Step 3
Ovaries: Ovarian Enlargement
Ovarian enlargement may be found incidentally on physical exam or may present
with symptoms. The following conditions should be considered.
Simple Cyst: Physiologic Cysts (Luteal or Follicular Cysts)
This is the most common cyst that occurs during the reproductive years. It
is asymptomatic, unless torsion has occurred (occurs with large cysts). The
β-hCG is negative; ultrasound shows fluid-filled simple cystic mass.
Management
··
Transvaginal or transabdominal ultrasound to assess initial visit. If it is
asymptomatic, no further follow up is necessary.
··
Laparoscopic removal if
--
cyst is > 7 cm diameter; or
--
there has been previous steroid contraception without resolution of the cyst.
Fine needle aspiration of
a complex ovarian cyst is
never the correct answer
on the test.
Complex Cyst: Benign Cystic Teratoma (Dermoid Cysts)
These are benign tumors. They can contain cellular tissue from all 3 germ
layers. Rarely, squamous cell carcinoma can develop. The β-hCG is negative;
ultrasound shows a complex mass.
Management
··
Laparoscopic/laparotomy removal, either
--
cystectomy (to retain ovarian function); or
--
oophorectomy (if fertility is no longer desired).
The initial workup of an
ovarian mass involves the
following:
• ß-hCG
• Ultrasound
• Laparoscopy/laparotomy
if complex or > 7 cm
A 31-year-old woman is taken to the emergency department complaining of
severe, sudden lower abdominal pain that started 3 hours ago. On examination,
the abdomen is tender, no rebound tenderness is present, and there is an adnexal
mass in the cul-de-sac area. An ultrasound evaluation shows an 8-cm left adnexal
mass. Beta-hCG is negative. What is the next step in management?
a. Appendectomy
b. Give high-dose estrogen and progestin
c. Laparoscopic evaluation of ovaries
d. Observation
e. Perform oophorectomy
Answer: C. Sudden onset of severe lower abdominal pain in the presence of an adnexal
mass is presumed to be ovarian torsion. Laparoscopy and detorsioning of the ovaries
is needed. If blood supply is not affected, cystectomy can be done. If there is necrosis,
oophorectomy is needed. She should then receive a 4-week follow-up and yearly
evaluation to ensure there is complete resolution.
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