Masses of the ovary, fallopian tube, or surrounding tissues are common and found in up to 35% of premenopausal patients and 17% of postmenopausal patients. They are often diagnosed incidentally on physical examination or at the time of pelvic imaging. The differential diagnosis is broad and includes both benign and malignant lesions, as well as gynecologic and non-gynecologic lesions. The patient’s age, family history, physical exam, imaging findings, and serum marker levels can aid with narrowing the differential. Risk factors for ovarian cancer include age, family history of ovarian cancer or genetic predisposition for ovarian cancer, nulliparity, early menarche, late menopause, and endometriosis. Management aims include identifying need for emergent surgery, identifying malignancy, managing symptoms, and preserving fertility when appropriate. Management options for pelvic masses include expectant management, surveillance, and surgical management. While minimally invasive surgery is often the preferred surgical approach for removal of an adnexal mass, open surgery may be required for larger masses or those concerning for malignancy. Ovarian cancer is the second most common gynecologic malignancy after uterine carcinoma and is the deadliest gynecologic cancer in the United States. Approximately 95% of ovarian cancer arise from the epithelial cells and include high grade serous, low grade serous, endometrioid, clear cell, and mucinous carcinoma. Most patients have advanced staged disease at the time of ovarian cancer diagnosis. While surgery alone can cure most patients with early-stage disease, most patients present with advanced stage disease and will require a combination of both surgery and chemotherapy. The standard chemotherapy regimen includes a combination of platinum- and taxane-based chemotherapy. Five-year overall survival rates are 89% for stage I, 71% for stage II, 41% for stage III, and 20% for stage IV disease.

A 28-year-old nulligravid woman presents reporting severe dysmenorrhea, deep dyspareunia, and dyschezia that worsens with menses. She states she has always had painful periods, but they have worsened over the past year. She describes it as sharp, twisting, and feels that something is “stabbing her from the inside out.” She is in a long-term relationship and desires future fertility. She has tried several different combined oral contraceptive pills, which mildly improved her pain. She has also tried non-steroidal anti-inflammatory drugs, medroxyprogesterone acetate, and a gonadotropin-releasing hormone agonist without relief. She states the dyspareunia and constipation have worsened over time. She underwent a diagnostic laparoscopy at age 26 and was told she had stage IV endometriosis. She continues to have debilitating pain that significantly impacts her quality of life. She would like to proceed with fertility-sparing surgical management. She has no other relevant relevant past medical or surgical history. She is currently taking oral contraceptives (ethinyl estradiol/norethindrone) and has no known drug allergies.

A 24-year-old female, gravida 0, presents to the office for follow-up of suspected endometriosis. Her last menstrual period started two days ago. She reports a three-year history of chronic pelvic pain that is worse during menses, is moderate to severe in intensity, and crampy in nature. She has tried combined oral contraceptive pills without symptomatic improvement. She denies fever, changes in bowel or bladder habits, or dyspareunia. She is sexually active with one male partner. She uses condoms regularly. She has no history of sexually transmitted infections. She has no significant past medical or surgical history.

Classically endometriosis develops sometime after menarche and has been reported in girls as early as 10 years. There is limited knowledge about early-onset endometriosis, particularly about disease progression and its effect on fertility. Patients often present with prevailing symptoms of dysmenorrhoea, cyclic or acyclical pelvic pain. NSAIDS and COCs are often used to treat non-specific nature of pelvic pain. Ultrasound is the first-line imaging modality but MRI offers better visualization of deep infiltrating endometriosis. A patient-centred approach with detailed explanation of treatment options incorporating the patient’s wishes should individualize the management plan. Medical treatment is the most preferred option and surgical intervention may be necessary in selected cases.