Adnexal Mass in India: What It Means, Workup and Treatment

• An adnexal mass is any lump near the ovary or tube; it is a finding to investigate, not a diagnosis by itself.
• Most masses in reproductive-age women are benign: functional cysts, endometriomas (chocolate cysts), dermoids, or cystadenomas.
• Risk of cancer rises with age, so postmenopausal masses are taken more seriously than the same finding in a younger woman.
• Doctors triage using ultrasound features, tumour markers (mainly CA-125), and scoring tools like IOTA Simple Rules, RMI and ROMA.
• Many low-risk masses need only repeat ultrasound; surgery is reserved for large, growing, symptomatic or suspicious masses.
• Sudden severe one-sided pelvic pain with vomiting can signal ovarian torsion, a surgical emergency requiring same-day care.

The adnexa are the structures sitting on either side of the uterus: the ovaries, the fallopian tubes, and the ligaments and tissue that support them. An adnexal mass is any abnormal lump, cyst, or solid growth arising from one of these structures. It is a descriptive label radiologists use because early imaging often cannot say exactly where a mass is coming from. The actual diagnosis follows from the next steps in the workup.

Most adnexal masses come from the ovary itself, which is unsurprising given how much the ovary changes every month. Ovarian masses may be cystic (fluid-filled), solid, or complex (a mix of both), and may affect one or both sides. They can be a few millimetres or, occasionally, large enough to fill the abdomen. A normal ovary in the reproductive years measures roughly 3 x 2 x 1 cm and shrinks after menopause.

Fallopian tube masses include hydrosalpinx (a dilated, fluid-filled tube, often after past infection), tubo-ovarian abscess, and, in a pregnant woman, an ectopic pregnancy. Paraovarian and paratubal cysts arise from harmless embryonic remnants in the supporting ligament and are usually simple cysts that need only conservative care.

Not every adnexal mass is gynaecological. Appendix-related masses, bowel abscesses, a pelvic kidney, and other structures can mimic ovarian disease, which is why a thorough evaluation always looks at the surrounding anatomy as well.

Frequency shifts with age. In teenagers and young women, functional cysts and germ cell tumours are more common. In the reproductive years, functional cysts, endometriomas, dermoids, and cystadenomas dominate. Around and after menopause, the share of cancers rises. Indian cancer-registry data place the lifetime risk of ovarian cancer at roughly 1 in 70 women, lower than Western rates but still meaningful.

Functional ovarian cysts are by far the most common adnexal masses in reproductive-age women, and they are a normal part of how the ovary works rather than a disease. They form from the ordinary cycle of growing a follicle and releasing an egg. The two main kinds are follicular cysts and corpus luteum cysts.

A follicular cyst forms when a follicle that should have ovulated keeps growing and fills with fluid instead. On ultrasound it looks reassuring: a single, thin-walled, smooth chamber with clear fluid, usually 3 to 10 cm. Most resolve on their own within one to three cycles. They are often found by chance and may cause only mild dull discomfort, if anything. A repeat scan in 6 to 12 weeks usually shows it has gone.

A corpus luteum cyst forms when the structure left behind after ovulation fills with fluid or blood rather than shrinking. It can look slightly more complex, with a thicker wall or internal echoes from old blood, but it too usually clears over one to three cycles. Occasionally one ruptures and causes sudden pelvic pain that needs checking.

Haemorrhagic corpus luteum cysts have a telltale lacy or "fishnet" pattern inside on ultrasound, from fibrin strands. Recognising this pattern lets doctors manage confidently with observation and avoid unnecessary surgery; most settle within 6 to 12 weeks.

Theca lutein cysts are larger functional cysts linked to very high hCG levels, such as in molar pregnancy or after ovarian stimulation for fertility treatment. They are often on both sides and resolve once hCG falls.

For an asymptomatic functional cyst, the plan is observation with a repeat scan in 6 to 12 weeks. Birth control pills do not meaningfully speed up resolution and are not prescribed for that reason, although women already on the pill tend to form fewer functional cysts. Simple pain relief with NSAIDs, a warm compress, and rest is enough for most. Surgery is rarely needed unless a cyst ruptures with heavy bleeding, causes torsion, or fails to resolve. For practical self-care, see our guide to ovarian cyst remedies that actually help.

Endometriomas, often called chocolate cysts, develop in women with Understanding Endometriosis: Causes, Symptoms & Management. Endometriosis is when endometrial-like tissue grows outside the uterus; when it forms inside an ovary, it bleeds with every period, and the trapped old blood turns thick and dark, like chocolate. Endometriomas affect roughly 17 to 44 percent of women with endometriosis.

On ultrasound they have a typical look: usually one or a few chambers filled with uniform low-level "ground glass" echoes from the old blood, with little internal blood flow on Doppler. They are commonly 3 to 15 cm, may affect one or both ovaries, and often sit alongside other signs of endometriosis such as adhesions. The IOTA group has standardised the ultrasound features that allow a confident diagnosis.

Symptoms vary widely. Many women have chronic pelvic pain, painful periods, deep pain during sex, and difficulty conceiving, while others have an endometrioma found by chance with few symptoms. Cyst size and pain do not track neatly together: a small endometrioma can hurt a lot, and a large one can be quiet.

Management depends on size, symptoms, age, and fertility plans. Small, symptom-free endometriomas (under about 4 to 5 cm) are often managed with hormonal suppression, such as combined pills, progestins, or GnRH analogues. Larger or painful ones may need laparoscopic surgery. The decision involves trade-offs: removing the cyst wall can reduce ovarian reserve and may not suit women hoping to conceive, while leaving a large one in place can mean ongoing symptoms.

For women planning IVF, whether to remove an endometrioma first is a nuanced call made with a fertility specialist, since surgery can affect egg numbers; our guide to the IVF process, success rates and cost in India gives useful background. Laparoscopic ovarian cystectomy at private Indian hospitals typically costs Rs 60,000 to 2,00,000 depending on the centre and complexity.

The cancer risk in endometriomas is small but real: clear cell and endometrioid ovarian cancers are linked to endometriosis. A persistent endometrioma in a peri- or postmenopausal woman, especially one developing new solid areas or growing, should be reassessed. This is why known endometriomas are kept under surveillance rather than simply ignored.

Mature cystic teratomas, usually called dermoid cysts, are the most common benign ovarian tumour in women under 30. They grow from germ cells, which can turn into any tissue type, so they may contain hair, teeth, skin, fat, and cartilage. On ultrasound they show bright (hyperechoic) areas from fat and calcification, often casting a shadow, and sometimes a "tip of the iceberg" appearance where dense contents hide the deeper part of the cyst.

Dermoids are usually on one side but are bilateral in 10 to 15 percent of cases. They grow slowly and may cause trouble through their size, through ovarian torsion, or rarely through rupture, which can irritate the abdominal lining. Many cause no symptoms and are found by chance.

Confirmed dermoids that cause symptoms or are above about 4 to 5 cm are usually removed by laparoscopic cystectomy, using careful technique to avoid spilling the contents, while preserving healthy ovarian tissue. Recovery is generally quick, and the risk of cancerous change is very low (under 1 to 2 percent), mainly in older women with larger or more complex tumours.

Serous and mucinous cystadenomas are common benign tumours of the ovary's surface lining, typically in women aged 30 to 60. Serous ones are usually thin-walled with clear fluid; mucinous ones are often larger and multi-chambered with a honeycomb look. Both are benign but are usually removed because they keep growing and carry a small chance of borderline or malignant change.

Borderline ovarian tumours (tumours of low malignant potential) sit between clearly benign and clearly cancerous. They can recur and very occasionally spread, but their outlook is far better than ovarian cancer; treatment is surgical removal with careful staging.

Other benign tumours include Brenner tumours, fibromas, and thecomas. A fibroma can be part of Meigs syndrome (fibroma with fluid in the abdomen and chest that clears after the tumour is removed). Sex-cord stromal tumours, such as granulosa cell and Sertoli-Leydig cell tumours, can make hormones and present with symptoms like postmenopausal bleeding or signs of excess male hormone, alongside the mass. These less common tumours need specialist gynaecological-oncology assessment.

A tubo-ovarian abscess (TOA) is a serious complication of pelvic inflammatory disease, in which infection has walled off into a pus-filled collection involving the tube and ovary together. It typically causes fever, severe pelvic pain, abnormal discharge, and a tender mass. Risk factors include past PID, untreated sexually transmitted infections such as chlamydia and gonorrhoea, and recent procedures inside the uterus.

Diagnosis combines symptoms with imaging. Ultrasound usually shows a thick-walled, multi-chambered mass with internal debris; CT may help in difficult cases. Inflammatory markers (CRP, ESR, white-cell count) are raised, and cultures help identify the organism. In an older woman without obvious infection risk, a TOA can be mistaken for ovarian cancer, so context matters.

Treatment is with broad-spectrum intravenous antibiotics that cover the usual PID organisms plus anaerobes, for example ceftriaxone with doxycycline and metronidazole. The typical course runs about 14 days, switching from IV to oral once the woman is clearly improving.

A large abscess (generally over 7 cm) or one that does not respond to antibiotics may need drainage, done by image-guided needle, laparoscopy, or open surgery depending on the situation. Initial care usually means a hospital stay. Costs at private Indian hospitals for TOA with admission can range from Rs 50,000 to 3,00,000 depending on length of stay and any procedures.

Genital tuberculosis is an important cause of adnexal masses in India, particularly affecting the tubes. It can appear as a chronic adnexal mass, a tubo-ovarian complex, hydrosalpinx, or fluid in the abdomen. Because symptoms can be vague (mild pelvic pain, infertility, irregular periods), diagnosis needs a high index of suspicion and specific tests such as endometrial biopsy, AFB staining, GeneXpert, and culture. Treatment is standard anti-TB therapy for 6 to 12 months under specialist care, and it is a recognised contributor to secondary infertility in Indian women.

Rarer infections include actinomycosis (linked to long-term IUD use) and, in some regions, parasitic infections. The takeaway is simple: not every adnexal mass is a tumour, and infection should always be considered, especially in younger women with symptoms of infection and in any Indian woman where TB is plausible.

Ovarian cancer is the diagnosis that drives the intensity of the workup. It is a leading cause of death from gynaecological cancer worldwide, partly because it often presents late with vague symptoms. Indian incidence is lower than Western rates but still significant, with a lifetime risk of about 1 in 70. Risk factors include older age, family history (especially BRCA1/2 gene changes and Lynch syndrome), never having been pregnant, early periods, late menopause, and certain forms of endometriosis.

There are several main types. Epithelial cancers (about 90 percent) include high-grade serous (the most aggressive), low-grade serous, endometrioid, clear cell, and mucinous. Germ cell tumours tend to affect younger women and generally respond well to chemotherapy. Sex cord-stromal tumours are less common and may be hormonally active.

Symptoms are often non-specific and easily blamed on other things: persistent bloating, feeling full quickly, pelvic or abdominal pain, needing to pass urine more often, a change in bowel habit, fatigue, and weight loss. Symptoms lasting more than two weeks, especially over age 50 or with risk factors, deserve evaluation. There is no reliable screening test for average-risk women, so most cases are found once symptoms appear. Our guide to the early warning signs of ovarian cancer covers this in more depth.

Risk assessment for a mass combines ultrasound features, tumour markers, and clinical context. Worrying ultrasound signs include solid areas, thick walls between chambers, finger-like projections, fluid in the abdomen, and brisk internal blood flow. The IOTA group's Simple Rules and ADNEX model use ultrasound to estimate risk, while the Risk of Malignancy Index (RMI) combines an ultrasound score, menopausal status, and CA-125. These tools help decide who needs a gynaecological oncologist.

Markers used here include CA-125 (raised in many epithelial cancers but also in benign conditions), HE4 (more specific), CEA (for mucinous tumours), and AFP, beta-hCG, and LDH (for germ cell tumours in younger women). A basic tumour-marker panel at Indian labs typically costs Rs 2,000 to 6,000.

A suspicious mass should be referred to a gynaecological oncologist. Tata Memorial Hospital in Mumbai, AIIMS Delhi, the Cancer Institute in Chennai, and several other centres offer this care. Importantly, early-stage ovarian cancer operated on by a gynaecological oncologist has better outcomes than the same surgery by a general gynaecologist. Treatment usually means staging surgery followed by chemotherapy for most cases.

Transvaginal ultrasound (TVS) is the first-line imaging for an adnexal mass in adult women. It gives excellent detail of the ovaries and tubes, is widely available across India, is well tolerated, and is relatively affordable (about Rs 1,500 to 4,500 at private centres such as Apollo, Fortis, and Cloudnine, and less at diagnostic chains). A transabdominal scan is added when a mass is very large. Either way, an experienced sonologist matters for reliable interpretation.

A good report describes the mass in detail: which side and structure, size in three dimensions, whether it is a simple single chamber or has solid parts, septations and projections, the nature of the internal contents, and the Doppler blood-flow pattern. It should note any fluid in the abdomen and assess the other ovary and the uterus.

The IOTA (International Ovarian Tumor Analysis) Simple Rules classify masses using five benign "B" features (such as a unilocular cyst, acoustic shadows, or no blood flow) and five malignant "M" features (such as an irregular solid tumour, fluid in the abdomen, four or more papillary structures, or very strong blood flow). Only B features suggest benign; only M features suggest malignant; a mix needs further evaluation.

The IOTA ADNEX model goes further, estimating the probability that a mass is benign, borderline, or a particular stage of cancer, using ultrasound features, age, and CA-125. It is available as online calculators and is increasingly used in major Indian centres to avoid unnecessary surgery for benign masses while still flagging the suspicious ones.

Doppler assesses blood flow within the mass. Cancers tend to grow new vessels with low-resistance flow, while benign masses generally show less or only peripheral flow. The modern IOTA approach uses an overall "colour score" rather than older spectral measurements.

Other imaging has specific roles. MRI helps characterise indeterminate masses, map deep endometriosis, and plan complex surgery. CT is used to stage suspected cancer and look for spread. Approximate private costs in India: MRI pelvis Rs 6,000 to 15,000; CT abdomen-pelvis Rs 5,000 to 12,000; PET-CT Rs 18,000 to 35,000.

Tumour markers are blood tests that support the assessment of an adnexal mass; they are not stand-alone diagnoses. CA-125 is the most widely used marker for epithelial ovarian cancer. It is raised in roughly 80 percent of these cancers, but also in many benign situations, including endometriosis, pelvic infection, pregnancy, menstruation, and uterine fibroids. In premenopausal women it is much less specific because so many harmless things lift it.

A postmenopausal woman with a mass and a raised CA-125 (over 35 U/mL) has a substantially higher risk of cancer than one with a normal level, though a high CA-125 alone does not confirm cancer, and a normal level does not rule it out, especially for mucinous, clear cell, and early-stage tumours. CA-125 at Indian chain labs typically costs Rs 800 to 1,800.

HE4 is more specific for ovarian cancer than CA-125. It tends to rise in serous and endometrioid cancers but generally not in mucinous tumours or benign conditions like endometriosis, and is most useful combined with CA-125. It costs roughly Rs 1,500 to 3,500 in India.

The ROMA (Risk of Ovarian Malignancy Algorithm) combines CA-125, HE4, and menopausal status into a single risk estimate, and is increasingly used in India to decide who should see a gynaecological oncologist.

The Risk of Malignancy Index (RMI) is a simpler sum: ultrasound score multiplied by menopausal score multiplied by CA-125 level. An RMI above 200 suggests meaningful risk and prompts oncology referral. RMI is popular because it is easy to calculate and well validated.

In younger women, particularly with solid components, AFP, beta-hCG, and LDH help screen for germ cell tumours; mucinous tumours often raise CEA, and granulosa cell tumours can raise inhibin and AMH. The exact panel depends on age, ultrasound features, and clinical suspicion, so a specialist guides which markers to order.

The bottom line: markers are supportive, not definitive. A mass with worrying ultrasound features still needs evaluation even with normal markers, and reassuring imaging with a raised marker needs sensible interpretation. History, examination, imaging, and markers together build the probability that drives the decision.

Whether and how to operate depends on the suspected diagnosis, size, symptoms, age, fertility plans, and risk of cancer. Surgery is usually considered for masses that are large (often over 5 to 7 cm depending on type), that persist beyond their expected timeframe, that cause symptoms, that look suspicious, or for any mass in a postmenopausal woman without clearly benign features.

Laparoscopy (keyhole surgery) is preferred for most benign or low-risk masses. It uses small incisions and offers faster recovery, less pain, a shorter hospital stay, and better cosmetic results than open surgery. Options include ovarian cystectomy (removing the cyst, sparing the ovary), oophorectomy (removing the ovary), and salpingo-oophorectomy (removing the ovary and tube). Laparoscopic ovarian surgery at private Indian hospitals typically costs Rs 60,000 to 2,00,000.

Laparotomy (open surgery) is chosen for very large masses, for suspected cancer needing full staging, and when keyhole surgery is unsafe. A vertical incision allows complete exploration and staging, including removing the omentum, taking washings, and sampling lymph nodes. Recovery is longer, around 4 to 6 weeks versus 1 to 2 weeks for laparoscopy.

When cancer is suspected, a gynaecological oncologist should ideally operate. Staging surgery typically includes hysterectomy, removal of both tubes and ovaries, omentectomy, peritoneal washings, multiple biopsies, and lymph node sampling. Adequate staging is critical for deciding on chemotherapy and for prognosis; incomplete first surgery is linked to worse outcomes.

Fertility-sparing surgery matters for younger women, particularly when the mass is benign or an early germ cell or borderline tumour. Approaches include removing only the affected ovary and tube, doing a careful cystectomy that preserves ovarian tissue, and avoiding hysterectomy. A fertility specialist's input is valuable, and in selected cases egg or embryo freezing can be considered before surgery.

After surgery, care focuses on pain control, early walking, watching for infection or clots, and a gradual return to activity. Final histopathology usually takes 5 to 10 days and longer if special staining is needed; the result decides whether any further treatment is required.

Masses found in pregnancy need special handling. Many are functional (a corpus luteum cyst that should resolve by 14 to 16 weeks) or benign, such as a dermoid. Cancer risk is low but not zero. Ultrasound is the main tool because it is safe; MRI without contrast can characterise further. Markers are hard to interpret in pregnancy because CA-125 and AFP are naturally raised.

Most simple cysts in pregnancy are watched with serial scans. When surgery is needed, it is usually done in the second trimester (about 14 to 22 weeks), when miscarriage risk has fallen and the uterus is not yet too large. Indications include suspected cancer, torsion, rupture with significant bleeding, or a large symptomatic mass.

Postmenopausal masses warrant extra attention because cancer risk is higher. A simple cyst under 1 cm has a very low risk and can usually be watched, as can a simple cyst of 1 to 7 cm with no worrying features and a normal CA-125. Larger, complex, or suspicious cysts need fuller evaluation and often surgery, with ROMA, RMI, or the IOTA ADNEX model helping to stratify risk. If a postmenopausal mass coincides with unexpected bleeding, it should be assessed promptly, as covered in our guide to endometrial cancer warning signs.

Recurrence after surgery varies by type. Endometriomas recur in 10 to 30 percent of cases over 2 to 5 years; other benign cysts recur less often. Hormonal suppression after surgery may reduce recurrence for some types. Because repeated surgery steadily reduces ovarian reserve, the long-term plan matters for anyone hoping to conceive later.

Ovarian torsion is an acute emergency, more likely with larger cysts and dermoids. The ovary twists on its blood supply, causing sudden, severe, one-sided pelvic pain, often with nausea and vomiting. Ultrasound can support the diagnosis (the "whirlpool sign" and abnormal flow), but clinical suspicion drives urgent surgery, because delay can cause the ovary to die. Laparoscopic untwisting with cyst removal is preferred when possible.

Family history carries weight. Women with a strong family history of ovarian, breast, or related cancers should be offered genetic counselling and possibly BRCA1/2 testing. Those with a confirmed BRCA mutation have a much higher lifetime ovarian cancer risk and may consider risk-reducing removal of the tubes and ovaries after completing their family. Genetic counselling services in India are concentrated in major cities but are expanding.

An adnexal mass usually does not need emergency care, but some situations do. Seek same-day or emergency care if you have sudden, severe, one-sided pelvic pain, especially with nausea and vomiting, which can mean ovarian torsion. Also seek urgent care for fainting, a racing heartbeat, or a swollen, very tender abdomen, which can mean a cyst has ruptured with bleeding, or for high fever with severe pelvic pain and discharge, which can mean a tubo-ovarian abscess.

Book a routine appointment, rather than waiting, if you have:

• ACOG Practice Bulletin: Evaluation and Management of Adnexal Masses
• RCOG Green-top Guideline: Management of Suspected Ovarian Masses in Premenopausal Women
• NICE Guideline NG12: Suspected cancer - recognition and referral (ovarian)
• IOTA Group: Simple Rules and ADNEX model for adnexal mass assessment
• WHO: Ovarian cancer
• National Cancer Registry Programme (ICMR-NCDIR), India