Ovarian masses range from harmless functional cysts to epithelial ovarian cancer, the deadliest gynecologic cancer. Age, imaging features, and tumor markers guide how worried to be.

Functional (physiologic) cysts — most common in reproductive years; usually resolve in 1–3 cycles

• Follicular cyst: a follicle that fails to rupture
• Corpus luteum cyst: may bleed or rupture around mid-cycle to the luteal phase → sudden unilateral pain, possible hemoperitoneum
• Theca lutein cysts: from high hCG (molar pregnancy, multiple gestation)

Benign neoplasms

• Mature cystic teratoma (dermoid cyst) — a germ cell tumor containing hair, fat, teeth; the most common ovarian neoplasm in young women; prone to torsion
• Serous cystadenoma — thin-walled cyst filled with clear serous fluid; the most common benign epithelial tumor; may be bilateral
• Mucinous cystadenoma — filled with thick mucin; can become very large
• Fibroma — solid, benign stromal tumor in older women; Meigs syndrome = ovarian fibroma + ascites + pleural effusion, which resolve after tumor removal
• Endometrioma ("chocolate cyst") — endometriosis of the ovary

Malignant tumors

Risk factors for epithelial ovarian cancer — more ovulations and inherited risk

• BRCA1/BRCA2 mutations (hereditary breast and ovarian cancer syndrome), Lynch syndrome; family history
• Increasing age, nulliparity, infertility, early menarche and late menopause, endometriosis (clear cell and endometrioid types), menopausal hormone therapy, obesity

Protective — combined oral contraceptives (risk falls with longer use), pregnancy and breastfeeding, tubal ligation or salpingectomy, risk-reducing salpingo-oophorectomy in carriers.

Benign cysts — often asymptomatic; pelvic fullness, dull ache, dyspareunia, irregular bleeding.

Acute presentations

• Ovarian torsion: sudden severe unilateral pelvic pain, nausea and vomiting, often with a known mass (dermoid) — a surgical emergency to save the ovary
• Cyst rupture / hemorrhage: sudden unilateral pain, often mid-cycle or after intercourse or exercise; peritoneal signs; shock if bleeding is large
• Always consider ectopic pregnancy in reproductive-age clients with pelvic pain

Ovarian cancer — vague, persistent symptoms that are new and occur more than about 12 times a month:

• Abdominal bloating or increased girth, early satiety or difficulty eating, pelvic or abdominal pain, urinary urgency or frequency
• Indigestion, constipation, fatigue, back pain, weight loss
• Advanced: ascites (shifting dullness, fluid wave), dyspnea (pleural effusion), bowel obstruction, fixed hard irregular pelvic mass, leg edema
• Red flags on exam: solid, fixed, irregular, bilateral mass, ascites, a palpable ovary in a postmenopausal woman

• Pregnancy test first in reproductive-age clients
• Transvaginal (and pelvic) ultrasound — first-line; features suggesting malignancy: solid components, thick septations, papillary projections, bilateral masses, ascites, increased blood flow; simple thin-walled cysts are usually benign. Doppler helps with torsion but a normal flow does not exclude it
• CA-125 — raised in most advanced epithelial cancers but also in endometriosis, fibroids, PID, pregnancy, menstruation, and liver disease; it is normal in about half of early-stage cancers, so a normal value does not exclude cancer, and it is less specific before menopause; most useful in postmenopausal women with a mass and to monitor treatment response and recurrence. Risk algorithms (e.g., ROMA with HE4) help triage
• AFP, hCG, LDH — for adolescents and young women with a solid mass (germ cell tumors)
• CT chest/abdomen/pelvis — extent of disease; paracentesis or biopsy when surgery is not the first step
• Surgical staging (FIGO): stage I ovary/tube; II pelvic spread; III peritoneal spread outside the pelvis and/or retroperitoneal nodes; IV distant (e.g., malignant pleural effusion, liver parenchyma)
• Germline genetic testing (BRCA and others) for everyone diagnosed with epithelial ovarian cancer; tumor testing guides targeted therapy
• Screening: not recommended for average-risk women (USPSTF grade D) — ultrasound and CA-125 did not reduce deaths and led to unnecessary surgery

Functional cysts — observe with repeat ultrasound in 6–12 weeks; analgesics; combined oral contraceptives prevent new cysts but do not shrink existing ones.

Benign neoplasms — ovarian cystectomy (preserves ovary) or oophorectomy, usually laparoscopic.

Torsion — urgent laparoscopy with detorsion (ovary usually preserved even if dusky).

Epithelial ovarian cancer

• Surgery by a gynecologic oncologist: total hysterectomy, bilateral salpingo-oophorectomy, omentectomy, peritoneal washings and biopsies, lymph node assessment, and cytoreductive (debulking) surgery to remove all visible tumor
• Neoadjuvant chemotherapy first, then interval debulking, when complete removal is unlikely or the client is too ill for surgery
• Fertility-sparing surgery for selected young women with early, low-grade disease
• Chemotherapy: carboplatin + paclitaxel (IV; intraperitoneal delivery in selected cases), often with bevacizumab
• Maintenance: PARP inhibitors (olaparib, niraparib) — especially for BRCA-mutated or homologous-recombination-deficient tumors
• Recurrence: platinum-based or other chemotherapy; mirvetuximab soravtansine for folate-receptor-alpha-positive tumors

Germ cell tumors — fertility-sparing unilateral salpingo-oophorectomy plus BEP (bleomycin, etoposide, cisplatin); very high cure rates.

Prevention in carriers — risk-reducing salpingo-oophorectomy (about 35–40 for BRCA1; 40–45 for BRCA2) after childbearing; opportunistic salpingectomy at other pelvic surgery for average-risk women.

Drug safety

Listed in priority order.

1. Recognize surgical emergencies — torsion or rupture: severe pain, peritoneal signs, tachycardia, hypotension → keep NPO, IV access, notify provider, prepare for surgery
2. Breathing with ascites or pleural effusion — semi-Fowler's or high-Fowler's position, oxygen as needed, monitor SpO₂ and respiratory rate; assist with paracentesis or thoracentesis
3. Paracentesis care — empty the bladder first (prevents puncture), measure weight and girth before and after, monitor blood pressure and heart rate (hypotension after large-volume removal; albumin may be given), check the site for leakage
4. Neutropenic fever and chemotherapy toxicity — temperature, CBC before cycles; stop infusion immediately for hypersensitivity (keep the line open with saline); monitor blood pressure and urine protein on bevacizumab
5. Postoperative care after debulking — bleeding, fluid balance (third spacing), ileus or bowel obstruction (distension, vomiting, absent flatus), ostomy care if bowel resected, VTE prophylaxis, pain control, early ambulation
6. Intraperitoneal chemotherapy — warm fluid to body temperature, infuse through the IP port with the client supine, then turn side to side as ordered for distribution; expect abdominal fullness and discomfort; watch for infection or leakage at the port and for signs of bowel injury
7. Nutrition — early satiety and bowel symptoms: small frequent meals, dietitian referral, weight monitoring
8. Psychosocial and palliative care — advanced disease, recurrence, and hereditary risk; referral to genetic counseling and palliative care early

• Report new, persistent bloating, early fullness, pelvic pain, or urinary urgency lasting more than 2–3 weeks — do not dismiss as indigestion
• Functional cysts: usually resolve; follow-up ultrasound; seek care for sudden severe pain with vomiting (torsion)
• Genetic counseling and testing for anyone with ovarian cancer, and for relatives of carriers; discuss risk-reducing surgery after childbearing
• Oral contraceptives lower ovarian cancer risk — a benefit to discuss when choosing contraception
• After surgery: no heavy lifting and no intercourse until cleared (about 6 weeks); surgical menopause symptoms may start if both ovaries are removed
• Chemotherapy: call for temperature 38.0 °C (100.4 °F) or higher; report numbness or tingling (paclitaxel), bleeding or bruising (low platelets), and severe abdominal pain (bevacizumab)
• PARP inhibitors: take at the same time daily; regular blood counts; report fatigue, bruising, fever; niraparib — check blood pressure; use contraception
• CA-125 is used to follow response; a single value is not a diagnosis

• Most common ovarian neoplasm in young women: dermoid (mature cystic teratoma) — torsion risk
• Serous cystadenoma = thin wall, clear fluid; mucinous = thick mucin, can be huge
• Meigs syndrome = fibroma + ascites + pleural effusion; resolves after removal
• Granulosa cell tumor → estrogen (postmenopausal bleeding, endometrial hyperplasia); Sertoli–Leydig → androgens (virilization)
• Epithelial cancer: postmenopausal, BRCA, nulliparity, many ovulations; vague GI symptoms, advanced at diagnosis
• CA-125 for epithelial cancer (monitoring, not screening); AFP/hCG/LDH for germ cell tumors
• No routine screening for average-risk women
• Protective: combined oral contraceptives, pregnancy, breastfeeding, tubal ligation/salpingectomy
• Treatment: debulking surgery + carboplatin/paclitaxel; PARP inhibitor maintenance
• Ascites with dyspnea: semi-Fowler's + oxygen; before paracentesis void
• Fever during chemotherapy → report immediately