Adnexal Masses: Diagnosis and Management.

Pelvic masses occur in up to 20% of women throughout their lifetime. These masses represent a spectrum of gynecologic and nongynecologic conditions. Adnexal masses-found in the fallopian tubes, ovaries, and surrounding areas-are mostly benign. Evaluation includes assessment for symptoms that may suggest malignancy, such as abdominal pain, abdominal bloating, and early satiety. A family history of ovarian, breast, or certain heritable syndromes increases the risk of malignancy. For women of reproductive age, ectopic pregnancies must be considered; a beta human chorionic gonadotropin level should be obtained. Transvaginal ultrasonography is the imaging test of choice for evaluating adnexal masses for size and complexity. Adnexal cysts that are greater than 10 cm, contain solid components, or have high color flow on Doppler ultrasonography are high risk for malignancy. Further imaging, if warranted, should be completed with computed tomography or magnetic resonance imaging, particularly if there is concern for disease outside the ovary. Multimodal assessment tools that use ultrasonography and biomarkers, such as the risk of malignancy index, are useful in the diagnosis and exclusion of malignant causes. Asymptomatic masses that are determined to be benign may be observed and managed expectantly. In symptomatic or emergent cases, such as ectopic pregnancy or ovarian torsion, a gynecologist should be consulted. In any adnexal mass with high risk for malignancy, a consultation with gynecologic oncology is indicated.

Cervical Ripening and Induction of Labor.

Induction of labor is a common obstetric procedure, and approximately one-fourth of pregnant patients undergo the procedure. Although exercise and nipple stimulation can increase the likelihood of spontaneous labor, sexual intercourse may not be effective. Acupuncture has been used for labor induction; however, it has not been shown to increase vaginal delivery rates. There is strong evidence that membrane sweeping can increase the likelihood of spontaneous labor within 48 hours. Cervical preparation or ripening is often needed before induction. Some evidence shows that the use of nonpharmacologic approaches such as osmotic dilators and cervical ripening balloons reduce time to delivery. The effect of amniotomy on labor is uncertain. Pharmacologic intervention with oxytocin or prostaglandins is effective for cervical ripening and induction of labor. Combining a balloon catheter with misoprostol is a common practice and has been shown to decrease time to delivery in a small study.

Cervical Cancer Screening.

Screening in women has decreased the incidence and mortality of cervical cancer. Precancerous cervical lesions (cervical intraepithelial neoplasias) and cervical carcinomas are strongly associated with sexually-transmitted high-risk human papillomavirus (HPV) infection, which causes more than 99% of cervical cancers. Screening methods include cytology (Papanicolaou test) and HPV testing, alone or in combination. The American Academy of Family Physicians and the U.S. Preventive Services Task Force recommend starting screening in immunocompetent, asymptomatic women at 21 years of age. Women 21 to 29 years of age should be screened every three years with cytology alone. Women 30 to 65 years of age should be screened every five years with cytology plus HPV testing or every three years with cytology alone. Screening is not recommended for women younger than 21 years or in women older than 65 years with an adequate history of negative screening results. The U.S. Preventive Services Task Force is in the process of updating its guidelines. In 2015, the American Society for Colposcopy and Cervical Pathology and the Society of Gynecologic Oncology published interim guidance for the use of primary HPV testing.