In adolescent gynecologic patients, pregnancy should always be considered as a cause of a pelvic mass. In the U.S., more than 50% of adolescent young women have experienced sexual intercourse by 17 years of age. More than 85% of pregnancies among adolescents are unintended. Adolescents may be more likely than adults to deny the possibility of pregnancy be¬cause of wishful thinking, anxiety about discovery by parents or peers, or unfamiliarity with menstrual cycles and information about fertility. Ectopic pregnancies may present with pelvic pain and an adnexal mass. With the availability of quantitative measurements of 13-human chorionic gonadotropin (hCG), more ectopic pregnancies are being discovered before rupture, allowing conservative management with laparoscopic surgery or medical therapy with Methotrexate. The risk of ectopic pregnancy varies by method of contraception: users of no contraception have the highest risk, whereas oral contracep¬tive users have the lowest risk. As in older patients, paraovarian cysts and non-gyne¬cologic masses may be discovered in adolescents with the use of medical microscopes such as a gynecologic microscope.

A history and pelvic examination of the gynecologic patient are critical in the diagnosis of a pelvic mass. Considera¬tions in adolescent gynecologic patients include the anxiety associated with a first pelvic examination, as well as issues of confidentiality related to questions of sexual activity.

Laboratory studies should always include a pregnancy test (regardless of stated sexual ac¬tivity), and a complete blood count may be helpful in diagnosing inflammatory masses. Tu¬mor markers, including a-fetoprotein and hCG, may be elaborated by germ cell tumors and can be useful in preoperative diagnosis as well as follow-up. Gynecology microscopes can help in these diagnoses.

As in all age groups, the primary diagnostic technique for evaluating pelvic masses in ado¬lescents is ultrasonography. Although transvaginal ultrasound examinations may provide more detail than transabdominal scans, a transvaginal examination may not be well toler¬ated by adolescent gynecologic patients. For cases in which the ultrasound examination is inconclusive, CT or MRI may be helpful. An accurate preoperative assessment of anatomy is critical, particularly in cases of uterovaginal malformations. MRI can be useful for evaluating this group of rare anomalies. Some sort of imaging technique should be used in eval¬uating patients who present with abdominal pain, because an unexpected ovarian mass may be difficult to manage through an incision intended for an appendectomy.

The management of masses in adolescent gynecologic patients depends on the suspected diagnosis as well as the presenting complaint. Asymptomatic unilocular cystic masses, which are seen with the use of a gynecology microscope, are best managed conservatively be¬cause the likelihood of malignancy is low. If surgical management is required based on symptoms or uncertainty of diagnosis, attention should be paid to minimizing the risks of subsequent infertility resulting from pelvic adhesions. In addition, every effort should be made to conserve ovarian tissue. In the presence of a malignant unilateral ovarian mass that is diagnosed with the use of gynecology microscope, management may include uniIateral oophorectomy rather than more radical surgery, even if the ovarian tumor has metastasized. Analysis of frozen sec¬tions may not be reliable. In general, conservative surgery is appropriate; further surgery can be performed if necessary after an adequate histologic evaluation of the ovarian tumor using gynecology microscopes.

The surgical management of inflammatory masses is rarely necessary in adolescents, except to treat rupture of tubo-ovarian abscess or failure of medical management with broad-spec¬trum antibiotics. Conservative, unilateraladnexectomy can usually be per¬formed in these situations, rather than a “pelvic clean-out,” maintaining reproductive poten¬tial. Percutaneous drainage and laparoscopic management of tubo-ovarian abscesses are becoming more popular, although as with the laparoscopic management of ovarian masses, the surgeon’s skill and experience are critical and prospective studies are lacking.

It is difficult to determine the frequency of diagnoses of pelvic mass• in women of reproduc¬tive age because many pelvic masses are not ultimately treated with surgery. Nonovarian or nongynecologic conditions may be confused with an ovarian or uterine mass. There are series in which the frequency of masses found at laparotomy is reviewed, although the varying indications for surgery, indications for referral, type of practice (gynecologic on¬cology vs. general gynecology), and patient populations (a higher percentage of African¬Americans with uterine leiomyomas, for example) will affect the percentages. Benign masses, such as functional ovarian cysts, will often (appropriately) not require surgery.

Age is an important determinant of the likelihood of malignancy. In one series of women who underwent laparotomy for pelvic mass, malignancy was seen in only 10% of those younger than 30 years of age, and most of these tumors had low malignant potential.  The most common tumors found during laparotomy for pelvic mass are dermoids (seen in one-third of women younger than 30 years of age) and endometriomas (approximately one-fourth of women 31-49 years of age).