Case study: Abdominal mass

A woman with irregular bleeding developed alarming symptoms.

Jane is a 45-year-old married woman who is normally fit and well. She has three teenage children all born by vaginal delivery in the past underwent a laparoscopic cholecystectomy for gallstones. She leads a busy life at home looking after her children and works part-time, so she rarely attends the surgery.

Bleeding
She presented complaining of postcoital bleeding and occasional intermenstrual bleeding over the previous three to four weeks. She had assumed that this was a minor blip that would resolve on its own, and being busy she had not rushed to the surgery.

She had no pain or discharge and her periods were normally regular and not heavy. She and her husband were using condoms for contraception.

On examination, her vulva and vagina were healthy, but there was an obvious cervical ectropion. This did not bleed when I took a cervical smear.

Her uterus was tilted forward and pelvic examination revealed it to be slightly bulky. There were no adnexal masses palpable.

I arranged a pelvic scan, which confirmed that the uterus was slightly bulky, and found a thickening of the endometrium at 15mm. The ovaries were well visualised and were normal.

Referral
As the bleeding was continuing intermittently, I referred Jane to a gynaecologist who confirmed the presence of cervical ectropion and undertook cautery with silver nitrate.

A review was scheduled two months later, at which point further cautery and hysteroscopy would be arranged under general anaesthetic if the bleeding persisted. However, the irregular bleeding resolved. At the follow-up appointment the cervix appeared healthy with no evidence of ectropion. She was discharged from the clinic.

Abdominal mass
I was surprised to see Jane in the surgery again a short time later as it was only a couple of weeks since I had received a letter from the consultant gynaecologist advising me that all was well. On this occasion, she mentioned that she felt bloated, and had noticed some lower abdominal discomfort and urinary frequency with no dysuria.

Urinalysis was negative but on abdominal examination I found a large mass in her lower abdomen extending almost to the umbilicus. This was confirmed on pelvic examination.

I arranged an urgent ultrasound scan, which was carried out later that week. On this occasion, only six months after the original scan, a 16 x 10cm mixed tissue mass arising from the right ovary with areas of calcification was found.

The uterus was separate from this mass, which was identified as a dermoid cyst based on the appearance of the scan.

I arranged for her to be seen again urgently in the gynaecology clinic, and following her consultation she was booked for total abdominal hysterectomy and bilateral salpingo-oophorectomy. She has recently undergone surgery.

Ovarian cyst
When it was removed, the ovarian cyst was found to have grown since the recent scan, now measuring 20 x 11cm. Histology confirmed that it was a benign dermoid cyst.

Dermoid cysts originate in ovarian cells which form into different tissues when the egg develops. They can contain hair, bone, cartilage or teeth as well as skin tissue.

Dr Lewis is a GP in Windsor, Berkshire

References

  • Joint British Societies. JBS 2: Joint British Societies' guidelines on prevention of cardiovascular disease in clinical practice. Heart 2005; 91 (Suppl 5): v1-v52.
  • Risk estimation and the prevention of cardiovascular disease Guideline No. 97 Scottish Intercollegiate Guidelines Network at: www.sign.ac.uk/guidelines/fulltext/97/index.html
  • QRISK calculator at: www.qrisk.org.

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