Ovarian masses are common findings in women of all ages, affecting about 8% of reproductive-aged women [3]. Ovarian mass can be categorized into two broad categories: functional (e.g., follicular or luteal cyst) or neo-plastic. Approximately 70% of the identified masses in reproductive women are functional [3]. They occur due to ovulatory disruptions. In the process of normal ovulation, a follicle develops to maturity and then ruptures to release an ovum; this is followed by formation and subsequent involution of the corpus luteum. Follicular cysts arise when rupture does not occur and the follicle continues to grow; corpus luteum cysts occur when the corpus luteum fails to involute and continues to enlarge after ovulation. These cysts are therefore called physiologic or functional [1], and they affect approximately 7% of reproductive-aged women [3].

Ovarian neoplasms arise from the surface epithelium, germ cells, and sex-cord-stromal tissue, and may be benign or malignant. An overwhelming majority are benign; the risk of malignancy of an adnexal mass is only 6–11% in premenopausal women and 29–35% in postmenopausal women [1, 4]. In women aged 20–39, the three most frequent types of benign ovarian masses are: (i) serous and mucinouscystadenoma (arising from surface epithelium), (ii) endometrioma (a.k.a. “chocolate cysts” arising from ectopic endometrial tissue) [1], and (iii) mature cystic teratoma (a.k.a. dermoid cyst arising from the germ cell layers) [5].

Recent advances in ultrasonographic technology have played a pivotal role in questioning the validity of our age-old assumptions with regards to the clinical significance of an ovarian mass. Cystic ovarian masses in premenarchial females, once viewed as pathologic and associated with premature puberty, are now known to be common [6]. In general, ultrasonographic evaluations and imaging of the upper genital tract should not be used routinely as a screening tool, especially with respect to the evaluation of dyspareunia.

Ovarian Mass and Dyspareunia

Because an ovarian mass is a common finding in women of reproductive age, its mere presence should not be thought as causative in painful intercourse. In fact, although commonly blamed as the cause of sexual pain in clinical practice, ovarian cysts are rarely associated with persistent dyspareunia [2]. Nevertheless, functional ovarian cysts can be associated with acute and/or cyclical pain and, less commonly, dyspareunia [3], and in cases in which symptoms of intermittent dyspareunia exist simultaneously with ovarian mass, deep dyspareunia is the most likely subtype to be found.

A common cause of deep dyspareunia is due to Mittleshmertz (a.k.a. ovulatory pain), which may last anywhere from 2 hr to 2 days. It may occur spontaneously or can be precipitated with intercourse in midcycle. Women with ovulatory pain may report cyclical pain that may be positional and exacerbated with deep thrusting. When examined, pain and discomfort with cervical movement and abdominal pressure is often noted during the painful episode. Upon ultrasound evaluation, an ovulatory cyst with a small amount of free peritoneal fluid is commonly found. Mittleshmertz is a self-limiting condition and spontaneously resolves with supportive therapy (e.g., heat application) and use of nonsteroidal anti-inflammatory drugs (NSAIDS). Hormonal suppression with oral contraceptive therapy is empirically [7, 8] used for the treatment of recurrent symptoms.

Other causes of deep dyspareunia may include tuboovarian abscess, adnexal torsion, and benign ovarian neoplasm [9]. These causes, in addition to other infection-and pregnancy-related causes, should always be ruled out before attributing the diagnosis to an adnexal mass. The first two conditions present with systemic signs of inflammation, such as fever and an elevated white blood cell count, as well as severe pain. Benign ovarian neoplasms, on the other hand, can enlarge without the presence of pain. In contrast, malignant neoplasms are indolent and more likely to present with vague abdominal pain and ascites.

Overall, radiological imaging (most commonly ultrasound examination) of the upper genital tract should be reserved for cases presenting with deep dyspareunia and/or findings of tenderness in the uterus, adnexa,and/or with cervical movement (commonly known as cervical motion tenderness). Ectopic pregnancy and infectious etiologies of deep dyspareunia should always be ruled out first. In our experience, even when an ovarian cyst is present, it is likely that other conditions such as endometriosis [10] are responsible for the dyspareunia.

Uterine Leiomyomata