Sally presented to her primary care provider with a complaint of increased girth and pelvic pressure that had worsened during the previous 3 months.


Sally, a 43-year-old Caucasian, was in generally good health. She had successfully quit smoking about 2 years before her visit after a 30 pack-year history and currently worked full time as a massage therapist. Her history was significant for a lumbar laminectomy 15 years ago and a recent laparoscopic umbilical hernia repair. She had given birth to 2 children by uncomplicated vaginal deliveries 15 and 18 years ago. She was taking no medications and had no known allergies.

Continue Reading

Since her laparoscopic hernia repair, Sally continued to complain of feeling bloated. She also had begun noticing constipation, which was an unusual problem for her. She denied pain but stated that her abdomen just felt “uncomfortable.” At the same time, she had found that several pairs of her jeans and slacks were too tight around her abdomen, and she had an increased sensation of pelvic pressure, along with urinary frequency. Sally still had regular menses and was sexually active with her husband, but she had a bilateral tubal ligation after her last child was born. She was current on her cervical cancer screenings with no history of atypia. Her symptoms became so pervasive and interfering with her daily life that she sought care from her primary care provider.

Physical exam

Sally presented to the office in apparently perfect health. Her skin was clear and supple, with no blemishes or rash. Her hair was soft, shiny, and without breakage or signs of hair loss. Neurologically, her gait was normal, her speech was intact and appropriate, and her pupils were equal, round, and reactive to light. A heart examination was normal with a pulse of 79 beats per minute in a normal sinus rhythm without murmurs. Her lungs were clear with a respiratory rate of 18 breaths per minute. Her blood pressure was 128/60 mm Hg, and her weight was 167 pounds.

On examination, her abdomen was visibly enlarged with an obvious left-sided dominance. A bimanual pelvic examination further revealed a large, smooth, left lower quadrant adnexal enlargement. The mass was nontender, firm, and not ballotable. No notation of cervical motion tenderness or discharge was observed. A rectovaginal examination confirmed these findings.

Laboratory tests and imaging

An ultrasound was subsequently obtained with external and transvaginal views. That report revealed a 14-cm round, smooth, solid, nonseptate mass that totally obscured the left ovary. A noncontrast CT scan did not show any other irregularity or invasive growth such as increased vascularization or adenopathy. Her laboratory workup showed a normal complete blood count with differential. The CA-125 (cancer antigen), which is a protein believed to be a tumor biomarker found in greater concentration in tumor cells than in other cells of the body, was 15 U/mL, which was within normal limits (0 to 35 U/mL). Vaginal swab cultures were negative for sexually transmitted infections. Her ECG and chest X-ray were also normal.