Introduction

Pelvic masses are a very challenging issue faced by many individuals across the world. It can be difficult to determine the correct diagnosis in the first instance of these symptoms. This means that many individuals go undiagnosed or misdiagnosed for long periods of time, often suffering discomfort and pain throughout the process. Over 50% of all pelvic masses are found within fertile individuals assigned female at birth, sometimes causing difficult and painful periods.¹ Importantly, not all pelvic masses are cancerous or cause symptoms. The reproductive health of individuals assigned female at birth has historically received very little attention and funding, with individuals assigned female at birth complaining of chronic pain often dismissed as hypochondriacs and given simple pain relief as treatment. Through awareness and education, this is something many scientists hope to change.

Uterine fibroids

What are uterine fibroids?

Uterine fibroids are the most common pelvic tumours in individuals assigned female at birth of reproductive age and have a decreasing incidence in those over the age of 45.² They are often considered to be driven by the hormones oestrogen and progesterone due to their increased prevalence amongst individuals experiencing periods. Most uterine fibroids occur in the outer lining of the uterus, known as the myometrium, and are made up of smooth muscle and connective tissue. They are non-cancerous and will not lead to cancer development; however, affected individuals can experience some very uncomfortable symptoms.³

What are the causes and risk factors?

Most of the risk factors associated with the onset of fibroids relate to the length and onset of periods. Experiencing a first pregnancy in your 30s and starting periods at an early age can increase your risk of developing uterine fibroids. Both high alcohol consumption and obesity can similarly increase your risk of developing uterine fibroids.⁴ In contrast to this, individuals who use oral contraceptive pills and those who smoke have a reduced risk of fibroid development. Other, non-modifiable risk factors, including genetics, also play a role in increasing/decreasing the likelihood of fibroid development. 

Common features

The most common symptom often experienced with uterine fibroids is heavy menstrual bleeding that can sometimes be painful. This pain can sometimes be felt as a buildup of pressure within the bladder or abdominal wall and can be chronic. Pain can also be felt during sexual intercourse or throughout different points of the cycle, following a cyclical pattern.⁵ Often, heavy menstrual bleeding is tackled with NSAIDs, the combined oral contraceptive pill (COCP) or the intrauterine device (IUD), depending on the extent of the bleeding. In some cases, where non-invasive methods fail to alleviate symptoms, surgery, like a hysterectomy, can be done to remove the affected parts.⁶

Ovarian cysts

Another cause of pelvic mass in individuals assigned female at birth could be ovarian cysts. These are filled with fluid and can be simple or very complex structures. More often than not, simple cysts don’t have many symptoms and can be found incidentally on certain scans. Complications occur if the cysts rupture, haemorrhage or cause ovarian torsion (a life-threatening condition that requires immediate medical attention).⁷ The most common time of onset is during pregnancy, when simple cysts form during the second trimester due to beta hCG hormone levels reaching peak levels. 

Ovarian cancer

In 2020, ovarian cancer was the 8th most commonly diagnosed cancer in the world. This is a startling statistic when we also know that the 5-year survival rate for those diagnosed with this type of cancer is below 50%. This is typically due to the late-stage diagnosis that often occurs with ovarian cancer.⁸ Similarly to uterine fibroids, obesity and genetics play a big role in the development of the disease. Later symptoms that point towards a diagnosis of ovarian cancer are weight loss, chronic pelvic and abdominal pain, postmenopausal bleeding, bloating and a change in bowel habits.⁹

Differentiating between masses

It can be very difficult to determine what a particular mass is based solely on the symptom profile. There is a range of investigative and diagnostic techniques that hospitals use in order to help make an informed decision and an accurate diagnosis. Transvaginal ultrasound scans can be useful in order to distinguish between non-cancerous and cancerous masses within some parts of the pelvis. Other techniques, including CT scans and MRIs, may be necessary if invasive cancers are suspected.¹⁰ In most cases, a blood test will be taken to detect circulating levels of CA-125 in the body. This is a protein marker that can aid ovarian cancers and also liver disease, pregnancy and endometriosis, meaning that a raised level alone is not enough to suspect a diagnosis of cancer. To obtain an accurate diagnosis, looking at the whole picture, including the age of the individual, risk factors, symptoms and other investigations, is needed in order to reach an accurate diagnosis. 

FAQs

What are the most common causes of pelvic mass?

The most common causes of pelvic masses are usually of gynaecological origin. This can include uterine fibroids, endometriosis, ovarian cysts and more sinister ovarian tumours. Other less common causes of pelvic mass may be due to bowel or bladder issues. This is why differentiating between mass types can be very difficult without a wide range of investigations. 

What are the main testing options available for pelvic masses?

As it can be difficult to diagnose pelvic masses purely based on symptoms alone, there are a number of different tests and investigations that can be done in order to help create a clearer picture for diagnosis. This can include blood tests to check for inflammation and raised CA-125 levels, as well as ultrasound scans and CT scans to view masses internally. Whilst these are all valuable tools to use, there still can be some issues when coming to a set diagnosis in a very small number of cases. In this case, more invasive techniques may be used that can include exploratory surgery in the pelvic region.

Summary

Pelvic masses consist of a wide range of different diagnoses, some more serious and harmful than others. It can be very difficult to determine what is causing some of the common pelvic symptoms in individuals assigned female at birth, including heavy menstrual bleeding and chronic pain. There have been some advancements in investigative and diagnostic techniques, meaning that medical professionals can more accurately determine what is the cause of symptoms. It is, however, quite a long and arduous process for those suffering with constant pain or bleeds, having to often deal with worry whilst they await a lot of tests and results. The reproductive health of individuals assigned female at birth is an area in which there is a need for more medical research and attention from scientists to provide accurate and efficient diagnoses for many indivduals struggling across the globe.