Pelvic masses include benign and malignant tumors, and the diagnosis should be closely related to individual factors such as the patient’s age and reproductive status. This article describes the significance of clinical examination, imaging findings and laboratory tests in identifying the nature of pelvic masses in turn. High risk factors for ovarian cancer include age, women with a family history of breast and ovarian cancer. Childlessness, primary infertility, and endometriosis can all increase the risk of ovarian cancer. Almost all pelvic masses in premenopausal women are benign, so the initial evaluation lies in their presence or absence of pelvic and abdominal symptoms. Proper evaluation includes history taking and physical examination, quantitative ? -HCG monitoring, complete blood count, and vaginal ultrasound. Rarely, malignancy presents as an acute abdomen, and most emergencies are due to acute bleeding from the cancer or acute blood loss due to abrupt tumor growth. These conditions are often seen in germ cell tumors that are prevalent in adolescent or women in their 20s. Malignant tumors tend to be irregular on palpation, hard, fixed, nodular, bilateral, and associated with ascites. Transvaginal ultrasound is used as the most common imaging modality to examine adnexal masses. The main limitation is the lack of specificity and low positive predictive value for cancer, especially in premenopausal women, and a combination of transabdominal and transvaginal ultrasound should be used. Ultrasound should characterize the size and nature of the mass (cystic, solid or mixed), unilateral or bilateral, the presence or absence of segregation formation, the presence or absence of nodules in the cystic wall, the presence or absence of papillary bullae and the presence or absence of ascites in the pelvis. Color Doppler ultrasound allows the determination of blood flow around the mass and may improve the specificity of 2D grayscale ultrasound. The role in the evaluation of pelvic masses remains controversial mainly because there are reports of some overlap in flow measurements such as resistance index, pulsatility index, and maximum systolic flow velocity in benign and malignant masses. CT, MRI, and PET are not recommended as the first choice for adnexal masses. In limited data, MRI may have a better advantage over ultrasound in the staging of malignant masses, and MRI is useful in identifying non-adnexal masses of origin, especially uterine smooth muscle tumors, and CT is useful in detecting metastases in the abdomen in patients with suspected malignancy. The incidence of malignancy in unicompartmental, thin-walled, smooth-surfaced, well-defined cysts with good sound transmission is about 0-1%, regardless of menopause and cyst size. The predictive value of CA125 for malignancy in premenopausal women is lower than that in postmenopausal women. Critical values are quite useful indicators. Mildly elevated in premenopausal women with certain benign disorders, and significantly elevated should be highly suspicious of malignancy. Studies have found that CA125 increases over time in the presence of cancer. Serum CA125 is elevated in 80% of patients with ovarian epithelial cancer, but is only present in 50% of stage I patients at diagnosis. -HCG, LDH and AFP levels may be elevated in certain specific malignant germ cell tumors, and inhibin A and B are markers of ovarian granulosa cell tumors. Postmenopausal women with adnexal masses are evaluated by vaginal ultrasound and blood CA125 levels. Elevated CA125 and ultrasound suggestive of a solid component of the mass, a superfluous cyst, ascites or pelvic fluid should raise a high suspicion of malignancy. Most postmenopausal women require surgery except for vaginal ultrasound suggesting a simple cyst. Colon, breast, and stomach are common sites of metastasis for malignant tumors. All postmenopausal women who have not had a mammogram in the last 12 months should have a mammogram and rectal examination after the development of an adnexal mass. Women with vaginal ultrasound suggesting thick endometrium or vaginal bleeding should undergo endometrial biopsy. If the patient is anemic, has a positive fecal occult blood test, and is over 50 years of age, a complete gastrointestinal examination should be performed to rule out primary gastric or colon cancer. Postmenopausal women are contraindicated for adnexal mass aspiration for the following reasons: cytologic examination of the cystic fluid has a low sensitivity for the diagnosis of malignancy, fluctuating from 25% to 82%; aspiration of malignancy can lead to dissemination and implantation of tumor cells in the peritoneum, which alters the disease stage and prognosis. Only in women with a high suspicion of advanced ovarian cancer that is not amenable to surgery, tumor aspiration can confirm the diagnosis so that neoadjuvant chemotherapy can be initiated. Aspiration is not a definitive treatment option even for benign tumors, and approximately 25% of cysts recur one year after aspiration regardless of pre or postmenopause; the incidence of adnexal masses in conjunction with pregnancy is 0.05-3.2% (number of live births). The most common types are ovarian mature teratoma and ovarian corpus luteum cysts. Malignant tumors occupy just 3.6-6.8%. The most common tumors are germ cell, mesenchymal cell, or low-grade malignant epithelial tumors. The evaluation of adnexal masses in pregnancy is similar to the approach used in premenopausal women. In addition to vaginal ultrasound, transabdominal ultrasound should be combined, depending on the gestational week, as the ovaries may be outside the pelvis with the gestational week.MRI is an excellent screening tool with no radiological damage to the fetus. In early pregnancy, CA125 peaks, fluctuating at 7-251 units|ml, and declines gradually thereafter. To avoid rupture or torsion of the cyst, surgery in mid-trimester is the most common modality. The incidence of acute abdomen during pregnancy is less than 2%. The risk of both malignant and acute adnexal masses in pregnancy is minimal and treatment can be expected. It has been reported that 51-70% of adnexal masses resolve spontaneously after pregnancy. Laparoscopy is the best option for patients who are considered benign after adequate preoperative evaluation. In general, laparoscopic surgery should be considered contraindicated in patients with preoperative suspicion of malignancy, although laparoscopy has been reported for the staging and treatment of ovarian cancer. Several retrospective studies have reported only 0%-10% minor complications with laparoscopic treatment of adnexal masses. In contrast, serious complication rates occurred when the masses were malignant. The extent of surgery should be determined by preoperative diagnosis, patient age and expectation of preservation of ovarian and reproductive function. Surgical options for premenopausal women tend to favor cystectomy. When ovarian tissue cannot be preserved, unilateral salpingo-oophorectomy or tubo-oophorectomy is indicated. Patients must be informed that the contralateral ovary may also accumulate at the same time, with benign plasmacytomas accumulating contralaterally in up to 25%, benign teratomas in 15%, and benign mucinous tumors in 2-3%. Dissection biopsy of the contralateral ovary that appears normal is not recommended because it may impair reproductive function. Cystectomy or unilateral adnexal resection is an option for peri- or postmenopausal women. For women who have completed their reproductive function, hysterectomy or bilateral adnexal resection or hysterectomy + adnexal resection is considered the most correct choice because it avoids the risk of subsequent ovarian, uterine, and cervical cancer. It is uncertain whether the potential benefits of ovarian preservation outweigh its risks. Studies have found that women who have their ovaries removed before age 39 have an increased risk of coronary heart disease and hip fracture. Once ovarian cancer is identified, including low-grade malignancy, the standard procedure is total hysterectomy plus bilateral adnexal resection, regardless of menopausal status. When premenopausal women have germ cell tumors,1 stromal cell tumors with potentially low-grade malignant cells, stage Ia, grade 1-2 invasive cancer, conservative surgery including unilateral adnexal resection or even ovarian cyst debulking does not appear to be associated with a poor prognosis. However, these patients still require full surgical staging. Recurrence rates are relatively low. Fertility outcomes are still generally optimistic. However, the number of patients involved in the study was small. Surgeons often rely on frozen results to determine the surgical approach. The diagnostic match rate for frozen sections was 72%-88.7%. At masses larger than 10 cm, the diagnostic agreement rate decreases because of the potential for sample error in larger specimens. Recommended treatment strategies: transvaginal ultrasound is the routine imaging option in asymptomatic women with pelvic masses; the specificity and positive predictive value of CA125 is higher in postmenopausal women than in premenopausal women; ultrasound findings of simple cysts greater than 10 cm in diameter are almost always benign and can be followed safely without intervention; conservative procedures such as unilateral adnexal resection or ovarian cyst debulking are used for germ cell tumors determined by comprehensive germ cell tumors as determined by surgical staging, stromal cell tumors of stage I with potentially low-grade malignant cells, stage 1a, grade 1-2 invasive ovarian cancer in women who require preservation of reproductive function and do not appear to be associated with a poor prognosis. (Level C evidence): Patients seen by gynecologic oncologists trained and experienced in the management of ovarian cancer have improved overall survival; most combined adnexal masses in pregnancy are at low risk of malignancy and acuity and can be considered expectantly treated.