Picture quiz: A hairy problem in gynaecology

A 19 year old UK born Nigerian nursing student, with no important medical or surgical history and regular periods, presented to her general practitioner with a history of vaginal discharge and abdominal bloating of four to five months' duration. She was not taking any medication. On abdominal palpation an ill defined swelling in the right iliac fossa, which was not tender, was found.

Her general practitioner arranged an abdominal ultrasound scan. It showed a normal uterus with a right multi-septate cyst measuring 8.2x4.9x7.8 cm. There was no free fluid in the pelvis. Her cancer antigen 125 was normal at 19 IU/ml (upper limit of reference range is 30 U/ml). The C19-9 was slightly raised at 118 IU/ml (cut off upper limit 37 IU/ml).

She was referred to the gynaecology outpatient department. After counselling she underwent a laparotomy and right ovarian cystectomy. At laparotomy, a mass was found (figs 1 and 2).