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The student emerged from the examination room, chart in hand, and planted himself next to me in the hallway where I was finishing up my notes on another patient. Anxious to share his discovery, he leaned over and whispered, “I think she has a mass in her pelvis.” I nodded and continued to write. One of the local medical schools occasionally assigned students to do a rotation with me in my internal medicine practice, and I had always found them to be bright and eager. This one was no exception. I finished my charting, then turned to the student and asked him to present what he had found. Earlier I had asked him to interview and examine a 50-year-old female patient who was in the office for her annual checkup.

“She didn’t complain of pelvic discomfort,” he reported, but he found the apparent mass while examining her abdomen. It was so easy to palpate, he continued, that he asked the patient if she had felt it herself. She said she had, adding that it had been there for several months. When he asked why she had waited so long before coming to the doctor, she replied that since it wasn’t painful, she figured it wasn’t cancer so she didn’t worry about it.

The student shook his head. “Can you imagine? She thought if it didn’t hurt it couldn’t be cancer. Amazing what bizarre ideas people carry around with them,” he observed. I smiled in silent agreement.


The list of possible diagnoses for pelvic masses in women is long. Tumors, of course, both malignant and benign, must be considered. Ovarian cancers often cause few (if any) symptoms until they have become advanced. Early symptoms like bloating and mild pain are frequently ascribed to less serious conditions, such as irritable bowel syndrome. Benign tumors, likewise, may develop into sizable masses before they produce any symptoms.

Other common causes of a pelvic mass include abscesses—accumulations of pus from a silent bowel leak, for example—that may take weeks or months to make themselves apparent. They often produce fever, but not always. Vascular anomalies like aneurysms (ballooning of a defective spot in a blood vessel) in the pelvis and groin may also present as masses. Those associated with an artery typically will have a pulse that the examiner can feel. And patients suffering from chronic constipation may have stool backed up into the left colon, which can lead less experienced hands to conclude that there is an elongated mass in the pelvis.

I knew the student had asked the patient a battery of questions, but how good was he at taking the next step—making the connections between her answers and his physical findings? I asked him if she had any symptoms that he thought might be related to a pelvic mass. “Related to the mass?” he echoed as I watched him struggle to come up with something. He drew a blank. (“OK,” I thought to myself, “time to teach.”)

“You already told me that she had no complaint of pain. Were there any changes in her bowel habits or unexplained weight loss?” I suggested. He shook his head no. “Abnormal vaginal bleeding?” No again.

“Dyspareunia?” His brow furrowed and his eyes nearly crossed. I realized he didn’t know what the word meant.

It has been estimated that medical students learn upward of 10,000 new words in the course of their medical education. Besides the names of innumerable body parts and physiologic phenomena that must be memorized, there are words for every conceivable symptom. There’s a word for pain with swallowing, pain with breathing, pain with defecation, and yes, even pain with intercourse.

“Dyspareunia,” I told him. “Pain with intercourse. It can accompany a number of conditions, including pelvic tumors.”

He stared at me, bewildered.