The symptoms leading to diagnosis are varied and not necessarily specific to the pelvic region. They may follow a chronic course mainly marked by poorly defined pain, heaviness or a palpable mass. In other cases there may be acute pain or an endocrine syndrome.

The most common complaint is abdominal pain: pain may be subacute, abdominal and pelvic, sometimes recurrent, and may or may not be accompanied by gastrointestinal signs such as nausea or vomiting or urinary signs such as pollakiuria or dysuria. These last may sometimes be the principal signs.

Acute pain with a localized, exquisitely painful spot suggests an ovarian complication such as torsion, rupture or hemorrhage, once other acute surgical pathologies of the lesser pelvis have been ruled out.

In other cases, a palpable mass may be detected after a complaint of pelvic heaviness with varying degrees of tenderness. The size of the tumor is not an indication of its potential malignancy. In some voluminous tumors, the upper pole of the mass extends beyond the pubic symphysis and develops within the abdomen. A mass may also be totally asymptomatic and revealed by ultrasonography.

Endocrine manifestations can occur and feminization and estrogen-producing ovarian tumors are more common than virilization. Abnormal estrogen secretion leads to isosexual precocity in young pubertal girls: rapid breast development with vaginal bleeding and enlargement of the uterus are the most common initial manifestations. In adolescent girls, we observe excessive swelling of the breasts accompanied by pain and tenderness and pronounced areolar pigmentation.

Excessive irregular vaginal bleeding and metrorrhagia seem to be more frequent than amenorrhea. On the other hand, virilizing tumors are associated with rapid hirsutism, male-type muscular development, clitoral enlargement and ‘defeminization signs’ with amenorrhea or irregular menses and breast regression.

Clinical examination should be completed by pubertal and menstrual histories in all cases, including dates of the first and last menses and detailed information on regularity, abundance and duration. Special attention is paid to disruption of the menstrual cycle, dysmenorrhea and leukorrhea. Questions on sexual activity, contraceptive practices and exposure to sexually transmitted diseases must also be asked. It is important to look for general signs such as fever, fatigue and weight loss.

An adequate pelvic examination is not often possible in virginal patients or those in pain. Rectal examination may allow physicians to palpate pelvic organs and search for a localized painful point and a palpable lateral uterine mass.