Reappraisal of residual ovaries

Effect of hysterectomy on ovarian blood supply and function

Ovarian blood supply and function were assessed before and after hysterectomy in 43 patients and 30 healthy subjects (control group). Before the hysterectomy, transvaginal colour Doppler resistance index values of ovarian artery and hormonal levels were measured. Five days and 6 months after operation, all these measurements were repeated and compared with those of a control group. The sole hormone whose serum level decreased on the 5th postoperative day was oestradiol. Serum levels of all the other hormones remained unchanged 5 days and 6 months after the surgical operations. We also did not find any statistically significant difference between the preoperative, the postoperative and the control group resistance index of the ovarian arteries. We propose that the decision whether to preserve or remove the ovaries must be based on assessment of their functional status. Advantages and disadvantages of leaving ovaries intact should be carefully evaluated and the most useful approach applied to each patient on an individual basis.

The feasibility and efficacy of laparoscopic oophorectomy in the management of pelvic pain after hysterectomy

We aim to assess the feasibility and efficacy of laparoscopic oophorectomy in women with pelvic pain after hysterectomy in this retrospective review of 35 consecutive women presenting with pelvic pain who had had their ovaries conserved at the time of hysterectomy. Pain was attributed to the presence of these residual ovaries if there was an adnexal mass--or the pain improved following ovarian suppression with a GnRH analogue. The procedure was completed laparoscopically in 32 (91%) women. Overall, 27 (77%) women reported symptomatic relief following surgery. We conclude that laparoscopic oophorectomy is safe and provides symptomatic relief in this group of women.

The role of prophylactic oophorectomy in the avoidance of ovarian cancer

OBJECTIVE

To determine the role of prophylactic oophorectomy at elective hysterectomy in the avoidance of ovarian cancer.

METHOD

A survey was performed of all members of the Society of Gynecologic Oncologists and all obstetrician-gynecologists in the State of Connecticut.

RESULT

Seventy-nine percent of gynecologic oncologists and 72% of obstetrician-gynecologists surveyed reported 0-1% of women would be saved from ovarian cancer if one ovary was removed at elective hysterectomy at age 45 years. If both ovaries were removed, 8.4% and 32.1% of these physicians respectively responded that 95-100% of women could be saved from ovarian cancer. Approximately 50% responded that macroscopic appearance and frozen section studies at surgery were helpful in deciding whether to remove ovaries at hysterectomy. A literature review suggested that 12% of ovarian cancers might be avoided if women undergo prophylactic oophorectomy at elective hysterectomy.

CONCLUSION

There is a lack of well-designed epidemiologic studies evaluating risk factors for ovarian cancer and the role of prophylactic oophorectomy at elective hysterectomy.

The residual ovary syndrome: a 20-year experience

OBJECTIVE

To address the controversy of ovarian preservation during a hysterectomy for benign indications by using our experience with residual ovary syndrome (ROS).

STUDY DESIGN

Over a period of 20 years, 2561 hysterectomies (during which one or both ovaries were preserved) were performed at the Golda Medical Center, Israel. A retrospective, quasi, case-control analysis was undertaken.

RESULTS

The incidence of ROS was 2.85%. While chronic pelvic pain was the principle indication for subsequent reexploration in 52 patients (71.3%), an asymptomatic pelvic mass noted during routine follow-up examination accounted for 24.6% of operations for ROS. The majority (75.4%) of patients underwent surgery during the first 10 years, while the highest incidence occurred within the first 5 years (46.6%). Furthermore, histological examination revealed functional cysts, benign neoplasm and ovarian carcinoma in 50.7%, 42.6% and 12.3% of the cases, respectively (in nine patients more than one pathology was observed).

CONCLUSIONS

Since ROS was found to occur in 1/35 women who had undergone previous hysterectomies mainly due to physiologic ovarian function and benign cyst formation, but not malignancy, we believe that routine oophorectomy is justified in premenopausal women over 45 years of age. However, the final decision to perform elective oophorectomy at the time of hysterectomy for benign disease should be established on an individual basis, taking into consideration age, individual and family risk factors, the patient's preference and ability to ensure long-term compliance to exogenous hormone replacement therapy.

GnRH analogue in assessing chronic pelvic pain in women with residual ovaries

OBJECTIVE

To assess whether suppression of ovarian function by a gonadotrophin releasing hormone (GnRH) analogue could assist in the diagnosis of chronic pelvic pain in women with residual ovaries.

DESIGN

Uncontrolled, observational study.

SETTING

District general hospital (seven women) and teaching hospital (one woman).

SETTING

Eight women with residual ovaries and chronic pelvic pain.

INTERVENTIONS

Goserelin 3.6 mg every 28 days was used followed by surgery to remove residual ovaries.

MAIN OUTCOME MEASURES

The women's response to goserelin and surgery (12 months or more post-operatively) was assessed clinically. RESULTS. Goserelin was associated with resolution of pelvic pain in the six women who obtained relief of pain with oophorectomy. The only woman who did not respond to goserelin also failed to gain relief with surgery. One woman who responded to goserelin declined surgery.

CONCLUSIONS

Suppression of ovarian function by GnRH analogues may allow differentiation of pelvic pain caused by the residual ovary syndrome from other causes. This would enable selection of cases likely to benefit from surgery, avoiding potentially difficult surgery in women who will gain little or no relief of symptoms with surgery. Only eight cases are reported and a randomised controlled trial would be required to determine the place of GnRH agonists in the treatment of the residual ovary syndrome.

Chronic pelvic pain caused by residual ovaries and ovarian remnants

OBJECTIVE

To determine the diagnostic effectiveness and treatment of women with chronic lower abdominal pain due to residual ovaries or ovarian remnants.

DESIGN

A prospective observational study.

SETTING

Tertiary referral pelvic pain clinic.

SUBJECTS

Seventeen women complaining of chronic pelvic pain of up to 25 years' duration, of whom seven had residual ovaries and 10 ovarian remnant(s).

MAIN OUTCOME MEASURES

Persistent lower abdominal pain, pelvic tenderness and quality of life one year post-operatively.

RESULTS

Six of the seven women with residual ovaries, and nine of the 10 women with presumed ovarian remnants experienced relief of the original pain, loss of pelvic tenderness and an improved quality of life.

CONCLUSIONS

Residual ovaries after hysterectomy and ovarian remnants are established causes of chronic pelvic pain. Diagnosis and surgical removal is frequently difficult. Management strategies are proposed for both conditions.

The residual adnexa syndrome

The clinical profile of a group of 208 women who presented with residual adnexal disease subsequent to hysterectomy was studied retrospectively; 121 patients had the uterus removed vaginally and 87 per abdomen. The majority of the patients had the hysterectomy at less than 40 years of age, with a mean and median age of 33 years, and more than 60% presented with adnexal symptoms and signs within 5 years of hysterectomy. A detailed analysis of the symptoms and signs and pathology of the removed uterus in both groups was similar although as expected there was an associated finding of prolapse in a significant number of those treated by vaginal hysterectomy. There were significant delays both in the definitive diagnosis of subsequent residual adnexal disease and definitive treatment. The pathological changes in the removed residual adnexa were varied, but with a high incidence of inflammatory changes involving both the tube and ovary. This was particularly evident in those patients in whom the uterus had been removed by the vaginal route, suggesting that this may be related to the usual fixation or approximation of the conserved tube to the vaginal vault at the time of vaginal hysterectomy.

Removal or preservation of ovaries during hysterectomy: a six year review

During six years (1982-1987) in our Department 965 consecutive hysterectomies were performed: 583 abdominal and 260 vaginal hysterectomies performed for benign indications (total = 843) have been reviewed. Preservation of ovaries was chosen in 234 cases (27.8%), while 609 women had their ovaries removed (72.2%). Indications and choice of surgical procedure have shown more significant correlation with ovariectomy than different age groups and parity. Incidence of subsequent signs and symptoms of menopause and osteoporosis has been detected and compared between premenopausal patients who had oophorectomy and those who had not. In removed ovaries no undiagnosed malignant ovarian diseases were found.

Preservation of the ovary: a reevaluation

The incidence of routine ovariectomy approximates 20% to 30% of all women at hysterectomy. The propriety of this practice is evaluated from three perspectives: the review of the longevity of ovarian hormonal function throughout life, the review of the low risk of subsequent disease in the retained ovary, and the review of epidemiologic considerations. Because oophorectomy and the loss of its steroid contribution has such a profound influence on many body functions, with the most devastating relation to osteoporosis, and because there are no meaningful data in the literature to support the value of routine oophorectomy, removal of ovaries should only be performed when the ovaries are diseased.

Ovarian function after radical hysterectomy for stage IB carcinoma of cervix

Ovarian function was assessed in 20 patients after radical hysterectomy and lymph node dissection for Stage IB cervical carcinoma. All patients were under 45 years of age, and four were or had been on estrogen therapy for postmenopausal symptoms. The other 16 patients were free of symptoms and demonstrated premenopausal gonadotropin profiles. Fourteen of these 16 had luteal phase serum progesterone levels. Only one patient required reoperation for a pathologic condition of the adnexa. A surgical approach to Stage IB cervical carcinoma conserves ovarian function in 80% of patients.

Pain in gynecologic practice

This paper has given a general discussion of the spectrum of pain complaints presented to the gynecologist. Specific information about pain sensation and localization has been reviewed together with the gynecologic causes of acute abdominal pain. Chronic pain has been classified as episodic or continuous, and the causes, mechanisms, diagnosis and treatment of episodic and chronic pelvic pain have been presented. The concluding remarks have outlined some diagnostic considerations for the patient with chronic pain. (The interested reader will find more extensive information on these subjects in the articles listed in the bibliography.).

The residual adnexa--asset or liability?

Nine hundred and twenty-two patients who had one or both adnexa conserved at the time of abdominal hysterectomy for benign diseases are presented. Thirteen patients (1.4%) have required subsequent re-exploration for adnexal pathology. Corpus luteum cysts were found in 10 (77%) of these patients. The primary pathology was found in the Fallopian tube in five patients (38%). No patient was found to have an ovarian malignancy in the short period of follow-up. Conservation of ovarian function is recommended in patients who have not undergone menopause.

The future function and fortune of ovarian tissue which is retained in vivo during hysterectomy

Hysterectomy was performed for 2,132 private patients; one third were done vaginally and two thirds, abdominally. Ages ranged from the 20's through the 80's, but 55% were between 40 and 55 years of age. Ovarian function was retained at the time of hysterectomy in 1,263 patients; ovarian tissue was retained in 1,557. Based on clinical criteria, 525 patients had continued ovarian function until last examined (one to 23 years); 328 had continued ovarian function until the end of the study (one to 25 years); 410 patients had cessation of ovarian function during the study at ages ranging from 41 to 64 years. Fourteen patients required second operations: three for hemorrhagic physiologic cysts, two for adhesions, one for ovarian endometriosis, four for cystadenomas, and four for ovarian cancer. Two cancer patients died; two are alive and well, five and 15 years after the second operations.

A survey of epithelial inclusions in the ovarian cortex of 470 patients

The ovaries of 470 patients obtained for various indications at operation revealed 178 with 193 ovarian cysts and tumors - including 63 serous, 23 endometrial, and 27 mucinous - as well as 103 with tubal (serous), 35 with endometrial, and 2 with cervical (mucinous) epithelial inclusions. A very high frequency of transformation of mucinous epithelial inclusions into cysts and tumors contrasted with about 40% similar transformation of serous and endometrial inclusions into cysts and tumors.

The acute effect of hysterectomy on ovarian function

The acute effect of abdominal and vaginal hysterectomy on the ovarian production of estradiol-17-beta (E2) and progesterone (P) was studied in a group of patients undergoing hysterectomy for various gynecologic indications. Plasma levels of steroids as well as gonadotropins (FSH and LH) were measured by RIA. There was a significant but transient drop of plasma E2 during the follicular phase and of plasma E2 and P during the luteal phase, following hysterectomy. No significant variations in the steroid plasma levels were found in a control group of patients undergoing laparoscopy for diagnostic purposes. No changes were noted in either group in the plasma levels of gonadotropins. The changes seen appear to be related to the surgical manipulation in the ovarian region rather than to the type of hysterectomy performed or the stress of surgery.