Detecting ovarian disorders in primary care

Ovarian cysts occur more often in premenopausal than postmenopausal women. Most of these cysts will be benign, with the risk of malignancy increasing with age. The risk of a symptomatic ovarian cyst in a premenopausal female being malignant is approximately 1:1,000 increasing to 3:1,000 at the age of 50. Ovarian cysts may be asymptomatic but presenting symptoms include pelvic pain, pressure symptoms and discomfort and menstrual disturbance. Functional cysts in particular can be linked with irregular vaginal bleeding or menorrhagia. Ovarian torsion is most common in the presence of an ovarian cyst. Dermoid cysts are most likely to tort. Torsion presents with sudden onset of severe colicky unilateral pain radiating from groin to loin. There may be nausea and vomiting. It is often confused with ureteric colic where the pain is similar but radiates loin to groin. Symptoms which may be suggestive of a malignant ovarian cyst, particularly in the over 50 age group, include: weight loss, persistent abdominal distension or bloating, early satiety, pelvic or abdominal pain and increased urinary urgency and frequency. CA125 levels should be checked in women who present with frequent bloating, feeling full quickly, loss of appetite, pelvic or abdominal pain or needing to urinate quickly or urgently. Symptomatic postmenopausal women, those with a cyst > or = 5 cm, or raised CA125 levels, should be referred to secondary care. Functional cysts, particularly when they are < 5 cm diameter, usually resolve spontaneously without the need for intervention. In premenopausal women simple cysts > or = 5 cm are less likely to resolve and need an annual ultrasound assessment as a minimum.

[Sonographic diagnosis of presumed benign ovarian tumors]

To discriminate ovarian lesions is of particular importance in gynecological practice. Two main problems need answers: discrimination of benign and malignant adnexal masses and choice of the appropriate surgical treatment if necessary. Nearly 2% of the adnexal masses are ovarian carcinomas or borderline tumors. It is now, well established that ultrasonography is the gold standard for ovarian cyst diagnosis. The purpose of this data was to review the literature and to establish, with the evidence base medicine model, which parameters and existing diagnostic models using ultrasound and Doppler perform best in the evaluation of adnexal masses. Transvaginal sonography has demonstrated considerable advantage over conventional transabdominal sonography. However, transparietal sonography is still useful in large tumors. Definition of the nomenclature and classification was done and should be used. Unilocular ovarian cyst characterization seems easy using sonography and Doppler. In front of complication, discrimination of such functional cyst may be difficult but spontaneous regression confirms usually the expectative management. Dermoid cysts and endometriomas seem to be easier to discriminate from other adnexal masses. Ultrasound and morphologic parameters have a sensitivity of about 90% and a specificity of 80%; that makes this exam the gold standard for ovarian masses diagnosis. Only 50% of ovarian masses are characterized by sonography. Scoring systems help to differentiate benign from malignant masses (sensitivity of about 90%). Logistic regression and models are good methods especially for LR1 and 2 and RMI and may be useful for malignancy prediction but are difficult to use in current practice. Expert diagnosis is a subjective but most important performing parameter. Any suspicious ovarian mass or not easily diagnosed mass requires sonography by an expert, which can first use all the techniques and the different parameters to discriminate benign and malignant tumors. An explicit report will help the physician to define the right attitude for an appropriate management. Six to 16% of adnexial masses are complex or not classified and will result in MRI prescription or surgery.

Combined development of thyroid gland and reproductive system benign diseases

The aim of the study is to establish the role of endocrine disturbances in development of malignant tumors in patients with thyroid gland and reproductive system pathology. We studied 207 patients with synchronic and metachronic development of thyroid gland and reproductive system benign tumors. The patients' average age was 35-58 years. According to study the following aspects were determined: clinical and hormonal aspect of thyroid gland and reproductive system benign tumor disease coincidence, analyses of thyroid gland and reproductive system pre-cancer disease pathogenesis, neuroendocrine relations-like increased thyrotrophic hormone secretion causes strengthening of prolactin secretion, which depresses luteinizing hormone release and increases production of follicular stimulating hormone. It has been proved that fibromyomas absolute hyperestrogenemia which develops during hypersecretion of follicular stimulating hormone (FSH) plays a role in etiology of uterine Gonadoliberin hypersecretion, especially follicular stimulating hormone FSH and corpus luteum deficiency is very important in development of ovarian pre-cancer and cancer diseases.

Prise en charge des kystes ovariens

Ovarian cysts occur frequently in women of reproductive age. These are usually functional cysts which resolve spontaneously and whose evolution can be followed with ultrasound. Non-functional cysts have diverse histologic origins. The most common are serous and mucinous cystadenomas which arise from the epithelial wall of the ovary, endometriomas which arise in the setting of pelvic endometriosis, and dermoid cysts which arise from the germinal cells of the ovary. Endovaginal ultrasound with Doppler enhancement is the best imaging technique to establish the nature of cysts and to distinguish cysts suspicious for malignancy which require more invasive investigation. Pelvic laparoscopy is the surgical approach of choice for the treatment of non-functional benign ovarian cysts. Conservative treatment to shell out the cyst and preserve functional ovarian tissue should be reserved for women desirous of future pregnancies. The risk of ovarian cancer remains a major preoccupation of the surgeon. Where malignancy is suspected, laparoscopy is contraindicated and a median laparotomy is appropriate for radical extirpative surgery. This article describes the diagnostic techniques which allow a laparoscopic approach to presumably benign cysts and discusses surgical techniques specifically adapted to their different histologic nature of ovarian cysts.

Logistic regression model to distinguish between the benign and malignant adnexal mass before surgery: a multicenter study by the International Ovarian Tumor Analysis Group

PURPOSE

To collect data for the development of a more universally useful logistic regression model to distinguish between a malignant and benign adnexal tumor before surgery.

PATIENTS AND METHODS

Patients had at least one persistent mass. More than 50 clinical and sonographic end points were defined and recorded for analysis. The outcome measure was the histologic classification of excised tissues as malignant or benign.

RESULTS

Data from 1,066 patients recruited from nine European centers were included in the analysis; 800 patients (75%) had benign tumors and 266 (25%) had malignant tumors. The most useful independent prognostic variables for the logistic regression model were as follows: (1) personal history of ovarian cancer, (2) hormonal therapy, (3) age, (4) maximum diameter of lesion, (5) pain, (6) ascites, (7) blood flow within a solid papillary projection, (8) presence of an entirely solid tumor, (9) maximal diameter of solid component, (10) irregular internal cyst walls, (11) acoustic shadows, and (12) a color score of intratumoral blood flow. The model containing all 12 variables (M1) gave an area under the receiver operating characteristic curve of 0.95 for the development data set (n = 754 patients). The corresponding value for the test data set (n = 312 patients) was 0.94; and a probability cutoff value of .10 gave a sensitivity of 93% and a specificity of 76%.

CONCLUSION

Because the model was constructed from multicenter data, it is more likely to be generally applicable. The effectiveness of the model will be tested prospectively at different centers.

[Antenatal diagnosis and postnatal management of ovarian cysts]

INTRODUCTION

Advances in perinatal sonography have brought to light the problem of ovarian cysts in the fetus and their management during pregnancy and after birth. The majority of such cysts disappear during infancy. According to most researchers, surgery is required when cyst diameter exceeds 5 cm. Complex cysts and complicated cysts also require surgical intervention.

AIM

To present an analysis of the diagnostic and surgical approach to ovarian cysts disclosed antenatally or during the first months of life and managed at the Department of Pediatric and Oncological Surgery, Pomeranian Medical University in Szczecin.

MATERIAL AND METHODS

A retrospective study was done in 11 newborns/infants treated for an ovarian cyst in 1998-2004, including 5 with antenatal diagnosis of ovarian cyst. Circumstances and time when the decision to operate was made were studied in the context of eventual complications and risk of loss of ovary.

RESULTS

The decision to operate in 10 newborns/infants (one cyst with a diameter of 1.86cm disappeared spontaneously in the fifth month of life) was made when cyst diameter was 4cm or greater or when the cyst was smaller but revealed mobility and sonographic signs of a complex cyst or torsion (5 cases). The diameter of cysts disclosed perinatally ranged from 2.5 to 7 cm (one of them was a chocolate cyst). The ovary was spared in eight patients.

CONCLUSIONS

Early sonographic monitoring should be undertaken in newborns with perinatal diagnosis of ovarian cyst. Because of the risk of torsion (50% of cases in the present study), surgical intervention is necessary when cyst diameter is 4 cm or greater.

[Doppler ultrasonography in the diagnosis of ovarian cysts: indications, pertinence and diagnostic criteria]

To discriminate ovarian lesions is of particular importance in gynecological practice. Two main problems need answers: discrimination of benign and malignant adnexal masses and choice of the appropriate surgical treatment if necessary. Nearly 2% of the adnexal masses are ovarian carcinomas or border line tumors. It is now well established that ultrasonography is the gold standard for ovarian cyst diagnosis. The purpose of this work was to review the literature and to establish, with the evidence based medicine model, which parameters and existing diagnostic models using ultrasound and Doppler performs best in the evaluation of adnexal masses. Transvaginal sonography has demonstrated considerable advantage over conventional transabdominal sonography. However, transparietal sonography is still useful in large tumors. It is no longer reasonable to subject all patients undergoing pelvic sonography to bladder distension. Functional ovarian cyst characterization seems easy using sonography and Doppler. In case of complication, discrimination of such functional cyst may be difficult but spontaneous regression confirms usually the expectative management. Dermoid cysts and endometriomas seem to be easier to discriminate from other adnexal masses. Papillary formations on the inside of the cyst wall and masses with a non hyperechoic solid component are the most statistically significant predictors of a malignant ovarian mass. Ultrasound and morphologic parameters have a sensitivity of 80% and a specificity of 93%, that make this exam the gold standard for ovarian masses diagnosis. Another parameter is important: experienced hands with subjective evaluation seems to be one of the best ultrasound method for adnexal masses discrimination. Scoring system help differentiate benign from malignant masses (sensitivity 90%, VPP 50%). Doppler flow measurement and assessment of tumor vascularity by doppler energy increase the confidence with which a correct diagnosis is made. Moreover, combined US techniques and a diagnostic algorithm perform significantly better than morphologic assessment, color doppler or CA125 measurement alone. Logistic regression and neural network models are good methods and may be useful for malignancy prediction but the improvement is small and the concordance with histology far from 100%. In front of a benign and maybe functional cyst, spontaneous resolution may be controlled by sonographic exam at 3 and 6 months. Three-dimensional ultrasound and power doppler, contrast enhanced sonography, and sonography during the laparoscopic procedure are not still validated. Every suspicious ovarian mass needs sonography by an expert which can first use all the techniques and the different parameters to discriminate benign and malignant tumors. Secondly, after control if necessary, he can propose the patient for appropriate surgical treatment.

[Histology of benign borderline ovarian and subperitoneal dystrophic cysts ]

Benign cysts of the ovary include a variety of histological types. We briefly describe here the different histological types of ovarian lesions with a cystic presentation. The cystic epithelial tumors of the ovary could be definitely benign or malignant, there also exist borderline cases which are particularly difficult to manage. Close collaboration between the surgeon and the pathologist is required to carefully define indications and the limitations of frozen-section diagnosis as well as good transfer of the operative specimen.

Classification of ovarian endometriotic cysts

Current literature describes 3 different pathogenetic types of ovarian endometriotic cysts. Cortical invagination cysts arise when surface ovarian endometriotic deposits adhere to another structure (such as the broad ligament), blocking the egress of menstrual fluid produced by cycling endometriosis, which then collects and causes the ovarian cortex to invaginate. Surface inclusion cyst-related endometriotic cysts develop when endometriotic tissue colonizes preexisting inclusion cysts. Physiological cyst-related endometriotic cysts occur when endometriosis gains access to a follicle, such as at the time of ovulation. To determine whether routine histological examination is of use in the classification of endometriotic cysts, and if so, whether such classification is of clinical relevance, we reviewed the histology of endometriotic cysts of 29 women under 35 years of age. Young women were chosen so that ovarian cortex surrounding the endometriotic lining in invagination cysts could be identified by the finding of oocytes. Ten women (34%) had cortical invagination endometriotic cysts, but no inclusion or physiological cyst-related endometriomas were found. The remaining 19 women (66%) had unclassified endometriotic cysts, of which 14 (48% of total) had a fibrous wall between the endometriotic lining and medulla and 5 had extensive destruction of ovarian tissue. We concluded that cortical invagination cysts were the only common diagnosable sort of the 3 types currently being investigated and that unclassified cysts required further study to determine their pathogenesis. Our study highlights the need for a prospective study using standardized pathological and clinical methods.

The relationship between ovarian structure and hyperandrogenism in premature pubarche

The aim of this study was to describe the ovarian structure (OS) and its relationship with hyperandrogenism in girls with premature pubarche (PP). A pelvic ultrasound was carried out in 23 girls with PP and in 57 prepubertal age-matched controls (C), and the OS was subdivided into five classes (c): 1-homogeneous; 2-microcystic, 3-multicystic, 4-polycystic and 5-follicular. In the girls with PP, an ACTH test was performed, and the presence of hormonal levels >3 SD of postpubertal normal levels and not compatible with late-onset congenital adrenal hyperplasia were considered an exaggerated response. The fasting levels of glucose (G) and insulin (I) were measured and the fasting I to G ratio (FIGR) was calculated. FIGR >22 was suggestive of I resistance (IR). The microcystic structure (c2) was more frequently found in the PP than in the C group (63% vs 35%, p=0.03). In the PP group, we observed the following OS: cl (n=6), c2 (n=15), c3 (n=1) and c4 (n=1). 11-Deoxycortisol--both basal and after ACTH--was greater in the PPc2 group than in PPc1 (p=0.04, p=0.0008, respectively). We also observed an exaggerated response to ACTH in 87% of the girls with PP, greater in the PPc2 group than in PPc1 (p=0.04). The FIGR showed IR in 44% of girls with PP, but I levels and FIGR were similar between PPc1 and PPc2. These findings suggest generalized adrenocortical hyperresponsiveness in girls with PP, which is more accentuated in PPc2. Long-term follow-up of girls with PP into adulthood is warranted to ascertain whether microcystic ovarian structure precedes functional ovarian hyperandrogenism.

Limitations of the evaluation of adnexal masses by its macroscopic aspects, cytology and biopsy

To investigate the relevance of intraoperative macroscopic evaluation of adnexal masses a prospective study was conducted from June 1st, 1993 to May 31st, 1994, which included 57 premenopausal and 60 postmenopausal women, who underwent laparotomy because of a cystic adnexal mass. The surgeons were asked to classify the tumor intraoperatively as benign or malignant and to assign to histologic groups. In addition cytology of the cyst fluid and a biopsy from the cystic wall were evaluated. Comparison of these items with the results of permanent section diagnosis revealed the tendency of the surgeons to underestimate adnexal masses depending on patients' age and the complexity of the tumor, despite of the knowledge of preoperative ultrasonographic findings. Sufficient cytolologic examination was possible in only one third of aspirates and only 21% of the examined postmenopausal malignant neoplasms have correctly been diagnosed by cytology. Evaluation of the biopsy specimens demonstrates a marked percentage of false negatives with respect to benign tumors (30% of non-functional benign neoplasms in the premenopause were assessed as functional cysts) as well as malignant neoplasms (only 72% were diagnosed correctly in the postmenopause group). In conclusion intraoperative subjective assessment, cytology and representative biopsies do not necessarily concur with the definitive histological diagnosis.

Evaluation of ovarian tumors in postmenopausal women by transvaginal sonography

OBJECTIVE

The aim of the present study was the evaluation of simple reproducible sonomorphological criteria for the preoperative evaluation of ovarian tumors in postmenopausal women by use of transvaginal sonography.

STUDY DESIGN

Postmenopausal women (> or =1 year of secondary amenorrhea) with ovarian tumors (n=378; tumors > or =3 cm and <3 cm but with solid parts) were examined in a prospective study by transvaginal sonography prior to surgery between 1987 and 1993. The sonomorphological criteria were correlated with the histological findings of the tumors.

RESULTS

Of all ovarian tumors in postmenopausal women, 6.3% were functional cysts (follicular or corpus luteum cysts). Almost all of them were detected within the first 5 years of postmenopause. The other ovarian tumors were diagnosed as retention cysts (17.5%), benign neoplasms (39.4%), and malignant tumors (36.8%). Simple ovarian cysts (monolocular, smooth inner wall) represented sonomorphologically the second most frequent type of ovarian tumors in postmenopausal women (35.7%). Of these tumors, 9.6% were diagnosed as malignant.

CONCLUSIONS

Simple reproducible sonomorphological criteria proved to be a useful clinical parameter in the preoperative evaluation of ovarian tumors.

CA-125 and carcinoembryonic antigen assay vs. cytodiagnostic experience in the classification of benign ovarian cysts

OBJECTIVE

To compare the relative strengths of two factors involved in making an accurate differentiation between functional and epithelial ovarian cysts, along with their combination: (1) the cytologist's level of experience in interpreting ovarian cytology, (2) the use of the tumor markers carcinoembryonic antigen (CEA) and CA-125 in cyst fluid, and (3) a combination of (1) and (2).

STUDY DESIGN

Papanicolaou-stained sediments from fluid aspirated from 31 resected ovarian cysts (6 functional and 25 epithelial) were blindly and independently evaluated by five pathologists with varying experience in ovarian cytology. Cyst fluid supernatant was used for CEA, enzyme-linked immunosorbent assay, and CA-125 radioimmunoassay; CEA levels > 5 ng/mL or CA-125 > 5,000 U/mL were considered elevated. Cysts were categorized cytologically and histologically as functional or epithelial and by tumor markers as "neither elevated" or "either or both elevated" (EBE).

RESULTS

The agreement of histologic diagnosis with each pathologist's cytologic diagnosis ranged from 53% to 84% (53%, 71%, 83%, 82%, 84%), corresponding to increasing level of experience. The percentage of agreement with EBE was 77%, whereas combined experienced pathologist's diagnosis and EBE was 87%. Kappa equaled .45 for experienced cytopathologist's diagnosis or EBE alone. Kappa equaled .53 when the pathologist or EBE diagnosed an epithelial cyst, indicating results unlikely to occur by chance.

CONCLUSION

The distinction of functional from epithelial ovarian cysts is best achieved by combining measurement of the tumor markers CEA and CA-125 with a high level of cytopathology experience.

[Ovarian cysts in the differential diagnosis of acute and recurrent abdominal pains]

The authors review the differential diagnosis in the acute and recurrent abdominal pain and the classification of ovarian cysts in prepuberal girls. They report the description of three cases of ovarian cysts in prepuberal girls and the role of ultrasonography in their diagnosis in a paediatric department.

[Modern imaging of ovarian cysts]

Ultrasonography and specially vaginal endosonography is at present the technique of choice for the screening of ovary cysts. Nevertheless, the method have some limits in the study of solid lesions and big masses; that's where CT scan and MRI have good indications: CT is more reliable than US to detect fat in teratomas. CT and MRI are superior to US in determining big tumor extend because of their ability of multiplanar study. MRI permit a molecular characterisation of cystic lesions.

Clinical and histologic classification of endometriomas. Implications for a mechanism of pathogenesis

One hundred eighty-seven consecutive patients with persistent ovarian cysts and endometriosis underwent laparoscopic evaluation and ovarian cystectomy. All patients had been followed for a minimum of 6 weeks prior to surgery. The cysts were identified initially to be endometriomas based on their gross appearance and the presence of endometriosis at other pelvic sites. Presumed endometriomas were classified into three types based on size, cyst contents, ease of removal of the capsule, adhesions of the cyst to other structures and location of superficial endometrial implants relative to the cyst wall. After clinical laparoscopic classification, the cysts were evaluated histologically without knowledge of the clinical assessment. Histologically small (< 2 cm), superficial ovarian cysts were always endometriomas, and the cyst wall was very difficult to remove (type I). Large cysts with easily removed walls were usually luteal cysts (type II). Large cysts with walls adherent in multiple areas adjacent to superficial endometriosis were generally endometriomas but some also had histologic characteristics of functional (luteal or follicular) cysts (types IIIa and IIIb). These findings led to the conclusion that superficial ovarian endometriosis is similar to endometriosis in extra-ovarian sites in that the formation of superficial cysts is limited in size by fibrosis and scarring. In contrast, large endometriomas may develop as a result of secondary involvement of functional ovarian cysts by the endometriotic process.

Risk factors for endometrioid, mucinous and serous benign ovarian cysts

To evaluate the risk factors for serous, mucinous and endometrioid ovarian cysts, data were collected in a case-control study conducted in the greater Milan area based on 202 women with benign cysts (114 endometrioid and 88 serous or mucinous) of the ovary and 1127 controls. Questions were asked about menstrual and reproductive characteristics, marital status, education, history of various diseases, and lifetime use of oral contraceptives and other hormonal treatments. Higher social class, earlier menarche and longer interval between age at first marriage and first birth, a likely indicator of subfertility, were associated with an increased risk of serous, mucinous and endometrioid cysts. Women with endometrioid cyst were characterized by low parity, less frequent irregular or long menses, more frequent oral contraceptive use and low body mass index, while the most relevant risk factor associated with serous and mucinous cysts was greater age at first birth. The present data point out the epidemiological differences between endometrioid and serous or mucinous cysts. Further, they suggest that analyses of risk factors for epithelial ovarian cancer subdivided by various histotypes may be of interest in order to confirm possible heterogeneities in the aetiology of ovarian epithelial neoplasms.

Gonadotropin levels and secretory patterns in patients with typical and atypical polycystic ovarian disease

Gonadotropin levels and secretory patterns were studied in 28 oligomenorrheic patients with various types of polycystic ovary disease (PCO). On the basis of ovarian morphology and histology, the patients PCOuld be separated into two distinct categories arbitarily designated "typical" (type I) and "atypical" (type II) PCO. Although no differences were noted in symptomatology or 17-ketosteroid, testosterone, or follicle-stimulating hormone levels, the 12 type I patients demonstrated widely fluctuating, but markedly elevated, luteinizing hormone (LH) levels, while the 16 type II patients demonstrated lower and less fluctuating LH levels which were comparable to those found during the normal follicular phase. It is likely that type I PCO is a distinct entity similar to that described by Stein and Leventhal, while type II co represents a heterogenous spectrum of disorders, many of which remain obscure.