Managing Ovarian Masses During Pregnancy

The management of adnexal masses during pregnancy can be challenging for the patient and the clinician. The specter of a possible malignancy can sway the decision for intervention versus expectant management. The etiologies of ovarian masses are reflective of the patient's age; and, therefore, benign entities such as functional ovarian cysts, benign cystic teratomas, and serous cystadenomas predominate. In the unusual cases when cancer is present, they are typically germ cell and borderline ovarian tumors, and are commonly low stage and low grade. Ultrasound is the primary modality used to detect ovarian masses and to assess the risk of malignancy. Morphologic criteria more accurately identify benign cysts compared with malignant tumors. Tumor markers are used primarily to monitor disease status after treatment rather than establish the ovarian tumor diagnosis as a result of lack of specificity, because several markers can be elevated inherent to the pregnancy itself (eg, CA-125, beta-hCG). Expectant management is recommended for most pregnant patients with asymptomatic, nonsuspicious cystic ovarian masses. Surgical intervention during pregnancy is indicated for large and/or symptomatic tumors and those that appear highly suspicious for malignancy on imaging tests. The extent of surgery depends on the intraoperative diagnosis of a benign versus a malignant tumor. Conservative surgery is appropriate for benign masses and borderline ovarian tumors. More aggressive surgery is indicated for ovarian malignancies, including surgical staging. Although rarely necessary, chemotherapy has been used during pregnancy with minimal fetal toxicity in patients with advanced-stage ovarian cancer in which the risk of maternal mortality outweighs the fetal consequences.

[Transvaginal aspiration as first treatment of ovarian follicular cysts in dairy cattle under field circumstances]

On dairy farms covered by the ambulatory service of the Department of Farm Animal Health, 55 Holstein-Friesian cows with suspected ovarian follicular cysts on the basis of rectal palpation underwent confirmatory transrectal ultrasonography. An ovarian follicular cyst was confirmed in 28 cows (50.9%) and was treated by single transvaginal-guided needle aspiration. Cows with a corpus luteum or a luteinized cyst were not treated. After aspiration, 82.1% (n=23) of the cows showed oestrus behaviour at 13.3 +/- 6.0 days. Artificial insemination was performed during the first heat after cyst aspiration and resulted in a pregnancy rate of 64.2%. In conclusion, single transvaginal-guided needle aspiration of ovarian follicular cysts is an easy and good method for the treatment of follicular cysts. Moreover, it is a safe and good alternative method for the manual, active rupturing of cysts during rectal palpation.

[Clinical aspect, diagnostics and treatment of follicular ovarian cysts]

48 young women aged 16 to 40 were observed for the menstrual cycle disorders and pain of various intensity in the lower abdominal region have been diagnosed for having at ovarian follicular cyst. The peculiarities of hormonal secretion in 30 patients have been studied. Existence of transitory hyperprolactinemia, excessive production of the lutheinizing hormone and deficit of progesterone production was determined. These factors hamper the folliculorexis and the follicular cyst does develop. Thus, in the occurrence of follicular cysts the major role belongs to the hypothalamic-pituitary disregulation. Therefore, the suppressive hormonal therapy is justified as highly effective. Dynamic ultrasound makes it possible to identify the conservative treatment terms and where necessary, timely transfer of the patient to the laparoscopic treatment.

Comparison of synchronization of ovulation with timed insemination and exogenous progesterone as therapeutic strategies for ovarian cysts in lactating dairy cows

The objective of this study was to compare the effectiveness of the Ovsynch and controlled internal drug releasing (CIDR) protocols under commercial conditions for the treatment of cystic ovarian disease in dairy cattle. A total of 401 lactating dairy cows with ovarian cysts were alternatively allocated to two treatment groups on the day of diagnosis. Cows in the Ovsynch group were treated with GnRH on Day 0, PGF2alpha on Day 7, GnRH on Day 9, with timed insemination 16-20 h later. Cows in the CIDR group were treated with a CIDR insert on Day 0 for 7 days; on Day 7, the CIDR was removed, and cows were treated with PGF2alpha. All cows in the CIDR group were observed for estrus and cows exhibiting estrus within 7 days following removal of the CIDR and PGF2alpha administration were inseminated. The outcomes of interest for this experiment were the likelihood to be inseminated, return to cyclicity (determined by a CL on Day 21), conception and pregnancy rates. Data for these variables were analyzed using logistic regression. The percentage of cows inseminated in the Ovsynch and CIDR groups were 82 and 44%, respectively. Cows in the Ovsynch group were 5.8 times more likely to be inseminated than cows in the CIDR group. Cows with a low BCS were 0.48 times less likely to be inseminated than cows with a high BCS. The percentage of cows with a CL on Day 21 for the Ovsynch and CIDR groups was 83 and 79%, respectively (P > 0.05). Cows with a low BCS were 0.49 times less likely to have CL on Day 21 than cows with a high BCS. Conception and pregnancy rates for cows in the Ovsynch group were 18.3 and 14.4%, respectively. Conception and pregnancy rates for cows in the CIDR group were 23.1 and 9.5%, respectively. There was no significant differences between conception or pregnancy rates in cows in both groups. Primiparous cows were 2.6 times more likely to conceive than multiparous cows. In conclusion, the results of this study suggested that fertility was not different between cows with ovarian cysts treated with either the Ovsynch or the CIDR protocols in this dairy herd. In addition, primiparous cows had an increased likelihood for conception compared to multiparous cows, and cows with a low BCS were less likely to be inseminated or have a CL on Day 21, regardless of treatment.

Ovarian cysts during pregnancy: dilemmas in diagnosis and management

With routine obstetric ultrasound examinations, ovarian cysts are now more commonly diagnosed during pregnancy and their management is still a challenging clinical issue among obstetricians. The aim of this paper is to review the different management options of ovarian cysts detected during pregnancy, and it highlights the emergence of laparoscopic technique as a valuable therapeutic tool in these conditions. The review shows that conservative management and ultrasound follow-up is sufficient for the majority of cases of ovarian cysts during pregnancy. It also discusses the limitations of tumour markers during pregnancy, and the controversy around ultrasound-guided aspiration procedures. Emerging evidence suggests that if surgery is necessary, then it is preferable to perform an elective laparoscopic procedure at 16 - 23 weeks' gestation. It is time to consider establishing a UK registry to monitor the treatment offered to those women and to develop national guidelines to help in the management of this controversial issue.

Adolescent chronic pelvic pain

The presentation of chronic pelvic pain in the adolescent can at times be quite daunting. A careful and insightful approach to obtaining the history and physical examination must be implemented while maintaining an appreciation of the various stages of adolescent development. The etiologies can range from gynecologic to nongynecologic causes. The ability to render an early diagnosis and appropriate treatment in this population of patients can significantly improve future reproductive health outcomes. The following minireview will outline a systematic approach to the adolescent with chronic pelvic pain.

Is Conservative Management of Prenatal and Neonatal Ovarian Cysts Justifiable?

OBJECTIVES

To evaluate conservative management of fetal and neonatal ovarian cysts.

METHODS

We followed the progress of 11 fetal and 2 neonatal ovarian cysts.

RESULTS

Ten fetal cysts were simple at recognition, but 8 silently became complex by birth, with ovarian loss in 6/11 cases (54%). In 2 cases where large simple cysts presented for the first time at birth, serious complications occurred, resulting in the death of 1 newborn.

CONCLUSIONS

If a fetal ovarian cyst is already complex before birth it can be managed conservatively, albeit with loss of the ipsilateral ovary in the majority of cases. As simple fetal ovarian cysts frequently become complex before birth, intervention may be justifiable to preserve the ovary. But any intervention also has the potential for complications, and may be ineffective. Intervention also requires accurate differentiation of ovarian cysts from other abdominal cysts.

Conservative Versus Surgical Treatment for Complex Neonatal Ovarian Cysts: Outcomes Study

OBJECTIVE

Prenatally diagnosed complex ovarian cysts are most often managed surgically in an attempt to save the ovary. Nevertheless, published surgical results disclose that most patients undergo oophorectomy or salpingo-oophorectomy. We assessed whether a surgical or conservative approach was more appropriate by comparing the long-term outcome of infants treated by both methods. A hypothesis for the cause of complex cysts is presented.

CONCLUSION

Clinical evidence questions the use of surgery for asymptomatic complex ovarian cysts. Histologic analysis suggests gonad maldevelopment as the origin of complex neonatal ovarian cysts.

Is expectant management of sonographically benign adnexal cysts an option in selected asymptomatic premenopausal women?

BACKGROUND

The objective was to assess whether expectant management of sonographically benign ovarian cysts may be an option for selected asymptomatic premenopausal women.

METHODS

This is a prospective observational longitudinal study. Between January 1997 and December 2002, 323 asymptomatic premenopausal women (mean age: 40.6 years; range: 19-50 years) diagnosed as having a sonographically benign ovarian cyst measuring <6 cm were offered conservative management with periodic follow-up at 6-12 month intervals. In all cases, a first check was performed 3 months after diagnosis to confirm the 'persistent' nature of the cyst. A total of 120 women agreed to participate in this study and constitute the basis of the data presented.

RESULTS

Mean diameter at diagnosis for the most frequent lesions were as follows: endometrioma 3.3 cm (SD 1.5); simple cyst 4.1 cm (SD 1.6); dermoid cyst 3.2 cm (SD 1.4); haemorrhagic cyst 3.5 cm (SD 1.2); hydrosalpinx 2.9 cm (SD 1.0). With a median follow-up of 42 months (range: 18-94 months), most lesions remained unchanged, both in size and sonographic appearance. Ten cysts (8.3%) disappeared during follow-up, all of them after more than 2 years of follow-up. No patient has developed signs or symptoms suggesting ovarian cancer.

CONCLUSION

Most sonographically benign ovarian cysts remain unchanged during long-term follow-up. Our data would support conservative management in these cases.

Adnexal Masses in Pregnancy: Surgery Compared With Observation

OBJECTIVE

To estimate whether the delay of surgery impacts the risk of adverse maternal and fetal outcomes in patients diagnosed with an adnexal mass during pregnancy.

METHODS

A review was performed of pregnant patients diagnosed with an adnexal mass 5 cm or greater in diameter. Data collected included age, gravity/parity, gestational age at diagnosis, and presenting symptoms. Ultrasound examinations were evaluated for mass size and complexity. Pregnancy outcome, complications, and surgical pathology were reviewed.

RESULTS

Between 1990 and 2003, 127,177 deliveries were performed at our institution. An adnexal mass 5 cm in diameter or greater was diagnosed in 63 (0.05%) patients. Pathologic diagnosis was available for 59 (94%) patients. The remaining 4 patients were lost to follow-up and excluded from the analysis. Antepartum surgery was performed in 17 patients (29%): 13 because of ultrasound findings that suggested malignancy and 4 secondary to ovarian torsion. The remaining patients were observed, with surgery performed in the postpartum period or at time of cesarean delivery. The majority of masses were dermoid cysts (42%). Four patients were diagnosed with ovarian cancer (6.8% of masses, 0.0032% of deliveries), and one patient (1.7%) had a tumor of low malignant potential. Antepartum surgery due to ultrasound findings that caused concern was performed on all 5 women diagnosed with a malignancy or borderline tumor, compared with 12 (22%) of the patients with benign tumors (P < .01).

CONCLUSION

In select cases, close observation is a reasonable alternative to antepartum surgery in patients with an adnexal mass during pregnancy.

[Neonatal ovarian cysts]

OBJECTIVES

Ovarian cysts are frequently find in fetuses and neonates. The optimal management of neonatal simple ovarian cysts is still a matter of discussion.

MATERIALS

Authors present four cases of neonatal ovarian cysts treated in Pediatric Surgery Clinic of Medical Academy in Bialystok in the period of 2002-2003. Three girls were managed conservatively--they are still in outpatient care. One girl was managed surgically.

CONCLUSIONS

The main aim of treatment is to preserve the ovary. Uncomplicated prenatal ovarian cysts should be treated depending on size and echographic patterns at birth.

Management of ovarian cysts

BACKGROUND

The treatment of an ovarian cyst relies on its nature, and accurate preoperative discrimination of benign and malignant cysts is therefore of crucial importance. This study was undertaken to review the literature concerning the preoperative diagnosis and treatment of ovarian cysts.

METHODS

Articles concerning ovarian cysts from a medline literature search during the period 1985-2003 were included in addition to articles found as references in the initial publications.

RESULTS

Different methods for discriminating between benign and malignant ovarian cysts are discussed. The diagnosis and the treatment are assessed in relation to age, menopausal status, pregnancy, and whether the cyst is presumed to be benign or malignant. In general, expectant management is the choice in premenopausal and pregnant women with non-suspicious cysts and normal levels of CA-125. In postmenopausal women, unilocular, anechoic cysts less than 5 cm in diameter together with a normal CA-125 may be followed up. Operation is recommended in women with cysts larger than 5 cm and/or elevated levels of CA-125. Women with symptoms should be operated regardless of age, menopausal status, or ultrasound findings.

CONCLUSIONS

The preoperative discrimination between benign and malignant ovarian cysts is a challenge. Multimodal methods improve the results of single modalities, but we still need improved preoperative diagnostic tools. Furthermore, these methods should be validated in consecutive patient populations large enough to give a reliable estimate of the method's sensitivity and specificity.

Sclerotherapy with 5% tetracycline is a simple alternative to potentially complex surgical treatment of ovarian endometriomas before in vitro fertilization

OBJECTIVE

Conventional treatment of endometriosis involves drainage and removal of the cyst wall, which often results in inadvertent resection of normal ovarian tissue. We previously reported that 12 patients were successfully treated with sclerotherapy using 5% tetracycline. We now report our experience with sclerotherapy before in vitro fertilization (IVF) in an additional 20 patients with ovarian endometriomas.

DESIGN

Prospective, cohort.

SETTING

Private practice.

PATIENT(S)

Women (n = 32) with sonographic evidence of an ovarian endometrioma were offered sclerotherapy in lieu of laparoscopy.

INTERVENTION(S)

Sclerotherapy was performed under conscious sedation and transvaginal ultrasound guidance. An 18-gauge, single-lumen needle was inserted into the endometrioma, and the cyst contents were sequentially aspirated and flushed with sterile saline until the aspirated fluid was clear. Tetracycline (5%) (5-10 mL) was then instilled into the cyst. Saline was injected into the cul-de-sac to dilute any tetracycline that may have leaked. The fluid was then removed. Ultrasound was performed 6 weeks later to assess the efficacy of treatment.

MAIN OUTCOME MEASURE(S)

Resolution of endometrioma and subsequent IVF pregnancy rate.

RESULT(S)

Complete resolution was observed in 24 (75%) of 32 patients, at follow-up exam. Repeat aspiration of watery fluid was required in eight patients before resolution. Repeat treatment with tetracycline was needed in two patients. Only one patient did not ultimately respond. In vitro fertilization was performed in 28 patients; an ongoing gestation resulted in 16 (57%) from the next cycle.

CONCLUSION(S)

Sclerotherapy with 5% tetracycline is a simple, effective (and, in our limited series, safe) alternative to surgical intervention for treatment of endometriomas before IVF.

[Transvaginal sclerosing therapy of cystic ovarian lesions with alcohol]

AIM

Description of puncture technique for conservative treatment of cystic ovarian lesions.

METHOD

The cyst should be unilocular, sonolucent, with a smooth inner wall of the capsule, without septa and neovascularisation on transvaginal colour Doppler. Serum CA-125 levels must be lower than 35 U/ml. The capsule of the cyst was punctured with a 18 gauge needle, sonographically guided with a 5 MHz transvaginal probe. After complete emptying of the cyst, (cytological examination of the cystic fluid was negative), we injected an amount of sterile 96 % alcohol equalling 50 % of the volume of the cyst. The alcohol remained in the cyst for 5 minutes and was then aspirated completely.

RESULTS

152 patients aged 18 to 60 with an ovarian cyst volume between 40 and 140 ml were treated. Five of the patients (3.3 %) had intensive pelvic pain and therefore received intravenous analgesics. After three months, relapse appeared in 8 patients (5.3 %), in most of whom the volume of the cyst had been more than 100 ml.

CONCLUSION

The proposed puncture technique is simple and easily performed. Treatment with 96 % alcohol showed good results. In cases where the cyst volume exceeds 100 ml, we advise surgical treatment by laparoscopy or laparotomy.

Fetal ovarian cysts: incidence, diagnosis and management

Greater numbers of fetal ovarian cysts are being diagnosed due to improved antenatal imaging. These numbers correspond to data from autopsy studies showing approximately 30% of neonates to have ovarian cysts. Fetal ovarian cysts pose a risk of acute and long-term complications. These risks must be weighed against the probability of cyst regression. The de- The decision to cision to intervene must be based on cyst based on cyst size, ultracharacteristic sound characteristics and clinical symptoms. Treatment options include conservative management, antenatal or neonatal cyst aspiration, laparoscopic cystectomy and laparotomy. Diagnosis is important, given the possible complications and the current management options. Criteria for management have been established at several centers; however, a controversy over conservative versus surgical therapy remains.

[Ovarian tumors in pregnancy--proposals of diagnosis and treatment]

We present the review of the literature and the proposals of the exact diagnosing and therapy of the ovarian tumors complicating pregnancy. The incidence of ovarian tumors in pregnant women is estimated on 1/1000 deliveries. The coexistence of an ovarian tumor with pregnancy presents problems to both the clinician (obstetrician, oncologist) and the patient. Depending of the increasing uterus during pregnancy, the appropriate diagnosis of adnexal mass is based on the initial pelvic and ultrasound examination. Most of ovarian tumors in pregnant women are asymptomatic and when they are unsuspicious simple cysts or cystic teratomas the conservative management is recommended. In cases of complex masses and/or torsion, rupture, hemorrhage the surgical intervention by laparotomy (in some cases laparoscopy) is required. The possibility of malignancy and its therapeutic implications (hysterectomy, salpingo-oophorectomy, delay to delivery) must be discussed with the patient and her family (the lives of two human beings together are affected).

Benign ovarian neoplasms

Benign ovarian neoplasms have the capacity to undergo malignant change and are difficult to diagnose in the early stages. Although rarely life-threatening, they can cause patients considerable physical and psychological distress. This article explains the structure and function of the ovaries and why they sometimes undergo benign neoplastic change.

Conservative management of recurrent bilateral ovarian cysts in pregnancy: a case report

This is a case report of recurrent bilateral ovarian cysts in pregnancy. From the clinical picture these are likely to be theca lutein cysts. A lookout for complications involving these cysts is important. Patients can be managed conservatively in the absence of complications. Likely mechanisms for the causation of this phenomenon are discussed.

Persistent unilocular ovarian cysts in a general population of postmenopausal women: is there a place for expectant management?

OBJECTIVE

At present it is not well known whether some persistent unilocular ovarian cysts can develop into malignancy. The aim of this observational study was to define the management of postmenopausal women with persistent unilocular ovarian cysts less than 50 mm in diameter and with normal serum CA 125 levels.

METHODS

Retrospective data were obtained from 226 postmenopausal women (mean age 56.2 years, range 45-87) with unilocular ovarian cysts who were followed up for a 5-year period. Women were referred because of postmenopausal symptoms, abdominal discomfort, and postmenopausal bleeding. All women underwent pelvic examination, transvaginal ultrasonography, and serum CA 125 measurement. Tumor-associated antigen CA 125 and ovarian cyst diameter were assessed routinely. Surgery was offered according to clinical indications and women's wishes.

RESULTS

Ovarian cyst diameter and serum CA 125 levels did not change in 172 of 226 women (76.1%). Conversely, the remaining 54 women had an increase in cyst diameter, and six of those (11.1%) also had raised serum CA 125 levels. All women with suspicious ovarian pathology (n=54) and 84 without ovarian pathology underwent surgical management. International Federation of Gynecology and Obstetrics stage IB well-differentiated serous cystoadenocarcinomas were diagnosed in two of 54 women (3.7%). Serum CA 125 levels were elevated in both cases.

CONCLUSION

These findings suggest that the majority of unilocular ovarian cysts with diameter less than 50 mm are benign and remain unchanged. These lesions can be managed expectantly when there is no increase in the ovarian cyst diameter and the serum CA 125 concentration is normal.

Acute abdomen due to endometriosis in a premenopausal woman taking tamoxifen

Tamoxifen exhibits agonistic properties on the uterus. We describe a premenopausal woman who, while having tamoxifen due to a diagnosis of in situ ductal carcinoma, developed endometriosis requiring surgery.