Hyperreactio luteinalis associated with chronic renal failure

Hyperreactio luteinalis is a rare benign condition characterized by bilateral ovarian enlargement associated with pregnancies where high concentrations of maternal serum human chorionic gonadotrophins are present. This condition may mimic the ovarian hyperstimulation syndrome. We report a case of a 34 year old woman with a history of chronic renal failure on haemodialysis who presented at 10 weeks' gestational age with hyperreactio luteinalis which was treated conservatively. Because of chronic renal failure, the presentation and course of the disease was different from that which has been previously reported.

Sonographically guided therapeutic aspiration of benign-appearing ovarian cysts and endometriomas

OBJECTIVE

The purpose of this study was to investigate the feasibility of therapeutic aspiration of symptomatic benign-appearing ovarian cysts and to show that endometriomas can be successfully aspirated when aspirated in conjunction with hormonal suppression therapy.

MATERIALS AND METHODS

Forty-three women referred for sonographically guided aspiration of symptomatic ovarian cysts were considered for the study cohort. Criteria for selection included sonographic changes consistent with a simple cyst (n = 32) or endometrioma (n = 9). In two patients, sonography revealed cysts suggestive of malignancy, and these patients were therefore excluded. Seven of the patients were pregnant. Forty-nine aspirations were attempted in 41 patients, 14 using a transabdominal approach and 35 transvaginal. Forty-eight aspirations were successful, and one attempted aspiration was technically unsuccessful. After aspiration, hormonal suppression therapy was recommended for all patients who had endometriomas.

RESULTS

Of the 40 patients who successfully underwent aspiration, all experienced relief from symptoms immediately after aspiration. Eleven of the 40 patients eventually experienced recurrence of symptoms. The overall recurrence rate was 27.5%. The recurrence rate for benign-appearing cysts was 16.1%. None of the seven pregnant patients had recurrence of symptoms. The recurrence rate for endometriomas was 66.6%; however, only one of these nine patients complied with hormonal suppression therapy. Those who did ultimately comply after undergoing a second aspiration experienced sustained relief of symptoms.

CONCLUSION

Sonographically guided therapeutic aspiration of symptomatic ovarian cysts is a viable alternative to surgical extirpation, even in pregnant women. Aspiration of endometriomas may alleviate symptoms when hormonal suppression therapy is also instituted.

Simple adnexal cysts in postmenopausal women: conservative management

OBJECTIVE

To evaluate the expectant management of asymptomatic small, anechoic, simple ovarian cysts diagnosed by echography in postmenopausal women. To gain insight in the natural history of these cysts.

METHOD

Thirty six postmenopausal women with asymptomatic ovarian cysts (from 1.5 to 5.0 cm) diagnosed by ultrasonography and with a CA 125 serum level within the normal range and a non-suspicious color Doppler were followed conservatively. Visits were scheduled at 8-10 weeks of the diagnosis, at 6-month intervals twice and annually thereafter.

RESULTS

The follow-up period extended from 4 to 70 months with an average of 31.5 months. There were no cases of cyst enlargement. The cysts remained unchanged in 29 cases (80.5%), decreased in size in four cases (11.1%) and disappeared in three cases (8.3%).

CONCLUSION

We think that the possibility of malignant transformation of one of these cysts is remote and the benefits of conservative management greatly outweighs its risks.

Simple cyst in the postmenopausal patient: detection and management

The aims of our study were to determine the prevalence of simple ovarian cysts in asymptomatic postmenopausal patients and to investigate the natural history of these cysts by ultrasonographic follow-up examinations. Three thousand five hundred and eighty-five women participated in the volunteer pelvic cancer screening program. Entry criteria were as follows: postmenopausal, no clinical symptoms, and no previous gynecologic pathology. An anechoic, small cyst less than 5 cm in greatest diameter was classified as a simple ovarian cyst. A scoring system to determine malignant potential had been established previously. All simple cysts had a score of 2 or less and had a morphology typical of benign lesions. In the case of a positive finding, the patient would be seen at 3 to 6 month intervals. The decision for surgical intervention was made by a private gynecologist or patient or if an interval change was noted. One thousand seven hundred and sixty-nine postmenopausal women (49.34% of all patients from the screening program) participated in this study. One hundred and sixteen simple cysts were found, with a prevalence of 6.6% in our population. Among those patients, 27 (23.28%) simple cysts resolved spontaneously, 69 (59.48%) have persisted, and 20 (17.24%) have been lost to follow-up study. Eighteen women (26.09%) with persistent simple ovarian cyst underwent surgery. No malignant ovarian conditions were identified. In conclusion, simple ovarian cysts are more common in postmenopausal women than previously was thought. This condition is very unlikely to be malignant and can be followed conservatively.

Diagnosis and management of the adnexal mass

Adnexal masses are frequently found in both symptomatic and asymptomatic women. In premenopausal women, physiologic follicular cysts and corpus luteum cysts are the most common adnexal masses, but the possibility of ectopic pregnancy must always be considered. Other masses in this age group include endometriomas, polycystic ovaries, tubo-ovarian abscesses and benign neoplasms. Malignant neoplasms are uncommon in younger women but become more frequent with increasing age. In postmenopausal women with adnexal masses, both primary and secondary neoplasms must be considered, along with leiomyomas, ovarian fibromas and other lesions such as diverticular abscesses. Information from the history, physical examination, ultrasound evaluation and selected laboratory tests will enable the physician to find the most likely cause of an adnexal mass. Measurement of serum CA-125 is a useful test for ovarian malignancy in postmenopausal women with pelvic masses. Asymptomatic premenopausal patients with simple ovarian cysts less than 10 cm in diameter can be observed or placed on suppressive therapy with oral contraceptives. Postmenopausal women with simple cysts less than 3 cm in diameter may also be followed, provided the serum CA-125 level is not elevated and the patient has no signs or symptoms suggestive of malignancy.

Ovarian cysts in children and adolescents: their occurrence, behavior, and management

STUDY OBJECTIVE

To evaluate the characteristics and symptoms of ovarian cysts, their connection with the methods of treatment, and the effectiveness of the therapy.

METHODS

A retrospective analysis of data on girls with ovarian cysts was performed at a university clinic. Participants included 119 girls in whom 144 ovarian cysts were found by ultrasound examination performed either routinely or for a specific purpose. One group of patients received gestogen to facilitate resolution of the cyst and as treatment of menstrual disorder. Others received clomiphene citrate exclusively as therapy for menstrual irregularity. Aside from this, patients were treated by surgical intervention, or only follow-up sonography was performed. The site, number, size, and type of the cysts were examined. The indications for ultrasonography and the effectiveness of the treatment were analyzed.

RESULTS

The ovarian cysts were mostly unilateral, unilocular, and simple, with the size varying between 3 cm and 5 cm in diameter in 90 cases, more than 5 cm in 41 cases, and less than 3 cm in 13 cases. A number of cysts were found incidentally on ultrasound. Girls were scanned most often because of irregular bleeding (80 cases). Hormonal treatment was given in 105 cases, whereas in 35 cases only follow-up sonography was performed. Cysts resolved spontaneously in 4.5 weeks on average, or in 3 weeks after hormonal treatment. Surgical therapy was necessary for nine patients. The indication for surgery was the detection of complex cysts indicative of dermoid type, size of the cysts, severe pelvic pain, or failure of the cyst to resolve or decrease in size spontaneously or in response to treatment as determined by follow-up sonography. All of the cysts were benign on pathological evaluation.

CONCLUSION

Most ovarian cysts in girls could be managed conservatively, even the larger ones greater than 5 cm in diameter. Only exceptional cases required surgical therapy. Hormonal treatment shortened the duration of the cysts somewhat, but not significantly, and thus was useful mainly in the treatment of concomitant menstrual disorders.

Management and outcome of borderline ovarian tumors incidentally discovered at or after laparoscopy

BACKGROUND

To evaluate in a series of patients with borderline ovarian tumors the clinical findings and the outcome after laparoscopic management.

METHODS

Retrospective study of 25 patients with borderline ovarian tumors first treated by laparoscopic approach.

RESULTS

Thirteen patients had mucinous tumors and 12 had serous tumors. Twenty-one patients had ultrasound examination which detected 24 ovarian cysts including multilocular cysts in 50% of cases and unilocular sonolucent cysts in 25% of cases. The serum CA 125 and CA 199 levels were elevated in 30.7% and 23% respectively. Among the 25 patients first treated by laparoscopic approach, 24 had stage I disease: six of them had cystectomy, seven unilateral salpingo-oophorectomy, two bilateral salpingo-oophorectomy and two laparoscopic hysterectomy with bilateral salpingo-oophorectomy. Seven patients had laparoconversion for presumption of ovarian cancer (5) and failure of laparoscopic procedure (2). One patient with stage III disease had laparoscopic biopsies and subsequent laparotomy. Among the 25 patients, 15 had conservative treatment and 10 had radical treatment. Three recurrences occurred after cystectomy. The mean follow-up was 41 months. Twenty-three patients were alive without evidence of disease, one died of intercurrent disease and one patient was lost to follow-up.

CONCLUSION

Our data suggest that the laparoscopic approach to borderline ovarian tumors is possible in early stage disease but associated with a high risk of recurrence after cystectomy.

Endometriomas in pregnancy

Endometriomas are rare in pregnancy, may not be large, may be difficult to diagnose definitively and although benign, may cause significant complications at any stage during gestation. They remain a management dilemma.

Cancer and endometriosis: do we need to be concerned?

The absolute risk of endometrioid carcinoma of the ovary is very small. When endometriosis is left behind at the time of hysterectomy, there may be increased risk and difficulties in hormone replacement management.

Fetal ovarian cyst decompression to prevent torsion

BACKGROUND/PURPOSE

Neonates who have ovarian torsion caused by an ovarian cyst often lose their ovary because the torsion and infarction occurred antenatally. Because ultrasound scan has been so effective in diagnosing ovarian cysts in utero, we have a better understanding of their natural history and can select appropriate cases for cyst decompression in utero to prevent torsion. The authors reviewed experience with seven fetuses who had fetal ovarian cyst.

METHODS

During a 26-month period, seven patients were referred for the evaluation of fetal ovarian cyst. The mean gestational age at presentation was 31.9 +/- 3.6 weeks (+/-SD; range, 27 to 37 weeks). There was no history of maternal risk factors such as diabetes mellitus or fetal risk factors such as hyperthyroidism or placentomegally. All seven cases involved isolated unilateral cysts without associated anomalies or chromosomal abnormalities. Mean initial cyst diameter was 3.4 +/- 1.7 cm (+/-SD; range, 1 to 6.1). Indications used for ovarian cyst decompression included anechoic cysts with a diameter > or =4 cm, a cyst "wandering" about the abdomen on serial sonograms, or demonstrating rapid enlargement (>1 cm/wk).

RESULTS

All but one cyst progressed in size during observation. One fetal ovarian cyst (diameter, 2 cm) subsequently regressed spontaneously and another (diameter, 2.1 cm) stabilized during prenatal ultrasound surveillance. One "cyst" observed with a diameter of 3.5 cm proved to be a persistent cloaca. Four fetal ovarian cysts met criteria for decompression. Because of fetal position, decompression could not be performed in one. One cyst (seen before defining criteria for decompression) with a diameter of 5 cm was observed only and underwent torsion. Two cysts (diameters, 6.1 cm and 4 cm) were decompressed in utero under local anesthesia with ultrasound guidance, of 95 mL and 35 mL, respectively. High cyst fluid progesterone (12,041 and 1,990 ng/dL, respectively) and testosterone (1,298 and 2,900 ng/dL, respectively) confirmed the etiology of the cyst as ovarian. Neither cyst recurred, and postnatal ultrasound scan confirmed resolution. There was no maternal or fetal morbidity or mortality and only the patient observed before development of criteria for decompression lost her ovary because of torsion.

CONCLUSIONS

Fetal ovarian cysts tend to present as isolated unilateral lesions in normal fetuses in the third trimester. Spontaneous regression of fetal ovarian cysts may occur. Fetal ovarian cyst decompression, in select cases, may preserve ovaries at risk for torsion.

Ovarian follicular cysts in dairy cows

Ovarian follicular cysts are anovulatory follicular structures that occur in 10 to 13% of dairy cows. This review focuses upon the dynamics of cyst growth, development, and persistence as well as on associated endocrine and cellular mechanisms. During the estrous cycle of cows, two to four waves of follicular growth occur. From a cohort of recruited follicles, one is selected for continued growth and dominance while the other undergo atresia and regress. In contrast, cysts have long been thought to be static structures that persist for extended periods. Although cysts can persist for extended periods, most regress over time and are replaced during subsequent follicular waves. The next dominant follicle either ovulates or develops into a new cyst. The recruitment of a cohort of follicles from which a cyst develops and the growth rate of cysts to ovulatory size are similar to ovulatory follicular waves, but the cyst continues to grow for a longer period. The interval between waves of follicular growth is longer for cows with cysts than for cows with normal estrous cycles. Each wave is preceded by a transient increase in circulating FSH. Near the time of cyst development and persistence, the concentration of FSH is not different from that during normal estrous cycles. Serum concentrations of LH and estradiol-17 beta are higher in cows that develop cysts than in cows that do not. Conversely, hypothalamic content of GnRH is lower in cows with cysts. Thus, cysts are dynamic structures, and their development and lifespan are likely associated with altered hypothalamic-hypophysial-ovarian function.

Primary hypothyroidism presenting as severe vaginal bleeding in a prepubertal girl

We describe a case of acquired primary hypothyroidism in a prepubertal girl who presented with profound bradycardia, precocious puberty, and severe vaginal bleeding. A pelvic ultrasound revealed markedly enlarged ovaries with numerous cysts. Cystic aspiration, in concert with L-thyroxine therapy, appeared to halt vaginal bleeding, and led to resolution of cysts. This is the first reported case of percutaneous cyst aspiration to treat ovarian hyperstimulation caused by hypothyroidism in a child.

Role of puncture and aspiration in expectant management of simple ovarian cysts: a randomised study

OBJECTIVES

To assess the potential of expectant management for simple ovarian cysts diagnosed by transabdominal or transvaginal ultrasonography. To compare the results of needle aspiration with those achieved with simple observation.

DESIGN

Randomised trial.

SETTING

Hospital department of obstetrics and gynaecology.

SUBJECTS

278 women with simple cysts randomly allocated to simple observation (143) or ultrasound guided fine needle aspiration (135) between 1990 and 1994.

MAIN OUTCOME MEASURES

Resolution of cyst or development of malignancy.

RESULTS

After six months 269 were available for follow up. The rate of resolution was 46% (59/128) with aspiration and 44.6% (63/141) with observation. Only the diameter of the cyst (P < 0.0001) was a significant independent prognostic factor for resolution in a multivariate analysis. Age and treatment had no significant effect. One woman was subsequently found to have borderline malignant changes on histopathological examination. Her cyst was detected by transabdominal ultrasonography.

CONCLUSIONS

Expectant management for up to six months does not cause risks for the patients and allows spontaneous resolution in over a third of cases, avoiding the costs and risks of unnecessary surgery. Aspiration does not provide better results than simple observation.

Hyperreactio luteinalis complicating a normal singleton pregnancy

Hyperreactio luteinalis is a rare, usually self-limited syndrome with bilaterally enlarged ovaries containing multiple theca lutein cysts. It is usually associated with gestational trophoblastic disease and/or pregnancies that have elevated maternal serum hCG levels. Hyperreactio luteinalis with maternal anasarca was diagnosed at 19 weeks in a spontaneously conceived gestation, in a 16-year-old primigravida. A second trimester termination for maternal respiratory decompensation secondary to pleural effusions and ascites was required. There was no evidence of trophoblastic disease on pathological examination of the products of conception. Hyperreactio luteinalis may be diagnosed prenatally by ultrasound, and intervention may be necessary for maternal indications. Following termination of pregnancy, spontaneous resolution and regression of ovarian size may be expected.

Ultrasound guided aspiration of benign ovarian cysts: an alternative to surgery?

Treatment of ovarian cysts remains a problem for gynecologists despite the different treatment modalities that are available. This prospective study included 19 patients (aged 16-34 years) who were treated with ultrasound guided aspiration; cyst diameter ranged from 6 to 16 cm (mean 8 cm). There were recurrent cysts in five of the 19 patients. The results indicate that in cases of benign ovarian cysts, ultrasound guided aspiration may be an alternative to other treatment modalities.

[Acute alcoholism after ethanol fixation for ovarian chocolate cyst]

We experienced a case of acute alcoholism after ethanol fixation for ovarian chocolate cyst. A 46 year old female was scheduled for ethanol fixation for ovarian chocolate cyst. Ethanol fixation was performed with 110 ml of 99% ethanol under general anesthesia. Ethanol 70 ml was not removed. After the operation, patient did not emerge from anesthesia within 30 min. Blood alcohol concentration was 232 mg.dl-1. It is important to remove total ethanol used for ethanol fixation in anesthetic management for ethanol fixation for ovarian chocolate cyst.

[Ovarian endometrial cysts--management and treatment]

The authors estimated the effects of combined operative and hormonal therapy in 23 women suffering from ovarian endometrial cysts. In the therapy the authors used Danazol. The authors concluded that removal of an ovarian endometrial cyst combined with 6-th month Danazol therapy prevents recurrence of endometriosis and in some women restores fertility.