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Residual ovarian syndrome: A case report with classic symptoms, imaging and pathology findings, and treatment
Taiwanese Journal of Obstetrics & Gynecology 57 (2018) 753e754
Contents lists available at ScienceDirect
Taiwanese Journal of Obstetrics & Gynecology journal homepage: www.tjog-online.com
Case Report
Residual ovarian syndrome: A case report with classic symptoms, imaging and pathology findings, and treatment Shao-Chi Fu, Her-Young Su* Department of Obstetrics and Gynecology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
a r t i c l e i n f o
a b s t r a c t
Article history: Accepted 8 December 2017
Objective: Residual ovarian syndrome (ROS) occurs after a hysterectomy in which one or both ovaries have been preserved and cause chronic pelvic pain, an asymptomatic pelvic mass, or dyspareunia. We present a case with classic symptoms and imaging and pathology findings, and review the treatment of residual ovarian syndrome. Case report: A 35-year-old woman with a diagnosis of ROS. Conclusion: Based on previous literature, almost 50% of patients with ROS require surgery for their symptoms. Treatment of ROS with gonadotropin-releasing hormone analogs or high dose progestogens may be helpful. However, there are limited data supporting the efficacy of pharmacologic therapy. Patients receiving pharmacologic therapy should be counseled about the limited data supporting the efficacy of this approach, the lack of a histologic diagnosis, and the risk of ovarian cancer in residual tissue. © 2018 Taiwan Association of Obstetrics & Gynecology. Publishing services by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Keywords: Residual ovarian syndrome Pelvic pain Gonadotropin-releasing hormone analogs
Introduction Residual ovarian syndrome (ROS) is a complication after hysterectomy in which one or both ovaries been preserved and cause chronic pelvic pain, an asymptomatic pelvic mass, or dyspareunia. Most patients undergo surgery within the first 5 years after hysterectomy to resolve their discomfort. However, the diagnosis of residual ovarian syndrome is seldom made due to lack of acknowledgement of this syndrome. We present a case with classic symptoms, imaging and pathology findings, and surgery for residual ovarian syndrome.
Department of Gastroenterology and Hepatology due to left lower abdominal pain for 4 months. Abdominal computed tomography showed a 3.8-cm cystic mass (Fig. 1) with debris deposition over the right hemipelvis. An ovarian cyst was suspected. She was referred to the outpatient Department of Gynecology, where transvaginal ultrasound revealed a well-defined, homogeneous hypoechoic 2.51 1.66-cm cystic lesion in the right adnexa without blood flow; the left adnexa had no abnormal findings (Fig. 2). After 2 months of treatment, her left lower quadrant abdominal pain persisted.
Case presentation A 35-year-old woman was regularly followed at the outpatient Department of Gynecology due to menorrhagia and severe dysmenorrhea for 2 years. Accordingly, laparoscopic-assisted vaginal hysterectomy was performed 20 months prior due to persistent symptoms. The histology of the operative specimen confirmed uterine adenomyosis. Both ovaries appeared normal during the operation. She subsequently presented to the outpatient
* Corresponding author. 5F, 325, Section 2, Cheng-Gong Road, Nei-Hu District, 114, Taipei, Taiwan. E-mail address: [email protected] (H.-Y. Su).
Fig. 1. Abdominal computed tomography: A 3.8-cm cystic mass in the right hemipelvis. No specific findings in the left ovary.
https://doi.org/10.1016/j.tjog.2018.08.027 1028-4559/© 2018 Taiwan Association of Obstetrics & Gynecology. Publishing services by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/).
754
S.-C. Fu, H.-Y. Su / Taiwanese Journal of Obstetrics & Gynecology 57 (2018) 753e754
Fig. 2. Transvaginal sonography: A 3.6-cm hypoechoic cystic mass in the right adnexa. No specific findings in the left adnexa.
A diagnosis of ROS was made and the treatment plan included observation with painkillers. Her lower abdominal pain and ovarian cyst persisted after 3 months of follow-up. Due to intractable pain she was admitted for surgical intervention. Laparoscopy was performed and a 4 4-cm right ovarian cyst was found. Right ovarian cystectomy was performed. Due to intractable pelvic pain in the left adnexa, left salpingo-oophorectomy was performed after thorough discussion. There were no adhesions in the pelvis and abdomen. Histology confirmed a cystic follicle in the left ovary and a hemorrhagic corpus luteum cyst in the right ovary. The patient made an uneventful recovery and was discharged home 2 days later. She was well at her 12-month postoperative check-up. Discussion ROS occurs when the ovaries are left in place during hysterectomy and later cause pelvic pain, a pelvic mass, or dyspareunia. This is in contrast to the ovarian remnant syndrome, in which a patient undergoes bilateral salpingo-oophorectomy, leaving a remnant of ovarian tissue. The incidence of ROS is 2e3% and the symptoms usually include chronic pelvic pain (71e77%), an asymptomatic pelvic mass (14e25%), or dyspareunia (67%) [1,2]. Almost 50% of patients with ROS require surgery within the first 5 years after hysterectomy, and 75% within 10 years [1]. Possible pathologies that can occur in residual ovaries include follicular cysts, a hemorrhagic corpus luteum, periovarian adhesions, endometriosis, and benign and malignant neoplasms. Malignant neoplastic change takes place in the residual ovary in 0.26e12.3% of cases. Most series, however, describe ovarian malignant change in no more than the population as a whole (1e2%) [3]. The ovaries are both endocrine and reproductive organs. They secrete hormones both before and after menopause. Ovarian hormones not only have important reproductive actions through control of ovulation, reproductive organs, and breast tissue but they also have important non-reproductive actions via receptors spread throughout most tissues and organs including the brain, muscle, bone, blood vessels, heart, and gastrointestinal tract [7]. Removal of the ovaries reduces the risk of ovarian cancer by 80e90% and breast cancer by 50e60%, but increases the risk of mortality by 28%, lung cancer by 45%, coronary heart disease by 33%, stroke by 62%, cognitive impairment by 60%, parkinsonism by 80%, osteoporosis and bone fractures by 50%, and impaired sexual function by 40e110% [4e6]. There is some evidence that supplemental low-dose estrogen will reduce the later development of cardiovascular disease and osteoporosis. Therefore, it is generally recommended that estrogen be continued in women who undergo
bilateral oophorectomy until the age of natural menopause (approximately age 50 years) [4]. The majority of women in the general population are at average risk of ovarian and breast cancer, and the risks associated with bilateral oophorectomy before age 50 far outweigh the benefits. However, the population at greater genetic risk of ovarian and breast cancer should consider bilateral oophorectomy after they have completed childbearing. They must be informed of the complex risk-benefit ratio of the surgery. Oophorectomy performed after age 50 and up to age 65 may still have deleterious effects, but the risk-benefit ratio seems to be less dramatic [5]. Pharmacologic options for treatment of ROS include medications that suppress ovulation such as gonadotropin-releasing hormone analogs or high dose progestogens [8,9]. However, there are limited data supporting the efficacy of pharmacologic therapy, which is a reasonable option only for women with suspected ROS who have pelvic pain and no pelvic mass, and who are not candidates for or who refuse surgery. Patients treated with pharmacologic therapy should be counseled about the limited data supporting the efficacy of this approach, the lack of a histologic diagnosis, and the risk of ovarian cancer in the residual tissue. Conflicts of interest The authors declare that there is no conflict of interests regarding the publication of this paper. References [1] Dekel A, Efrat Z, Orvieto R, Levy T, Dicker D, Gal R, et al. The residual ovary syndrome: a 20-year experience. Eur J Obstet Gynecol Reprod Biol 1996;68: 159e64. [2] Christ JE, Lotze EC. The residual ovary syndrome. Obstet Gynecol 1975;46: 551e6. [3] Kazadi BJ, Rovira MJ, Laparte EM, Lopez GG. Residual ovary after hysterectomy. Is castration at peri-menopause necessary to prevent ovarian cancer? Rev Fr Gynecol Obstet 1994;89:15e20. [4] Shuster LT, Rhodes DJ, Gostout BS, Grossardt BR, Rocca WA. Premature menopause or early menopause: long-term health consequences. Maturitas 2010;65(2):161e6. [5] Parker WH, Broder MS, Chang E, Feskanich D, Farquhar C, Liu Z, et al. Ovarian conservation at the time of hysterectomy and long-term health outcomes in the Nurses' Health Study. Obstet Gynecol 2009;113(5):1027e37. [6] Rocca WA, Grossardt BR, de Andrade M, Malkasian GD, Melton 3rd LJ. Survival patterns after oophorectomy in premenopausal women: a population-based cohort study. Lancet Oncol 2006;7(10):821e8. [7] Rocca WA, Ulrich LG. Oophorectomy for whom and at what age? Maturitas 2012;71:1e2. [8] Hauser GA. Residual ovary syndrome-significance of medical therapy. Geburtshilfe Frauenheilkd 1980;40:17e24. [9] Carey MP, Slack MC. GnRH analogue in assessing chronic pelvic pain in women with residual ovaries. Br J Obstet Gynaecol 1996;103:150e3.
Contents lists available at ScienceDirect
Taiwanese Journal of Obstetrics & Gynecology journal homepage: www.tjog-online.com
Case Report
Residual ovarian syndrome: A case report with classic symptoms, imaging and pathology findings, and treatment Shao-Chi Fu, Her-Young Su* Department of Obstetrics and Gynecology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
a r t i c l e i n f o
a b s t r a c t
Article history: Accepted 8 December 2017
Objective: Residual ovarian syndrome (ROS) occurs after a hysterectomy in which one or both ovaries have been preserved and cause chronic pelvic pain, an asymptomatic pelvic mass, or dyspareunia. We present a case with classic symptoms and imaging and pathology findings, and review the treatment of residual ovarian syndrome. Case report: A 35-year-old woman with a diagnosis of ROS. Conclusion: Based on previous literature, almost 50% of patients with ROS require surgery for their symptoms. Treatment of ROS with gonadotropin-releasing hormone analogs or high dose progestogens may be helpful. However, there are limited data supporting the efficacy of pharmacologic therapy. Patients receiving pharmacologic therapy should be counseled about the limited data supporting the efficacy of this approach, the lack of a histologic diagnosis, and the risk of ovarian cancer in residual tissue. © 2018 Taiwan Association of Obstetrics & Gynecology. Publishing services by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Keywords: Residual ovarian syndrome Pelvic pain Gonadotropin-releasing hormone analogs
Introduction Residual ovarian syndrome (ROS) is a complication after hysterectomy in which one or both ovaries been preserved and cause chronic pelvic pain, an asymptomatic pelvic mass, or dyspareunia. Most patients undergo surgery within the first 5 years after hysterectomy to resolve their discomfort. However, the diagnosis of residual ovarian syndrome is seldom made due to lack of acknowledgement of this syndrome. We present a case with classic symptoms, imaging and pathology findings, and surgery for residual ovarian syndrome.
Department of Gastroenterology and Hepatology due to left lower abdominal pain for 4 months. Abdominal computed tomography showed a 3.8-cm cystic mass (Fig. 1) with debris deposition over the right hemipelvis. An ovarian cyst was suspected. She was referred to the outpatient Department of Gynecology, where transvaginal ultrasound revealed a well-defined, homogeneous hypoechoic 2.51 1.66-cm cystic lesion in the right adnexa without blood flow; the left adnexa had no abnormal findings (Fig. 2). After 2 months of treatment, her left lower quadrant abdominal pain persisted.
Case presentation A 35-year-old woman was regularly followed at the outpatient Department of Gynecology due to menorrhagia and severe dysmenorrhea for 2 years. Accordingly, laparoscopic-assisted vaginal hysterectomy was performed 20 months prior due to persistent symptoms. The histology of the operative specimen confirmed uterine adenomyosis. Both ovaries appeared normal during the operation. She subsequently presented to the outpatient
* Corresponding author. 5F, 325, Section 2, Cheng-Gong Road, Nei-Hu District, 114, Taipei, Taiwan. E-mail address: [email protected] (H.-Y. Su).
Fig. 1. Abdominal computed tomography: A 3.8-cm cystic mass in the right hemipelvis. No specific findings in the left ovary.
https://doi.org/10.1016/j.tjog.2018.08.027 1028-4559/© 2018 Taiwan Association of Obstetrics & Gynecology. Publishing services by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/).
754
S.-C. Fu, H.-Y. Su / Taiwanese Journal of Obstetrics & Gynecology 57 (2018) 753e754
Fig. 2. Transvaginal sonography: A 3.6-cm hypoechoic cystic mass in the right adnexa. No specific findings in the left adnexa.
A diagnosis of ROS was made and the treatment plan included observation with painkillers. Her lower abdominal pain and ovarian cyst persisted after 3 months of follow-up. Due to intractable pain she was admitted for surgical intervention. Laparoscopy was performed and a 4 4-cm right ovarian cyst was found. Right ovarian cystectomy was performed. Due to intractable pelvic pain in the left adnexa, left salpingo-oophorectomy was performed after thorough discussion. There were no adhesions in the pelvis and abdomen. Histology confirmed a cystic follicle in the left ovary and a hemorrhagic corpus luteum cyst in the right ovary. The patient made an uneventful recovery and was discharged home 2 days later. She was well at her 12-month postoperative check-up. Discussion ROS occurs when the ovaries are left in place during hysterectomy and later cause pelvic pain, a pelvic mass, or dyspareunia. This is in contrast to the ovarian remnant syndrome, in which a patient undergoes bilateral salpingo-oophorectomy, leaving a remnant of ovarian tissue. The incidence of ROS is 2e3% and the symptoms usually include chronic pelvic pain (71e77%), an asymptomatic pelvic mass (14e25%), or dyspareunia (67%) [1,2]. Almost 50% of patients with ROS require surgery within the first 5 years after hysterectomy, and 75% within 10 years [1]. Possible pathologies that can occur in residual ovaries include follicular cysts, a hemorrhagic corpus luteum, periovarian adhesions, endometriosis, and benign and malignant neoplasms. Malignant neoplastic change takes place in the residual ovary in 0.26e12.3% of cases. Most series, however, describe ovarian malignant change in no more than the population as a whole (1e2%) [3]. The ovaries are both endocrine and reproductive organs. They secrete hormones both before and after menopause. Ovarian hormones not only have important reproductive actions through control of ovulation, reproductive organs, and breast tissue but they also have important non-reproductive actions via receptors spread throughout most tissues and organs including the brain, muscle, bone, blood vessels, heart, and gastrointestinal tract [7]. Removal of the ovaries reduces the risk of ovarian cancer by 80e90% and breast cancer by 50e60%, but increases the risk of mortality by 28%, lung cancer by 45%, coronary heart disease by 33%, stroke by 62%, cognitive impairment by 60%, parkinsonism by 80%, osteoporosis and bone fractures by 50%, and impaired sexual function by 40e110% [4e6]. There is some evidence that supplemental low-dose estrogen will reduce the later development of cardiovascular disease and osteoporosis. Therefore, it is generally recommended that estrogen be continued in women who undergo
bilateral oophorectomy until the age of natural menopause (approximately age 50 years) [4]. The majority of women in the general population are at average risk of ovarian and breast cancer, and the risks associated with bilateral oophorectomy before age 50 far outweigh the benefits. However, the population at greater genetic risk of ovarian and breast cancer should consider bilateral oophorectomy after they have completed childbearing. They must be informed of the complex risk-benefit ratio of the surgery. Oophorectomy performed after age 50 and up to age 65 may still have deleterious effects, but the risk-benefit ratio seems to be less dramatic [5]. Pharmacologic options for treatment of ROS include medications that suppress ovulation such as gonadotropin-releasing hormone analogs or high dose progestogens [8,9]. However, there are limited data supporting the efficacy of pharmacologic therapy, which is a reasonable option only for women with suspected ROS who have pelvic pain and no pelvic mass, and who are not candidates for or who refuse surgery. Patients treated with pharmacologic therapy should be counseled about the limited data supporting the efficacy of this approach, the lack of a histologic diagnosis, and the risk of ovarian cancer in the residual tissue. Conflicts of interest The authors declare that there is no conflict of interests regarding the publication of this paper. References [1] Dekel A, Efrat Z, Orvieto R, Levy T, Dicker D, Gal R, et al. The residual ovary syndrome: a 20-year experience. Eur J Obstet Gynecol Reprod Biol 1996;68: 159e64. [2] Christ JE, Lotze EC. The residual ovary syndrome. Obstet Gynecol 1975;46: 551e6. [3] Kazadi BJ, Rovira MJ, Laparte EM, Lopez GG. Residual ovary after hysterectomy. Is castration at peri-menopause necessary to prevent ovarian cancer? Rev Fr Gynecol Obstet 1994;89:15e20. [4] Shuster LT, Rhodes DJ, Gostout BS, Grossardt BR, Rocca WA. Premature menopause or early menopause: long-term health consequences. Maturitas 2010;65(2):161e6. [5] Parker WH, Broder MS, Chang E, Feskanich D, Farquhar C, Liu Z, et al. Ovarian conservation at the time of hysterectomy and long-term health outcomes in the Nurses' Health Study. Obstet Gynecol 2009;113(5):1027e37. [6] Rocca WA, Grossardt BR, de Andrade M, Malkasian GD, Melton 3rd LJ. Survival patterns after oophorectomy in premenopausal women: a population-based cohort study. Lancet Oncol 2006;7(10):821e8. [7] Rocca WA, Ulrich LG. Oophorectomy for whom and at what age? Maturitas 2012;71:1e2. [8] Hauser GA. Residual ovary syndrome-significance of medical therapy. Geburtshilfe Frauenheilkd 1980;40:17e24. [9] Carey MP, Slack MC. GnRH analogue in assessing chronic pelvic pain in women with residual ovaries. Br J Obstet Gynaecol 1996;103:150e3.