RESIDUAL OVARY OR OVARIAN REMENANT SYNDROME

Stephanie aged 48, came to see me with severe Dyspareunia.
She had a Hysterectomy with the ovaries conserved six years ago, and for the last two years this pain was gradually increasing, she had seen two other clinicians who had advised her to use local oestrogen cream and maybe change coital position. This treatment did not help her.
When I saw her on examination her vagina was not dry and she was tender on both sides where her ovaries were supposed to be located, and on moving the vaginal apex she felt pain.
My diagnosis was immediately clear that it was what we call Residual Ovary Syndrome(ROS).

A pelvic ultrasound was performed , this did not show any disease of the ovaries. I offered Stephanie Bilateral Salpingo-oophorectomy.(Removal of both tubes and ovaries), followed by hormone replacement.
Stephanie agreed to this and was a million dollars after treatment.

ROS is a condition which is not often thought of and many times women are older and are reluctant to discuss the condition of dyspareunia. Even if they do, they are more often offered local treatment.

ROS has been found to happen in two to three percent of cases after hysterectomy when the ovaries have been conserved. Usually three percent of these are found to be cancerous. Arguments continue if the ovaries should be removed with each hysterectomy. The general consensus of opinion is that if a woman is older than 45, removal should be considered depending on the woman's risk factors if she takes HRT for a long time. These are family history of breast cancer, stroke, deep venous thrombosis and heart disease.
If there is a family history of ovarian cancer it can become a bit tricky.
The final decision should be made by the woman depending on her individual choice.

ROS is characterised by pelvic pain, pelvic mass and dyspareunia. When a woman presents with one or more of these symptoms a clinical examination should be performed. An ultrasound examination often gives a diagnosis if there is an ovarian cyst or a mass. Further evaluation can give an idea if there is any suggestion of malignancy. Often a CT and a MRI is performed which can help the diagnosis in difficult cases. Sometimes these cysts arise from the peritoneum, which is a membrane that covers the inside of our belly.

The blood test for the patients general health and hormone studies to assess the ovarian function are useful. There is a test called CA125 which is a screening test for cancer, if it shows a low value, we can  assume that there is no cancer.
If we have excluded ovarian cancer with certainty by our tests, then the treatment can be one of the following;
1- Can be medical by hormones-Depo-Provera, GnRH Analogues, both these hormones suppress the ovaries and give temporary relief.
2- Aspiration of the cyst on the ovary, this fluid is sent for testing to exclude any cancer cells. This is also temporary, but it can be repeated more than once.
3- Radiation of the ovaries will stop them making physiological cysts.
4- The final and definitive treatment is by the removal of the ovaries or the remnants. This can be done either by key hole surgery or open surgery. This can be a difficult surgery because the adhesion's form around the ovaries, involving the bowel and ureter which can be damaged in the process.
In the first place these remnants are left behind because the initial operation was difficult due to pelvic adhesion's as a result of endometriosis and pelvic infections.
This has to be followed by supervised hormone replacement.
5 If there is any doubt about the ovarian mass or cyst being cancerous have it removed.

In summarising do not ignore post hysterectomy pelvic pain if you have one or both of your ovaries, have the necessary investigations and treatment. Do not be frightened of Hormone Replacement Treatment, it can make your life very comfortable if given under proper supervision.
      
    
  

ADNEXAL CAUSES OF DYSPAREUNIA

Mary went to see her Gynaecologist all upset to find that she had a cyst on the left ovary.
Recently there has been a fair bit of talk about Ovarian Cancer, however all the cysts are not cancer, there are lots of different types of cysts on the ovaries which are harmless, particularly in young women.
What are ovaries?, they are the main sex organs in the female who along with the uterus perform the human reproductive function. Ovaries along with their tubes are referred as Adnexa.

The above diagram shows the maturation of the egg.

These amazing organs lay dormant until puberty then they become active for 30 to 40 years of a women's reproductive life and then they stop again and this is then called Menopause.
Scientists are still trying to study what suddenly brings on puberty.
I think that they are close to solving this puzzle.
Scattered in the ovary are millions of immature eggs. these are called primordial follicles.
In the foetal ovary there are millions of these , at puberty there are about four hundred thousand, they gradually mature into eggs, the rest dry up and at menopause we run out of them.
As the primordial follicle matures it makes a cyst that is a cavity full of fluid, this has hormones and this is called follicle cyst. This is one of the common cause of pelvic pain, especially in the midcycle when it is growing and releases the egg. Sometimes it overgrows and causes a follicular cyst, which causes pain. After the follicle ruptures it forms another cyst, which is called corpus luteum cyst and when picked up by ultrasound , both these cysts cause anxiety in women, however they are not cancerous. We call them physiological cysts as they are the result of cyclical ovarian function.

They are causing symptoms , such as acute pain, haemorrhage, torsion(twisted), grow bigger than five centimetres and do not resolve by themselves, then they require surgical removal which can be done by key hole surgery. It is often best not to disturb the corpus luteum cyst as it can bleed during surgery and subsequently causes scar tissue.
There are many different types of ovarian cysts and we will discuss these in another post, and most of these are often pain free, unless touched during intercourse.

The other Adnexal Pathology that causes Acute Dyspareunia is an ectopic pregnancy , which means pregnancy in the tube. The diagnosis is made by a pregnancy test and an ultrasound. Again urgent treatment is recommended.
The other ovarian conditions related to acute pain not necessarily related to dyspareunia are torsion of the ovary, rupture of an ovarian cyst. All these conditions require urgent medical attention.       

 

PELVIC CONGESTION SYNDROME

In our previous posts we enumerated some causes of Deep Dyspareunia and we are endeavouring to cover all these causes, in a little bit more detail but not in the order that we posted previously.

In this post we will focus on Pelvic Congestion Syndrome (PCS). Nearly 30 percent of women suffer from this condition in their lifetime. The top age group is between 20 to 45 years of age. It is caused by , varicose veins in the pelvis around the uterus and ovaries, similar to varicose veins in the legs.
It is not understood  if there is a genetic factor or anatomical factor in the formation of the veins.
The women suffer from chronic lower abdominal discomfort, backache and pain on intercourse, it gets worse at the end of the day and after sex.
The other symptoms they suffer is heavy painful periods, vaginal discharge, bladder discomfort and mood swings.
It usually happens after child birth, with the hormone changes and weight gain during pregnancy, which puts pressure on the ovarian veins and the blood flow is impeded. High levels of oestrogen during pregnancy dilates the veins, further contributing to the problem. With each pregnancy over time the uterus enlarges, the lining of the uterus becomes thicker and often the uterus falls backwards(this is called Retroversion), this further adds to the problem of dyspareunia, the periods become heavier and painful.
The diagnosis of PCS is difficult because there are nearly twenty other conditions which cause the complex chronic backache, heavy and painful periods and dyspareunia.
About twenty years ago we offered them medical treatment, often followed by hysterectomy.This did not really help the women and their symptoms continued. The removal of the ovaries was more helpful, but then the problem was of sudden surgical menopause and hormone replacement was required. And we replaced one problem with another.
Luckily we have learnt a lot more about PCS and are able to help the vast majority of women.
Most of the clinicians being aware of the problem, try to tackle it in the modern way.
The history and clinical examination helps us to exclude many other conditions, such as large fibroids and ovarian cysts.
The diagnosis is of exclusion of other causes. An ultrasound examination is useful to exclude other pathology, but often it does not highlight the veins because it is carried out in a supine position. The new colour ultrasound is useful if available to show us the uterine congestion.
CT and MRI is useful however CT is more invasive as we have to use injection of dyes to highlight the problem and the patient is exposed to radiation.
Venogram  is most helpful in making a diagnosis, as it is not too drastic. Only, it has to be done by a special radiologist at a specialist centre.
They can inject the veins with sclerosing agents to block them and they can put little clips inside the veins so that the backward blood flow is stopped. This simple treatment of embolization gives women satisfactory results for several years. The very latest diagnostic and therapeutic technology to manage this condition, treating it effectively with a minimally invasive outpatient procedure.

 

 

 

 These pictures show the vascular uterus on colour ultrasound, a venogram of pelvic organs with venous congestion, and post treatment ,left ovarian vein. 
For those women who cannot avail themselves of the most current and remarkable treatment for PCS
the old medical treatment  still helps.
This consists of pain relief by non steroidal antinflammatory medications, oral contraceptive pills, and drugs to suppress the ovaries. Some people believe in Acupuncture, Homeopathic and Osteopathy. Surely all this can be tried with adequate rest and counselling.

In the next post we will talk about Adnexal Pathology (Tubes and Ovaries)