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.
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