Dysmenorrhea in adolescents and young adults: etiology and management

Dysmenorrhea is the most common gynecologic complaint among adolescent and young adult females. Dysmenorrhea in adolescents and young adults is usually primary (functional), and is associated with normal ovulatory cycles and with no pelvic pathology. In approximately 10% of adolescents and young adults with severe dysmenorrhea symptoms, pelvic abnormalities such as endometriosis or uterine anomalies may be found. Potent prostaglandins and potent leukotrienes play an important role in generating dysmenorrhea symptoms. Nonsteroidal anti-inflammatory drugs (NSAID) are the most common pharmacologic treatment for dysmenorrhea. Adolescents and young adults with symptoms that do not respond to treatment with NSAIDs for 3 menstrual periods should be offered combined estrogen/progestin oral contraceptive pills for 3 menstrual cycles. Adolescents and young adults with dysmenorrhea who do not respond to this treatment should be evaluated for secondary causes of dysmenorrhea. The care provider's role is to explain about pathophysiology of dysmenorrhea to every adolescent and young adult female, address any concern that the patient has about her menstrual period, and review effective treatment options for dysmenorrhea with the patient.     

Laparoscopic management of ovarian dermoid cysts: potential fear of dermoid spill, myths and facts

The objective of this study was to evaluate the safety and potential advantages of laparoscopic approach for management of ovarian dermoid cysts and challenge the potential fear of spillage of contents of dermoid cyst during laparoscopic surgery. Out of 384 operative laparoscopies conducted at Al Ebtesama Hospital, Unit of Advanced Laparoscopic Surgery, and Cairo University Hospital, during the period May 1999 to February 2005, 26 patients underwent laparoscopic removal of dermoid cysts. We employed the three-puncture technique: a 10-mm umbilical trocar for the telescope and two auxiliary 5-mm punctures for operative intervention. Thirty-one dermoid cysts with a mean diameter of 7.5 cm were removed successfully in 26 patients. The operative techniques employed were ovarian cystectomy for 28 cysts, salpingo-oophorectomy for three cysts, and one case had salpingo-oophorectomy together with laparoscopy-assisted vaginal hysterectomy (LAVH). In one case, we performed concomitant hysteroscopic excision of complete uterine septum. Fourteen cysts were removed through enucleation and removal through the trocar sleeve. Ten cases were treated via enucleation and removal within impermeable endobag. Seven cases were managed by removal of cysts via posterior colpotomy; one was managed during LAVH. We encountered 14 spillages during the procedures: in ten cases (71%) of trocar removal without the use of endobag, in one case (10%) of removal within an impermeable endobag, and in three cases (42%) of colpotomy removal. After a review of 14 studies in the literature, added to our study, we found only 0.2% incidence of chemical peritonitis following laparoscopic removal of dermoid cysts. Laparoscopic approach allows proper exposure of the cul-de-sac and forceful jet lavage aspiration, ensuring pelvic clean out from any microscopic material of the dermoid cyst. Such a situation may not be available during open laparotomy.     

腹腔镜手术和开腹手术治疗良性卵巢囊肿的比较研究

目的探讨腹腔镜手术治疗良性卵巢囊肿的临床应用价值。方法 回顾性分析1999年1月至2001年8月间80例腹腔镜手术治疗的卵巢囊肿病例(其中完成腹腔镜手术者为腹腔镜组),选择同期54例开腹手术治疗的良性卵巢囊肿病例作为对照组。结果80例腹腔镜手术有4例术中转开腹,其中1例为卵巢恶性肿瘤;76例卵巢囊肿为良性,以子宫内膜异位囊肿和成熟性畸胎瘤最多见。囊肿切除术腹腔镜组占88.2％,开腹手术组占64.8％。两组手术时间差异无显著性。腹腔镜手术组术中出血、术后住院及恢复时间短于开腹手术组,差异有显著性。结论腹腔镜手术治疗良性卵巢囊肿比开腹手术更具优越性。     

Laparoscopic management of a 20-cm ovarian cyst in a patient with a BMI of 70: a case report

A woman in her mid-40s with a body mass index (BMI) of 70 presented with lower abdominal pain of 24-h duration. The trans-abdominal scan revealed a large cystic ovarian mass. Laparoscopic salpingo-oophrectomy was performed by placing six ports in the upper abdomen; initial Verres needle entry and pneumoperitoneum were established through the left upper quadrant. A low CA-125 and the benign appearance of the ovary allowed the operation to continue laparoscopically with fewer perioperative complications. The histology of the specimen demonstrated a benign epithelial serous cystadenoma of the ovary with torsion.     

Frequency and treatment of ovarian cysts in adolescence

Ultrasound examination of the ovaries was performed monthly in the follicular phase of 139 healthy adolescents for one years. In 17 girls (12,2%) ovarian cysts spontaneously disappeared within 3 months of first observation. In 6 subjects, treatment with the combined estrogen/progestogen pill was given. The treatment was effective in 4 girls after 2 – 6 months while 2 subjects required surgical intervention for a cystic teratoma and a simple follicular cyst respectively. A spell of serial sonographic observation of ovarian cysts would seem appropriate in adolescents. Received: 3 August 1993 / Accepted: 14 December 1993     

Laparoscopic excision of large ovarian cysts

OBJECTIVE: The aim of this study was to check the ability of operative laparoscopy to help in the management of large ovarian cysts that may reach above the level of the umbilicus. MATERIAL AND METHODS: Fifteen cases of large ovarian cysts reaching above the level of the umbilicus were chosen. Clinical and ultrasonic diagnosis denied any signs of malignancy. Pneumoperitoneum and a 5 mm trocar were inserted safely in the left midclavicular line below the ninth costal margin. This trocar allowed us to inspect the peritoneal cavity thoroughly. Another 5 mm trocar was inserted suprapubically in the contralateral side of the cyst and better inspection of the cyst and peritoneal cavity was then done. In the case of an apparently benign cyst, aspiration of the cyst fluid was done after puncturing its wall, then the cyst was removed as usual. RESULTS: In all of these cases, there was no laparoconversion and no other complications were recorded. Nine cases were mucinous and six were serous cystadenomas. The mean operation time was 53.66 +/- 14.7 min. CONCLUSION: Laparoscopic excision of large ovarian cysts is possible, and safe in suitable conditions, with immediate laparoconversion at hand at any time.     

Giant ovarian cyst in a woman in rural Africa

A 42-year-old woman presented to the open access surgical outpatients clinic run by an international Non-Governmental Organisation in the south western region of Chad in central Africa. She gave a 2-year history of increasing abdominal girth, which had recently been associated with breathlessness and lower back pain. This had forced her to stop work, culminating in her self-referral to the clinic. In the absence of access to helpful investigatory modality, we performed an exploratory laparotomy, during which a large cyst (15.1 kg, 12.5 l) in the left ovary was excised and abdominoplasty was performed. She made a good recovery with no complications and was discharged 5 days postoperatively.     

Laparoscopic management of ovarian dermoid cysts. A series of 83 cases

We did a retrospective survey of 83 patients who had laparoscopic removal of a benign dermoid cyst in our hospital since 1994. Preoperative transvaginal sonography led to the correct diagnosis in 57 cases (69%). In 59 cases cystectomy with ovarian conservation was performed; spillage of cyst contents occurred in 39 cases (66%). Salpingo-oophorectomy was performed in 24 patients with spillage in 8 cases (24%). The mean tumor size (n=83) was 4.5±1.6 cm and 4.9±2.8 cm for unspilled and spilled cysts, respectively. The tumor was placed in an endobag in 62 cases. No intra- or postoperative complications occurred. No case of chemical peritonitis was noted. Received: 22 November 2000 / Accepted: 8 July 2001     

Comparison of laparoscopy versus laparotomy for the surgical treatment of ovarian dermoid cysts

To compare laparoscopy with laparotomy for the surgical management of ovarian dermoid cysts, a retrospective analysis of data of 108 patients who had surgery at our institution from January 1998 to August 2001 was performed. The surgical data of these patients were obtained from a computerized data base. The following data were abstracted: the patients demographic features, size of dermoid cysts, spillage rate, estimated blood loss, operative times, duration of hospital stays, and intraoperative or postoperative complications. Statistical techniques included Students t-tests, Fishers exact tests, Mann-Whitney tests, and chi-square analysis. Of 108 patients with dermoid cysts, 53 (49.1%) underwent laparoscopy and 55 (50.9%) had laparotomy. The mean estimated blood loss was significantly less in laparoscopy (71.6±63.5 ml) compared with laparotomy (119.2±101.6 ml). Hospital stay was significantly shorter in the laparoscopy group (0.6±0.8 days) compared with the laparotomy group (2.2±1.0 days). Also, the postoperative complication rate was lower in the laparoscopy group (3.8%) compared with the laparotomy group (14.5%), but the difference did not reach statistical significance. Whereas the laparotomy groups spillage rate of 4.1% and operative time of 86.7±39.6 min were significantly lower than the laparoscopy groups spillage rate of 31.4% and operative time of 118.4±51.5 min, the laparoscopy group had less blood loss, shorter hospital stay, and fewer complications. The laparoscopic management of benign cystic teratomas can be safely performed.Presented at the American Association of Gynecologic Laparoscopists meeting (2001).     

Management of non-neoplastic ovarian cysts with sclerotherapy.

OBJECTIVE: To evaluate sclerotherapy with alcohol and erythromycin in the management of simple ovarian cysts. METHODS: Twenty-four simple ovarian cysts were subjected to sclerotherapy with alcohol and erythromycin. All procedures were performed under local anesthesia and in an outpatient setting. Cytological examination was carried out in all cases and two patients were excluded from the study because of suspicious cytological results. The patients were followed up monthly with color Doppler sonography for more than 12 months. RESULTS: Cyst fluid was serous in 17 cases and dark-chocolate colored in seven cases. The volume of aspirated fluid ranged from 100 to 220 ml. The size of ovarian masses and cyst-wall thickness ranged from 5.5 to 8.5 cm and 1.5 to 5 mm, respectively. Cytological analysis of 15 cysts revealed acellular sediment, seven cysts were compatible with endometrioma, and two were reported as suspicious. During the 12-month follow-up, seven cyst recurrences were detected. CONCLUSION: Aspiration and sclerotherapy with alcohol and erythromycin are followed by a relatively high recurrence rate when the aspirate is bloody. However, patients with a simple cyst that is painful or liable to torsion could benefit from sclerotherapy. Such patients, who are at low risk for malignancy, are relieved with sclerotherapy while avoiding surgery.     

腹腔镜与剖腹行良性卵巢囊肿剥出术的对照研究

目的:比较腹腔镜术与剖腹术两种方法行良性卵巢囊肿剥出术的结果。方法:将妇科手术治疗的75例良性卵巢囊肿患者随机分为腹腔镜组(38例)和剖腹术组(37例),对两组患者的特征及术中、术后情况进行对比分析。结果:两组在年龄、体重、剖腹术史、囊肿大小、病理类型等方面差异无显著性(P>0.05)。术后病率、对镇痛药的需求、术后住院日及恢复时间,腹腔镜组显著减少(P<0.01或P<0.05)。结论:腹腔镜行良性卵巢囊肿剥出术优于传统剖腹术。     

Laparoscopic Specimen Retrieval Bags

Specimen retrieval bags have long been used in laparoscopic gynecologic surgery for contained removal of adnexal cysts and masses. More recently, the concerns regarding spread of malignant cells during mechanical morcellation of myoma have led to an additional use of specimen retrieval bags for contained "in-bag" morcellation. This review will discuss the indications for use retrieval bags in gynecologic endoscopy, and describe the different specimen bags available to date.     

Simple ovarian cysts in postmenopausal women: scope of conservative management

Objective

This study was done to evaluate/investigate the natural history of simple ovarian cysts in postmenopausal women and to determine the risk for malignant transformation of these cysts.

Study design

Ultrasound reports of all the postmenopausal women who attended St. Francis Hospital and Medical Center, Hartford, USA from January 1997 to April 2010 with an ultrasound diagnosis of simple cysts of ovary were reviewed retrospectively. A total of 619 patients with 743 simple ovarian cysts were evaluated. It was found that 305 out of 619 patients (49.27%) were lost in follow-up. Therefore, 314 patients (50.73%) with 378 cysts could be followed further by ultrasound study.

Results

One hundred and seventy-five (46.30%) of the 378 cysts that could be followed further had spontaneous resolution and 166 cysts (43.91%) persisted unchanged over the follow-up period. Thirty cysts (7.94%) turned into complex cysts and four cysts (1.06%) significantly increased in size. One cyst significantly decreased in size, though it did not resolve. Only one patient developed papillary serous carcinoma (high grade) of the ovary. This occurred three years after her last ultrasound for simple cyst surveillance.

Conclusion

Simple ovarian cysts during the menopause can be followed conservatively because their risk for malignant transformation is low. The majority of these cysts either resolve spontaneously or persist unaltered on follow-up.     

Laparoscopic treatment of ovarian dermoid cysts

Dermoid cysts are the most common germ cell tumors of the ovary in women of reproductive age. We report 67 cases of patients with dermoid cysts (mean age, 31.31 years) originating from the ovary treated from 1994 to 2006 at the Obstetrics and Gynecology Department of Aschaffenburg Hospital-Clinic in Germany. Most patients (60) underwent cyst removal. In two patients salpingo-oophorectomy was performed and in five partial oophorectomy was performed. Additional surgery ensuing laparotomy was never necessary. None of the patients had long-term postoperative complications. Two patients were at nine and 15 weeks of gestation and postoperatively were well following termination of pregnancy. In a group of 43 women, who desired pregnancy, 37 pregnancies resulted. The overall intrauterine pregnancy rate was 83.7%; one patient had an ectopic pregnancy (2.32%). To receive more information on this disease, treatment should be performed according to international protocols.     

Knowledge of reproduction in teenagers and young adults in Sweden

Objective To investigate the knowledge of reproductive physiology and anatomy among adolescents and young adults in Sweden, and to evaluate the education obtained on these issues.

Methods Two hundred and nine study specific questionnaires were distributed, of which 206 were answered by students in primary school, upper secondary school and at first year of university. A total knowledge score based on 21 out of the 35 questions in the questionnaire was calculated. As only 44 of the 206 respondents answered all the questions a revised score was also calculated, in which partial dropouts were interpreted as wrong answers.

Results The mean of the total knowledge score was 28.7 out of 54 among the 44 respondents answering all questions, and the revised knowledge score was 24.0. The level of knowledge tended to be higher in older age groups, among women, as well as among respondents who had visited a Youth clinic. The time of ovulation was known by 21.4% of men compared to 63.4% of women. Almost 50% of the students knew one mechanism whereby oral contraceptives act to protect against pregnancy. Of the respondents, 77.2% knew of Chlamydia trachomatis but the knowledge of other STIs, like condyloma, was poorer (16.5%). Reasons for infertility were relatively well known among the respondents. Of the respondents, 57.5% stated that they had not received enough information on reproductive issues.

Conclusions The students have not achieved sufficient knowledge concerning sexual and reproductive matters that they, according to the national curriculum, should have attained by the end of the 9th grade. An improvement of the quality of the education, adapted to the students' age and pre-existing knowledge, and a review of the contents of the education is therefore needed.     

卵巢子宫内膜异位囊肿腹腔镜手术的治疗价值

应用电视腹腔镜手术治疗卵巢子宫内膜异位囊肿７８例，镜下施行卵巢子宫内膜异位囊肿剔除术６３例附件切除术１５例，无１例中转开腹，全部手术均未发生严重并发症。７８例患者Ⅲ期６０例，Ⅳ期１８例，不孕症患者４６例，占５９％，术后随访７１例，随访率为９１．０２％；术后复发５例，复发率为６．４１％，不孕组中妊娠２４例，妊娠率为５２．１７％。     

The histology and management of ovarian cysts found in children and adolescents presenting to a children's hospital from 1991 to 2007: a call for more paediatric gynaecologists

Objective  To determine the nature and surgical management of ovarian cysts.
Design  Retrospective case-note study.
Setting  Large Childrens' Hospital: Alder Hey NHS Foundation Trust.
Sample  Children undergoing surgery for ovarian cysts between 1991 and 2007.
Methods  Cases identified using coding and the pathology database, and analysed using snap  9.
Main outcome measures  Extent of surgery performed. Size and histological features of cysts removed.
Results  A total of 155 cases were identified. There were 62 ovarian cysts in children under nine who were prepubertal. There were 58 neoplastic cysts in total. Most were benign teratomas (36). Ten cysts were malignant, including five granulosa cell tumours, one yolk sac tumour, one endodermal sinus tumour and one dysgerminoma. Tumour markers were performed in only 16 cases (10%). Sixty-one (39%) had an ultrasound scan and 16 (10%) had a computed tomography (CT) or magnetic resonance imaging (MRI) scan. Ninety girls (58%) had an oophorectomy and 40 (25%) had an ovarian cystectomy. Oophorectomies were performed for all cases of malignancy, but 75 were also performed for benign or normal pathology. Only 16% of cases were referred to the paediatric gynaecologist and all were for post-operative management.
Conclusions  We recommend the greater use of imaging of the pelvis and tumour markers preoperatively. There should be greater use of conservative expectant management or ovarian-sparing surgery in view of the low risk of malignancy in this age group. The practice of removing ovaries for benign cysts may be overcome by appointing more gynaecologists with advanced training skills training in paediatric and adolescent gynaecology.     

卵巢囊肿患者手术指征的探讨

目的 :探讨卵巢囊肿患者的手术指征。方法 :诊治单纯囊肿患者 2 2 1例 ,其中最大径 <5cm 76例、≥ 5cm 14 5例。 184例施行了腹腔镜手术 ,37例施行了剖腹手术。结果 :病理学分析无 1例恶性。单纯囊肿、卵巢冠囊肿和黄体囊肿最大径在 <5cm和≥7cm者中的发生率分别为 90 .8%和 6 0 % ,二者差异有显著性 (P <0 .0 1)。单纯囊肿 ,卵巢冠囊肿和黄体囊肿在绝经前和绝经后者中的发生率为 81.5 %和 84 .0 %。结论 :最大径≥7cm的卵巢囊肿应及时手术 ,<7cm者可短时间观察 ,如囊肿持续存在 ,则应手术。绝经后者的卵巢囊肿应及时手术