Ovarian surgery in premenarchal girls

Study ObjectiveThis study was undertaken to assess the indications, procedures, and pathology in premenarchal girls undergoing ovarian surgery.DesignRetrospective chart review.SettingUniversity of Michigan Medical Center 1980–1996.ParticipantsPremenarchal girls, who underwent ovarian surgery.InterventionsNone.Main Outcome MeasuresAll available charts (n = 52) had information extracted concerning age at time of surgery, presenting symptoms, preoperative and postoperative diagnosis, procedure, and pathology report.ResultsOf the 52 patients, 50% were less than 1 year old, 31% were between 1 and 8 years old, and 19% were between 8 and 12 years old. Presenting complaints in 31 patients included structural and or endocrinologic abnormalities, and the other 21 patients presented with abdominal or systemic complaints. The most common preoperative diagnosis was an abdominal/pelvic mass (n = 24). The postoperative diagnoses revealed 18 torsions and 16 ovarian masses without torsion, 8 chromosomal abnormalities, 5 hernias, and 5 malignancies. Procedures included 37 salpingo-oophorectomies (28 unilateral and 9 bilateral), 7 oophorectomies, and 7 cystectomies. One patient underwent a staging procedure. Pathology reports confirmed hemorrhagic infarctions (n = 19), dysgenic gonads (n = 8), simple cysts (n = 7), teratomas (n = 6), theca lutein cysts (n = 4), fibroma (n = 1), stromal tumor (n = 1), mucinous cystadenoma (n = 1), granulosa cell tumor (n = 1), uterine neuroblastoma (n = 1), mixed germ cell neoplasm (n = 1), metastatic Wilms' tumor (n = 1), and gonadoblastoma (n = 1).ConclusionsTorsion was the most common diagnosis in our study group and was usually unsuspected. Premenarchal ovarian surgery usually included removal of the entire ovary. However, because malignancies are uncommon in this population (9.6%), a cystectomy should be considered when appropriate and technically feasible.     

Ovarian hyperandrogenism in adolescent girls with menstrual disorders

OBJECTIVES: In women with polycystic ovaries (PCO) hyperandrogenemia, an increased LH-concentration and a hightened ratio of LH/FSH are common. In adolescent hirsute girls with menstrual disorder, which may herald PCO in adulthood, ovarian hyperandrogenemia was under scrutiny. In most of them functional ovarian hyperandrogenism (FOH) is present in response to challenge with GnRH analog. It is not known whether FOH is involved in the pathogenesis of menstrual disorders in adolescent girls without hirsutism. MATERIAL AND METHODS: 24 girls with menstrual disorder in the mean age of 17.5 +/- 1.6 years old were investigated and compared to the age matched group of girls with regular menses. Basal and GnRH stimulated levels of ovarian androgens and gonadotropins were measured and USG of the ovaries were performed in all girls. RESULTS: In over 50% of girls with menstrual disorder basal and stimulated 17 OH progesteron and androstenedione levels were found significantly higher as compared to the control groups. In all girls but three they were not associated with the polycystic structure of the ovaries. Only half of these girls had an increased LH/FSH ratio. CONCLUSIONS: Functional ovarian hyperandrogenism may be present in adolescent girls with menstrual disorder in spite of the absence of the clinical signs of hirsutism and polycystic structure of the ovaries.     

Breast malignancy in girls]

The authors described 19 year old patient with breast cancer and two teen-age patients with juvenile papillomatosis of the breast. Authors have postulated that among different problems of pediatric gynecology it is necessary to notice pathology of breast.     

Ovarian cysts in adolescent girls: report of 196 cases

OBJECTIVES: The aim of the study was a retrospective analysis of the procedure employed at girls with diagnosed ovarian cyst changes. MATERIALS & METHODS: The material examined was 196 girls (at the age 9-20) with diagnosed ovarian cyst changes being medical treatment in Research Institute Polish Mother's Memorial hospital between 1995-1997. Operations were performed because of the pains or ultrasound suspected features. The patients who were not operated on were under observation and had ultrasound tests every two months. The presence of the change was the indication for sonographically guided fine needle puncture. RESULTS: From among 196 patients 15 (7.6%) were initially qualified for the operation because of strong pains or ultrasound equivocal changes. After two months observation (with gestagen or estrogestagen formulations being used) no cysts were found at 141 (72%) patients. After another two months no cysts were found at another group of 10 (5.1%) patients. 30 (15.3%) patients had find needle puncture. No malignant tumours were in the observed group found. CONCLUSION: Clinical observation periodically repeated ultrasound tests seems to be the most appropriate procedure employed at adolescent girls with asymptomatic ovarian cysts.     

Ovarian borderline mucinous tumor in a premenarchal girl: review on ovarian epithelial cancer in young girls.

Ovarian tumors constitute the most common gynecological neoplasms during childhood. Unlike in adult women, ovarian epithelial tumors are uncommon in young girls and extremely rare prior to menarche. To our knowledge this is the first report of a borderline malignant mucinous tumor of the ovary in a premenarchal girl. It was successfully treated by conservative surgery. In our review of ovarian neoplasms in girls under 20 years of age, epithelial tumors were found in 19.3%, with a malignancy rate of 15.9%. Of these malignant tumors, 39.4% were of the mucinous type and 30.3% were borderline malignant. The occurrence of such a tumor at this age underscores the possibility of malignant transformation of the ovarian epithelium even prior to menarche. Its mucinous nature confirms the predominance of the mucinous subgroup in young girls. Hypotheses on the origin of mucinous tumors are discussed.     

Ovarian tissue cryopreservation for prepubertal girls: indications and feasibility

OBJECTIVE: Survival improvement of children, adolescents and young women with cancer has led to consider with more cautiousness the long time iatrogenic side effects of treatments. Among those, premature ovarian failure has been described even for children. The aim of the study was to evaluate the indications and the feasibility of ovarian tissue cryopreservation for prepubertal girls. PATIENTS AND METHODS: From September 2000 to December 2004, 47 prepubertal girls were referred by oncologists for ovarian tissue cryopreservation. After informed consent, the ovarian tissue was collected and frozen by a slow cooling protocol until the temperature of liquid nitrogen. A histological analysis and a follicular account were performed. RESULTS: The harvest of ovarian tissue was performed for 45 patients. No surgical side effect occurred. The younger girls had a follicular density higher than the older. No metastatic ovarian tumour was found. DISCUSSION AND CONCLUSIONS: Numerous arguments as the follicular density in the ovary, the age of the patient, no surgical side effect, no metastatic ovarian tumour and recent progress in term of birth after ovarian tissue autografting allowed to think it is very important and ethical to propose an ovarian tissue cryopreservation even for children before sterilising treatment.     

Ovarian cancer screening

Annual screening of asymptomatic postmenopausal women using a combination of transvaginal sonography and serum Ca-125 has been evaluated in 4 major clinical trials as a means to facilitate earlier detection of ovarian cancer. In several trials, screening has caused a decrease in stage at detection. These ovarian cancer screening trials are reviewed. The effect of screening on ovarian cancer mortality varies in different trials and is the subject of further investigation.     

Ovarian cancer screening

For populations in which preventive measures have been applied for the more common causes of death, the early detection of ovarian cancer becomes the next focus of efforts to reduce premature death among women. Data regarding the effectiveness of ultrasonography in detecting early-stage ovarian cancer are reviewed. Ultrasonography is more sensitive than pelvic examination in detecting ovarian abnormalities but lacks specificity in distinguishing benign from malignant ovarian lesions. Combined with serum CA 125 levels, ultrasonography may provide an effective screening tool, although cost-effectiveness has not been demonstrated and its effectiveness in reducing mortality from ovarian cancer has not been completely evaluated. Guidelines are presented for the use of ultrasonography in evaluating the postmenopausal ovary.     

Ovarian involvement in extragenital cancer

Ovarian involvement from extragenital cancer often presents clinically as probable primary ovarian neoplasm. A retrospective review of the 29 such cases at Parkland Memorial Hospital from 1962 to 1985 was analyzed looking at clinical, surgical, and pathological parameters. The most frequent primary sites were colon (52%), breast (17%), stomach (10%), and pancreas (10%). Most common presenting symptoms were abdominal pain in 48% and increased abdominal girth in 45%. Preoperatively a palpable pelvic mass was detected in 93% and clinical ascites in 41% of patients. At surgery only 20% of patients had isolated ovarian metastases. Abdominal exploration identified the original tumor in 84% of the cases in which the primary originated in the abdomen. Bilateral ovarian involvement was found in 60%, and in 33% of these the contralateral involvement was occult. Eighty-three percent of patients have died with a median survival of 6 months. We conclude that mode of presentation, physical findings, and intraoperative assessment of patients with secondary ovarian neoplasms are no different from primary ovarian malignancy, and that when evaluating a pelvic mass, consideration should always be given to the possibility of secondary ovarian neoplasms.     

Ovarian cancer in the young

An epidemiological study of ovarian cancer in the young under 20 years old in Israel during the years 1972-1976 are presented. During these 5 years 22 new cases were reported. Germ cell tumors accounted for 63.6% and the epithelial tumor for 23%. The incidence of this group was 2.2% of the incidence of all ovarian maligancies. The five years survival was 54.5%. The less malignant tumor was dysgerminoma. There was no difference of the incidence between the various ethnic groups in this population.     

Sterilization of mentally retarded girls]

About 1000 sterilizations are performed in mentally retarded women in Germany every year out of about 30,000-50,000 operations. Considering that 10 out of 1000 people are mentally retarded, they are overrepresented in this procedure. There are no clear regulations concerning their sterilization because of the historical antecedents of abuse of the rights of the mentally retarded. A 1933 law about hereditary health resulted in the forced sterilization of 300,000-400,000 persons mostly based on ideological indications. During the 1972 reform of the penal code the attempt to regulate sterilization with abortion and set very stringent conditions for minors and competent persons did not succeed. In 1987 federal medical association guidelines and the Einbecker recommendations were published permitting sterilization if it was in the well-meant interest of the mentally retarded person and the indications analogous to abortion could be considered. The consent of legal representative, guardian, and possibly both parents had to be secured, and the guardian court had to be given prior notice. The patient had to be advised and without her consent the operation could not be carried out. A draft proposal to become law in 1992 would forbid sterilization of minors: the consent of the guardian court is needed for incompetents of age if pregnancy would likely result without sterilization and it could not be prevented by other means. The handicapped oppose the sterilization of mentally retarded and the use of genetical criteria laid down in the regulation for indications for legal abortion. In 1990 the federal parliament passed the law on the rights of guardianship and care for those of age forbidding forced sterilization and sterilization of minors. This legislation will give clear guidelines for doctors. Some legal uncertainties still exist that can be used responsibly for the interest of the patient.     

Genital findings in sexually abused prepubertal girls]

Genital findings in sexually abused prepubertal girls.Childhood sexual abuse is defined as the involvement of dependent, developmentally immature children and adolescents in sexual activities that they do not fully comprehend, to which they are unable to give informed consent or that violate the social taboos of family roles. Essential to the diagnosis of sexual abuse is an awareness of the problem and acknowledgement of its manifestations. The evaluation of the sexually abused girl usually is performed in a pediatric and adolescent gynecology outpatient department. Thus, the gynecologist will be part of a multidisciplinary approach to the problem and will need to be competent in the basic skills of history taking, physical examination, selection of laboratory tests und differential diagnosis. Findings secondary to sexual abuse are often subtle. Acute tears or bruisings are rare, because force is seldom part of sexual acts committed against a child. A vaginal opening of greater than 5 mm is not common and may indicate vaginal penetration. An intact hymen not necessarily exclude vaginal intercourse. Lack of physical evidence never rules out abuse because sexual acts may leave no physical findings.