Ovarian adnexal tumors

It is extremely common to see young patients who have already had one or both ovaries removed for something as simple as a cyst. The doctor says “Tumor” and we all think “Cancer” but #KnowledgeIsSuccess and most likely you can preserve your ovaries and protect your fertility.

Dr. Arturo Valdés, Creafam fertility expert, shares this master class with us, it is a bit extensive but it is worth listening to.

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Seeing the need, patients often come and say “They already removed an ovary five years ago because I had a cyst” or “They removed an ovary because they told me I had cysts, or polycystic ovaries.” So we are overusing ovarian surgery without doing conservative surgeries and even many of the tumors do not need surgery.

On this occasion we want to touch on the topic of benign ovarian tumors or adnexal tumors. Why? Because it is almost as common as ovarian cysts but ovarian cysts are not operated on. Ovarian cysts can generate benign tumors, which is the simple cyst, and that is what this talk is about. Afterwards, Dr. Carlos Cortés, who is our specialist in oncological surgery, is going to talk specifically and punctually about malignant tumors, which fortunately is the minority of the population of reproductive age so that you can know, remember that knowledge is power. Know how to differentiate between a benign tumor and a malignant tumor and, above all, make the best decision whether to have surgery or not and ask for a second opinion with us if we have doubts about whether it is necessary not to remove benign tumors or ovarian adnexal tumors.

It is a very important topic because the ovary can give us problems even from childhood long before puberty, but mainly from the moment puberty begins in women and throughout their reproductive life the ovary can go through certain alterations and generate cysts or tumors. benign ovarian lesions that are often treated similar to fibroids with radical surgery, a surgery that removes the ovary unnecessarily or rather harms the woman’s reproductive health at this stage of her life.

The anatomy of the ovaries

Anatomically, the ovary are two structures that are in the pelvic cavity or internal genitalia of the woman and in the anterior part, the uterus, we will have the bladder, which can be seen in this part here, and in the posterior part is the sigmoid rectum, that is, The descending colon duct goes down and then the rectum comes towards the anus for evacuations, but on the sides of the uterus we have the ovaries.

The ovaries are gonads whose main function is obviously to produce sexual hormones and also the production of gametes, that is, the egg or the female cell for fertilization and procreation. They will measure between 1, 2 to 3 centimeters, 3 centimeters long, 2 centimeters high, wide and 1 centimeter high and also weigh a small weight of 6 to 7 grams, but the ovary inside, if we made a cut, we will have follicles. primordial follicles, which are the first to start growing, then the primary follicle, the secondary follicle and then when ovulation comes in the secondary follicle, the oocyte and then the corpus luteum. I would not like to get so involved in a physiological explanation of what happens from the beginning to the end of the growth of that follicle. The important thing is to know that the follicles are generally on the periphery of the ovary, it obviously has some suspensory ligaments that we will do now, the irrigation , and in the center is, as it were, the stroma, which is called the ovary.

And see how beautiful the irrigation of the ovary is, mainly the ovary is going to be irrigated by the ovarian artery, obviously and this ovarian artery is a branch of the abdominal aorta, so it is an artery that brings too much pressure because you have to understand that the ovary, Being a gonad, it constantly needs irrigation for growth, development and the entire generation of female gametes, which at some point in its life is where there may be certain alterations, whether in doctrines or even mechanics, that cause these to form. tumors or these ovarian cysts and the uterine artery, both the artery and the vaginal arteries come through the internal iliac artery.

What are adnexal tumors?

Adnexal tumors, we must remember, many people write to us and tell us: “They told us that I have a tumor” and they automatically associate them with cancer, no, every tumor, what we in medicine call a tumor, is every lesion. , mass or protuberance that exists in the body can be made of fat that are called lipomas, they can be the same warts that are warty tumors or they can be cystic tumors. But we must remember that with ovarian adnexal tumors, 10% of women worldwide will undergo an evaluation for an adnexal tumor at some point in their lives, that is, 10 out of every 100 women will be able to have the tumor adnexal actions in some process of its reproductive life.

In the United States, 60,000 excisions of adnexal tumors are performed a year, that is, it is an infinite number of ovarian pathologies just like fibroids. In fact, I think that the ovarian pathology is slightly greater than what the myomatosis is. Because? Because that is month after month the ovary is working and functional cysts or simple cysts can be generated that we will review after a while. The vast majority, this is very important, the vast majority of ovarian tumors are benign, so people should not be scared. It is important to have some diagnostic or presumptive criteria to rule out malignant pathology.

Symptoms of tumors

The most important thing is to know: How do I realize it? Just like they sometimes ask me about fibroids, do I have cysts? Well, you generally have to have symptoms. The majority will not cause any discomfort, they are prison patients, I do not feel any problem, sometimes I have political problems, sometimes I have a little inflammation, but sometimes there can be pain during intercourse, that is very important.

They are women who in their reproductive life say “Hey, normally I have never had pain and for two or three months I have had discomfort when I have sexual life.” Yes, that is called dyspareunia. So, changes in menstrual cycles due to hormonal alterations, too. When a woman says: “Yes, I was regular month after month I had my periods, I had two or three days of bleeding but I have had intermonthly bleeding for two or three months now” Or maybe even “My period stopped because three months, I thought she was pregnant and nothing.

These women must be suspected of having a simple functional cyst, surely. Metrorrhagias, which meant intermonthly spotting. Uterine hemorrhages can also cause bleeding, as sometimes occurs mainly in polycystic ovary. Amenorrhea, that is, menstruation does not come and then a cyst can cause it to be blocked by the pituitary gland and then there is no menstrual cycle because all the development of the endometrium stops, peeling and again the beginning of new follicular growth.

The pain can be intense and sudden, yes, this is very important because in this type of cystic tumors, when it is intense and sudden pain, the diagnosis is relatively easy or it is a twisted ovarian cyst or it is an endometriotic cyst that perhaps had a rupture or it is a functional cyst that maybe twisted or it could be a hemorrhagic cyst even when the woman ovulates that space fills with blood, but many times the bleeding does not self-limit quickly and it becomes a hemorrhagic cyst and produces a lot pain.

Abdominal pressure or distension, there begins to be discomfort or a sensation of pain when touching myself, or there begins to be a sudden inflammation of the abdomen and sensitivity or discomfort when doing physical activities, these are women who say I normally exercise but for two or three months I do exercise and I feel discomfort or I feel that something moves and it hurts a lot, then you have to go to the doctor with this type of symptom.

Tumor diagnosis

How am I going to make a diagnosis of all these types of pathologies? Well, the most important thing is the medical questioning, that is, knowing what your cycles are like, if they have changed, how many days it lasts, if there have been changes in your menstrual cycles, if you have missed menstrual cycles, if there has been intermenstrual spotting, pain to relationships, some type of directed interrogation, physical examination: Check the abdomen how it is, if it is distended, if it is resistant to palpation, and I believe that the most important in the gynecological-obstetrics area and in the consultation of The first medical checkup is an ultrasound.

The vaginal ultrasound will always give us a better visualization, it is more direct when we insert the probe into the cervix that we mentioned, I can focus more on the ovary and have a much more important, clearer view and above all, be able to better differentiate what type of adnexal tumors; If it is a simple cyst, if it is a solid cyst and they are mixed cysts, if there are trabeculations, we will see a discussion later. But why is the abdominal also important? Because adolescents or pubescent girls who do not yet have a sexual life can visit us, we cannot do a vaginal ultrasound in them, or it would not be ideal, so the approach would be through the abdomen.

Two complementary studies that are a little more sophisticated: Tomography and MRI can also help us a lot, especially to make the delimitation in the differentiation of these tumors between cystic or solid or mixed. Laboratories, there are a series of markers called tumor markers. Tumor markers are nothing more than an enzyme that is released depending on what type of tumor it is. Why is it useful to us? Because tumor markers will always give us a numerical figure, so if I have a tumor that is benign or a tumor that is borderline or a malignant tumor, these markers can be interpreted: Normal, slightly elevated or very elevated and that is fine.

Important, not especially for the benign ones but for the malignant one, once you make the approach and do the surgery, then your idea of ​​seeing if that patient is progressing adequately is with these tumor markers, seeing if their numbers have already started to decrease or They have even returned to normal states, so there is CA 125, carcinoembryonic antigen (CEA), alpha-fetoprotein (AFP), mainly free hCG, 19-9 lactic dehydrogenase and neuronal specific enolase (NSE). Generally, almost all obstetrician-gynecologists mainly use the first three, so I put them first: CA125, Carcinoembryonic Antigen and Alpha-Fetoprotein. The other three are a little more for tumors suspected of malignancy and obviously a blood count to see if there is anemia or if the patient in good general condition.

Characteristics of tumors on physical examination

This is what I told them; Clinical characteristics of high and low grade or risk of initial tumors upon physical examination, that is, we have certain medical criteria to say whether a tumor may be high grade or low risk for benign or malignant initial tumor actions. The main ones, low risk. Look!: Less than 10 centimeters, that is, I can have a tumor, or a cyst of 6 or 7 centimeters and it does not necessarily mean that it is malignant or that it is cancer. Unilateral: All tumors that are only on one side have a lower or low risk of being malignant. That there is no pain: If the patient does not have pain and it was due to an ultrasound finding, she is better. Why? Because surely that cyst is going to be reabsorbed or can be managed a little conservatively. Mobile, that is, if I do the examination with the vaginal or bimanual probe and I see that it is not fixed, that it moves well, that there is no discomfort, it is a low-risk tumor.

That there is no free fluid in the cavity, which can only be seen with ultrasound, will also give us a low risk and that it is a cystic lesion: We return to the same thing. What does a simple cyst look like? I did not show images, we will upload them later, but the ultrasound shows the ovary and a large, well-defined tumor is seen, that is, its capsule is perfectly delimited, a thin capsule and the entire interior is black, what we call hypoechoic, that is It is a hypoechoic, homogeneous lesion, no trabeculations are seen, nothing is seen inside, it is a simple cystic tumor. Those of high grade or high risk, which does not mean that if we are here we already have cancer, simply that you have to suspect it depending on the age, the questioning and the family or personal history: Size greater than 10 centimeters, instead of unilateral that both ovaries have these tumors, that there is pain on palpation, that the tumor is fixed, that there is free fluid and that it is solid. What is a solid tumor like? It also looks a little hypoechoic, but inside there may be small lesions and/or vegetations or small trabeculations as if they were a small tissue that divides that tumor… Or it may be mixed, one part I see solid and another part cystic, That is when we can have a higher grade lesion or risk of malignancy, but that does not mean that it is the same as cancer, which is why we must also rely on everything else.

Characteristics of tumors on ultrasound

For all these things that are a little more technical, there must be someone who really knows how to do an ultrasound and has a vaginal presence and who has the equipment, obviously… High risk: Tumors greater than 7 centimeters, volume greater than 20 cubic centimeters in premenopausal women, in postmenopausal women greater than 10 cubic centimeters, bilateral solid or complex, thick irregular septa greater than 3 millimeters and greater than 3 septa, papillary or complex projections as well as irregular vegetations, thick capsule, ascites present, an index of pulsatility greater than 1 and a resistance index less than 7. So, so that you can see that it is not so easy to say “This is a tumor and I have to operate on you” No! There must be adequate questioning, an adequate approach and, above all, the surgical decision must be well taken jointly between the doctor and the patient.

How can I as a patient decide if I am going to have one, or if I am going to want to take a second opinion? I always tell the patient, let’s see, did they explain to you in the ultrasound what they saw? No. Hey, did they tell you how big the tumor was? No. What kind of tumor was it? No… Well, even if it was done by a radiologist and then reviewed by an obstetrician-gynecologist, the main thing is that the doctor has to explain to the patient why the study is done, what the ultrasound looks like, what tumor markers we are going to ask for. and then interpret them. That is the most important thing for the patient to make her decision whether to have surgery with him or not to have surgery with him. Because many times they are not given the information or perhaps the doctor does not know how to give the information, it is not a good option to operate on you.

Ovarian tumor statistics

Just look, this is from a magazine that I found from the Autonomous University of Sinaloa that they wrote in 2016 and I found it very interesting. Of all the patients who underwent laparoscopy, which were 427 patients for adnexal tumor, here is the percentage of tumors or characteristics of tumors that were found, look at the simple cyst as I told you, 57%, that is, more than half of the patients It was a simple cyst. This type of simple cysts have three ways of treatment: It can be just conservative without doing anything to them, manage it with contraceptives to see if it decreases and even before doing surgery we can even puncture them or do a vaginal aspiration of that tissue if we are sure that it is a simple cyst and not undergo surgery. The simple cyst is: The ovary month after month will generate a primordial follicle, a secondary follicle, a follicle, the Graafian follicle ruptures, the woman ovulates and then that rest or corpus luteum is reabsorbed, but they are not always reabsorbed and simple cysts, that is, the follicle grows, it does not rupture, the woman does not ovulate, she is left with that tumor and that small cyst begins to grow, to grow, one month to two months, but generally they are not tumors that reach more four or five centimeters.

Polycystic ovary are not cysts. We have many small primordial follicles, many eggs that remain in a stage of immaturity, that is, they do not reach the ovulation period and then these types of polycystic ovary patients are prone to also generate simple cysts for obvious reasons: This follicle struggles to grow. but it does not have enough hormone to ovulate and a simple cyst remains, and then on many occasions I have had patients come to me who say “They removed my ovary because they told me I had polycystic ovary, that I had many cysts” No! Those ovaries should not be removed. Of all these that we are putting, notice, ovarian cancer was only 0.5% of the patients of these 427 patients, that is, only 2 patients had cancer, the probability is very low. Yes, it is important to make the diagnosis both before and postoperatively because surveillance is very different from all benign cysts, but what do we mean by this? Among the simple, dermoid, endometriotic and mucinous cysts are the vast majority of pathologies of women of reproductive age and they are mainly benign cysts, so it is very important to go to your specialist, have a good diagnosis and, as I told you, fibroids, if we have doubts about whether the surgery is urgent, “They told me it was urgent”, Seek a second opinion or go to Creafam, we have the obstetrics and gynecologist specialist and also if there is any doubt we have our surgeon specialist oncologist.

Treatment options for tumors and cysts

The management mainly or almost always of being conservative: Visualize. You get a patient who says “Hey, I have a lot of pain this month, it’s not normal.” You examine her, she has a hemorrhagic cyst that shows internal trabeculations, it has a slightly solid consistency and it looks like mixed degeneration inside… Well, those types of patients have to ask: When was your period? When is your ovulation in theory? You do the ultrasound, generally you will see that there is free fluid, the pressure will be a little annoying, it is a cyst of at best 4.5 centimeters… Very simple: If it is in the middle of the cycle or a little more It is probably a hemorrhagic cyst and you are waiting for your period, do a checkup with your menstruation to see if it has already decreased and if not, the first step is oral contraceptives, nothing will happen.

Normally there is no urgency or rush to do a quick surgical procedure, to say “Today I was diagnosed, tomorrow the doctor told me he has to operate on me.” This is not true. Generally you have to do a range of studies and then decide if it is a surgical or conservative approach. Why? Because these emergencies or urgencies often cause us to remove an ovary that really did not need to be removed. Surgical, surgical can be laparoscopic, but unlike fibroids, I think laparoscopy is the ideal approach, unless it is an emergency. But, if it is a patient that is planned, programmed, a laparoscopy has better recovery, less injury to the abdominal cavity obviously and the patient can do her regular or normal activities in a week.

Exploratory laparotomy, well yes, opening is also an option but preferably only excision of the tumor and a histopathological study are always done. What does this mean? Once I am inside, be it laparoscopic or open, I need to preferably just remove that cyst with everything and its capsule, send it for analysis to see what type of tumor it is, one of the ones we had mentioned, and obviously be certain that it is benign. . But the only indication for removing an ovary is if that ovary is twisted, it looks necrotic and dead tissue, but if not, the ideal is to always try to preserve even a little bit of ovarian tissue on that side where the adnexal tumor is.

Important points

Finally, important points for the management and treatment of patients with tumor adnexal actions: 1 the choice between surgery or conservative (that is, surveillance) depends on symptoms and the age of the woman. It is not the same to want to include a 16 or 18 year old patient as a 43 or 44 year old patient because the stages of life can suggest to us if there is a mismatch between the beginning of menstruation and this prepubertal or pubertal or adolescent woman is having those endocrine changes and they are functional cysts, in a 42-year-old woman, as we have seen, that age and then comes with large tumors and it is mixed, so there the suspicion is greater.

The time of evolution and the anamnesis are of utmost importance. When did your pain start? How did it start? Has it been increasing or is it just a nuisance? Because on many occasions they operate on them and say “It’s an emergency” and the patient really had a small, dull pain, because it had not increased in two or three days and it is still present, well that is not an ovarian torsion and that It is surely not a tumor that has to be operated on in an emergency. The only emergency of an adnexal tumor is an acute abdomen. Important Why? Because a patient may come to me with a hemorrhagic cyst, with moderately intense pain and say “It was sudden, it’s hurting, it twists me.” But you do the examination, you touch him, if there is a little resistance, you do an ultrasound, no. There is free fluid, there is not so much pain on pressure and you see that tumor, so many times it is even not giving painkillers but rather monitoring and saying: Let’s see, let’s wait a day or two and see if the pain decreases or disappears, Because it is true that hemorrhagic cysts are one of the most urgently operated surgeries because of course, they begin to fill with blood, it hurts a lot and is often confused with even mixed tumors or high-risk tumors and it is sometimes not necessary to remove them. Well, a hemorrhagic cyst because that is going to be reabsorbed.

Endometriotic cysts can also cause acute abdomen when that capsule ruptures and that tissue that we have already talked about endometriosis is secreted, yes, since that matter that is secreted is very toxic or is very chemical, it irritates the peritoneum and gives an acute abdomen, We would have to go in there… But be careful! The vast majority of adnexal tumor emergencies should not necessarily have been surgical. Priority in most cases is only cystectomy, that is, even if it is an emergency surgery, preferably having an ultrasound before to see the lesion, and what we can do whether laparoscopic or open is to incise the cortex of the ovary, puncture The cyst was scheduled to see if it is hemorrhagic and if not, if we suspect that it is malignant, then we cannot puncture it, but the most important thing is to try to only remove that tumor and preserve the ovary.

The management of benign ovarian adnexal tumors is very different than that of malignant tumors. I am not going to talk about malignant cancers, but I do want you to know that as I mentioned, the possibility of ovarian cancer is very small in the standard or average population, which is from 12 years old to 45 or 50, and above 50 years old. The risk of ovarian cancer can be further increased. The indication for Oopherectomy must be well evaluated, the only indication to remove the ovary as I had told you is a twisted cyst, if you see the ovary already necrotic, it will look dark or bruised and it no longer makes any sense to leave it, because there Yes we cannot preserve that ovary, but the most important thing is: If it is an acute abdomen then you only have to go to a hospital there if a doctor cannot see you in consultation and if it is not an acute abdomen go to an obstetrician-gynecologist and secondly ask a second opinion if you have doubts about whether to have surgery or not because it is very important to try to preserve the two gonads, that is, the two ovaries as much as possible so as not to have infertility repercussions later.

“We hear tumor and immediately think cancer and let them remove the entire ovary, but in many cases it is not even necessary to intervene”

Dr. Arturo Valdés
Dr. Arturo Valdés
Reproductive Medicine and Gynecological Endocrinology
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