Ovarain volumes and PCO & POF cases

 

 

Ovarian volume and diagnois of PCO –How helpful??  Ans; Ovarian volume is an important parameter in diagnosing polycystic ovarian syndrome. When the volume of any one the ovary exceeds 10 ml  then there will be always a suspicion of having polycystic ovarian syndrome (PCO).

The other morphological features of so called PCO are  1) peripheral arrangement of small follicles each  measuring 2 mm  10 mm in diameter numbering more than 12 per ovary and  echogenic stroma. The typical ring like arrangement of atretic follicles in the outer part of ovaries is often termed as necklace sign.

 

Relationship of POF with ovarian volume ? Ovarian volume and diagnosis of premature ovarian failure: We are aware of the fact that the ovaries are full of thousands of non- growing follicles which are often termed as NGF by reproductive physicians .These lie in dormant state but do contribute to volumes of ovaries.

 

Diminished ovarian reserve is defined as reduced capacity of the ovaries to produce oocytes or the oocytes produced are of poorer quality leading to the formation of poor quality embryos. The most severe form of DOR can be represented clinically as premature ovarian failure (POF). The condition may result from disease or injury, but most commonly occurs as a result of normal aging.

 

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Does small volume of ovaries speaks in favour of POF?? A small volume ovary in childbearing age will usually but not always speak of diminished ovarian reserve. Not only low per centile of ovarian volume but a low Antral Follicular Count (AFC) will support the diagnosis of premature ovarian follicle. There are some recognized   serum markers of dwindling ovarian reserve. Such serum markers are low anti Mullerian hormone (AMH) ,) and high basal follicular Stimulating hormone.

 

 

 

 

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Ovarian volume has an important predictive value in  prevention and also in diagnosis of OHSS .  If ovarian volumes are high enough then ovarian stimulation protocol should be   cautiously planned   by an experienced reproductive physician lest there can be ovarian hyperstimulation syndrome which is an life threatening condition (OHSS ). Prediction   of OHSS in most cases can be made by prior estimation of ovarian volumes.

Diamanti-Kandarakis E, Pandas D. Unravelling the phenotypic map of polycystic ovary syndrome (PCOS): A prospective study of 634 women with PCOS. Clin Endocrinol (Oxf) 2007;67:735-42.    

 

Dahl Lyons, C.A., Wheeler, C.A., Frishman, G.N. et al. (1994) Early and late presentation of ovarian hyperstimulation syndrome: two distinct entities with different risk factors. Hum. Reprod., 9, 792–799.

Danninger, B., Brunner, M., Obruca, A. and Feichtinger, W. (1996) Prediction of ovarian hyperstimulation syndrome by ultrasound volumetric  assessment  [corrected] of baseline ovarian volume prior to stimulation. Hum. Reprod., 11,1597–1599.

 

 

Nidhi R, Padmalatha V, Nagarathna R, Amritanshu R. Prevalence of polycystic ovarian syndrome in Indian adolescents. J Pediatr Adolesc Gynecol. 2011;24:223

Golan, A., Ron-el, R., Herman, A. et al. (1989) Ovarian hyperstimulation syndrome: an update review. Obstet. Gynecol. Surv., 44, 430–440

Balen AH, Laven JS, Tan SL, Dewailly D. Ultrasound assessment of the polycystic ovary: International consensus definitions. Hum Reprod Update 2003;9:505-

 

In addition to diagnosing PCO and premature ovarian failure as mentioned above   there are other important indication of estimation of ovarian volume such as different kinds of beningn and malignant cysts of ovaries. In such cases not only follicular diameters are important as a follow up protocol   but serial estimation of volumetric enlargement is also relevant

Ovarian cysts may be of  various etiologies.   Such ovarian cysts do commonly have an effect on ovarian volume and planned imaging of ovarian volume are an important tool in follow up of different kinds of ovarian cysts.. Though presence of functional cysts do alter the volume of ovaries minimally still any slight  increase in ovarian volumes in an asymtomatic women will raise a suspicion of presence of follicular or lutein cysts. As mentioned , presence of any cyst in the ovary often  warrant long term follow  up about progression or regression  of so called functional cysts .. Ovarian cystic masses include a spectrum of benign, borderline and high grade malignant neoplasms. Imaging plays a crucial role in characterization and pretreatment planning of incidentally detected or suspected adnexal masses, as diagnosis of ovarian malignancy at an early stage is correlated with a better prognosis. Knowledge of differential diagnosis, imaging features, management trends and an algorithmic approach of such lesions is important for optimal clinical management. This article illustrates a multi-modality approach in the diagnosis of a spectrum of ovarian cystic masses and also proposes an algorithmic approach for the diagnosis of these lesions

 

Cysts in ovary vary widely in etiology, from physiologic, to complex benign, to neoplastic with internal echoes. An ovarian cyst which is < 1 cm cysts is commonly seen in this age group and is considered clinically unimportant. Ovarian cystic lesions constitute a spectrum from benign to malignant pathology. Imaging can confidently characterize the majority of cystic lesions as benign, thereby avoiding an aggressive surgical approach.

Anechoic unilocular simple cysts (no septations or solid component) less than 5 cm in diameter and seen on ultrasound have a very low malignant potential. Cysts more than 1 cm and less than 7 cm should have a yearly follow up ultrasound to document stability. If more than 7 cm, either surgical evaluation or further imaging with MRI should be considered.

Any complex cystic mass demonstrating thick, irregular septations and a solid component with or without intralesional vascularity is mostly malignant and should undergo surgical evaluation. Some of these patients may undergo CT or MRI imaging prior to surgery to define the nature and extent of the disease and also as baseline study for post treatment follow up.

 

. Lesions that remain indeterminate can be closely followed or surgically resected with a relatively conservative approach. Whilst cases of malignant lesions while imaging can raise a high diagnostic concern, it can also evaluate the extent of disease, thereby guiding appropriate treatment planning

 However, a fluid-fluid level and foci of calcification (posterior acoustic shadowing) is likely to represent a dermoid/ possibly beningn teratoma. In such fluid filed cases volumetric assement may not be diagnostic about the nature of the tumour .For confirmation of any such so called functional cyst serum tumour markers are of immense help as is CT or MRI which hopefully will  confirm the diagnosis . Coming back to the issue of dermoids which exhibits the presence of fat and it is also necessary to evaluate the extent of the lesion (as many dermoids with calcification can represent just the tip of iceberg) and all such reports like ovarian imaging, MRI and serum tumour markers taken together should formulate a standard treatement plan as applicable for a given case. Incidentally, a detected lesion on CT with foci of fat attenuation, fat-fluid level and calcification is diagnostic of a dermoid. . 

Sonographic complex cystic lesions with solid components and/or mural nodules and/or thickened irregular septa remains a concern for a malignant neoplastic process and surgical evaluation or imaging with contrast enhanced MRI is recommended for characterization and evaluation of the extent of the disease .