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Background: Giant ovarian cysts (GOCs)complicated with progressive bulbar paralysis (PBP) are very rare, and no such literature about these cases have been reported. Through the diagnosis and treatment of this case, the perioperative related treatment of such patients was analyzed in detail, and early-stage ovarian mucinous carcinoma was unexpectedly found during the treatment, which provided reference for clinical diagnosis and treatment of this kind of diseases., Case Presentation: In this article, we reported a 38-year-old female patient. The patient was diagnosed with PBP 2 years ago. Examination revealed a large fluid-dominated cystic solid mass in the pelvis measuring approximately 28.6×14.2×8.0 cm. Carbohydrate antigen19-9(CA19-9) 29.20 IU/mL and no other significant abnormalities were observed. The patient eventually underwent transabdominal right adnexal resection under regional anesthesia, epidural block. Postoperative pathology showed mucinous carcinoma in some areas of the right ovary. The patient was staged as stage IA, and surveillance was chosen. With postoperative follow-up 1 month later, her CA19-9 decreased to 14.50 IU/ml., Conclusions: GOCs combined with PBP patients require a multi-disciplinary treatment. Preoperative evaluation of the patient's PBP progression, selection of the surgical approach in relation to the patient's fertility requirements, the nature of the ovarian cyst and systemic condition are required. Early mucinous ovarian cancer accidentally discovered after operation and needs individualized treatment according to the guidelines and the patient's situation. The patient's dysphagia and respiratory function should be closely monitored during the perioperative period. In addition, moral support from the family is also very important., (© 2024. The Author(s).)

Purpose: This study investigated the clinicopathological features and surgical procedures of adnexal masses with abdominal pain in pediatric and adolescent patients. Our objective was to better define the clinical presentation of adnexal torsion and to distinguish characteristics of those with torsion and those with an alternate diagnosis., Methods: Retrospective cohort study of 212 pediatric and adolescent patients was performed who admitted for abdominal pain and presenting with an adnexal mass between March 2012 to December 2019.Medical records were reviewed for age at operation, including presentation of symptoms and signs; the levels of tumor markers; imaging examinations; pathologic findings; the size of masses; treatment; and outcome. Data management and descriptive analyses were performed using SPSS 26.0., Results: The median age of the patients was 14.5 ± 3.6 years at the operation. 126 (59.4%, 126/212) patients presented with an abrupt onset of abdominal pain. A total of 82.1% (174/212) of the participants underwent adnexal conservative surgery. 179 (84.5%, 179/212) patients underwent laparoscopic surgery with an average tumor size of 7.7 ± 3.4 cm, while 33 patients ( 15.6%, 33/212) underwent laparotomy. Rupture of mass and ectopic pregnancy accounted for 7.5% (16/212) and 0.9%(2/212), respectively. Torsion was responsible for 36.8% (78/212) of all patients. Among the patients with torsion, the symptom of nausea and vomiting was more common among girls without torsion (P < 0.0001). 88.5% of the girls with torsion had acute onset of abdominal pain, while 92.3% had persistent pain that could not be relieved or occurred repeatedly, which significantly higher than that in the patients without torsion (P < 0.001). 69.2% of patients with torsion had fixed pain sites, compared with 42.2% in patients without torsion (P < 0.001). 88.5% of girls with torsion had an ovarian cyst/mass ≥ 5 cm, compared with 75.0% in girls without torsion (P = 0.038). 66.7% of girls underwent ovary-preserving surgery, compared with 92.2% in patients without torsion. The most common pathologic types were mature teratoma and simple cyst, accounting for 29.4% and 25.6%, respectively. The multivariate analyses confirmed that mass size greater than 5 cm (OR 4.134, 95% CI: 1.349-12.669,P = 0.013), acute onset pain (OR 24.150,95%CI: 8.398-69.444,P = 0.000), persistent or recurrent pain (OR 15.911,95%CI: 6.164-41.075,P = 0.000) were significantly associated with increased risk of torsion., Conclusions: Torsion which is a relatively rare event in the pediatric population was not an uncommon condition and responsible for more than one third of all pediatric and adolescent patients presented with adnexal masses and abdominal pain. Pain assessment in children and adolescents is important to distinguish characteristics of those with torsion and those with an alternate diagnosis.Thus, pediatric and adolescent patients particularly with a pelvic mass size greater than 5 cm, acute onset pain, persistent or recurrent pain have a benign cause and not missing the devastating condition that needs emergent attention. Thus, a strategy of earlier and liberal use of Diagnostic Laparoscopy (DL) may improve ovarian salvage., (© 2024. The Author(s).)

Long-standing, overt hypothyroidism-induced bilateral multiloculated ovarian cysts represent an infrequent occurrence. Our first case, presented with bilateral complex ovarian masses, exhibited overt hypothyroidism symptoms, including lethargy, weight gain and subfertility, prompting consideration for surgical intervention. Similarly, in the second case, a girl aged 11 years with stunting, delayed bone age and academic challenges was referred for surgical exploration due to bilateral complex ovarian masses. Both cases revealed elevated thyroid-stimulating hormone levels during preoperative workup. Commencing levothyroxine replacement therapy resulted in complete regression of ovarian cysts and substantial symptom improvement within an 8-week timeframe. The third case, a previously diagnosed patient with Hashimoto's thyroiditis, benefited from the lessons gleaned in managing the initial cases, responding well to levothyroxine therapy, thereby averting the necessity for surgery in all three instances. These cases underscore the significance of considering thyroid function in the evaluation of ovarian masses and highlight the efficacy of levothyroxine replacement therapy in resolving both hypothyroidism and associated ovarian cysts, thereby obviating the need for surgical intervention., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

An adolescent female presented with an acute abdomen and elevated beta-human chorionic gonadotropin levels and underwent a laparoscopy for a suspected ruptured ectopic pregnancy. Intraoperatively, a ruptured haemorrhagic corpus luteal cyst and tissues suggestive of products of conception were noted in the same ovary. Histology confirmed an ovarian ectopic pregnancy. Haemorrhagic ovarian cysts, and ectopic pregnancies, can cause acute pelvic pain in women of childbearing age. Their similar clinical signs and symptoms pose a diagnostic dilemma for any gynaecologist. Ruptured corpus luteal cysts, as well as ruptured ovarian ectopic pregnancies, should be considered rare but differential diagnoses in women presenting with acute abdominal pain, an adnexal mass and ultrasound features of haemoperitoneum. The mainstay of treatment is a diagnostic laparoscopy, which is a safe and feasible management strategy without compromising patient safety or ovarian function in the long run., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: Peripheral precocious puberty (PPP) is the precocious development of secondary sexual characteristics without pulsatile gonadotropin-releasing hormone (GnRH) secretion. In girls, PPP suggests a hyper-oestrogenic state, such as autonomous ovarian cysts and McCune-Albright syndrome (MAS). We aimed to investigate PPP in girls with ovarian cysts, with or without MAS., Design: A retrospective study design was used., Patients and Measurements: The study included 12 girls diagnosed with ovarian cysts with PPP between January 2003 and May 2022. Pelvic sonography was performed in cases of vaginal bleeding or areolar pigmentation in PPP. The clinical characteristics, clinical course and pelvic sonographic findings of girls with ovarian cysts were investigated., Results: We found 18 episodes of ovarian cysts in the 12 girls. The median size of the ovarian cysts was 27.5 mm. Five of the girls were diagnosed with MAS. The median time to spontaneous regression was 6 months. Later, 4 out of 12 girls progressed to central precocious puberty (CPP), and three of them had a recurrence of ovarian cysts. Compared to the non-recurrent and recurrent groups, there was a difference in peak luteinizing hormone (LH) in the GnRH stimulation test and period to cyst regression., Conclusions: Most ovarian cysts in PPP spontaneously disappear. However, this could be one of the findings of MAS. Some girls progress from PPP to CPP. Therefore, follow-up is necessary for ovarian cysts in patients with PPP. The recurrence of ovarian cysts may occur when spontaneous regression is prolonged., (© 2023 John Wiley & Sons Ltd.)

Ovarian cysts exhibit variable clinical presentations depending on their size, type and resulting sequelae. Rupture of ovarian cysts is infrequent, and cyst infections are even rarer. Here, we report an unusual case involving a young, non-pregnant woman who presented acutely with features of peritonitis and sepsis and was found to have a complex adnexal mass. Following a rigorous diagnostic evaluation, which included an urgent exploratory laparotomy and salpingo-oophorectomy, common diagnoses including tubo-ovarian abscess, endometriotic cyst and pelvic tuberculosis were ruled out. Instead, she was diagnosed with an ovarian mucinous cystadenoma that had become infected, possibly due to pelvic inflammatory disease, leading to spontaneous rupture. Such a presentation has rarely been reported, especially in a non-pregnant setting. Therefore, we emphasise the importance of considering this rare complication as a potential differential diagnosis in similar clinical presentations and discuss the management implications, including the importance of adequately treating pelvic inflammatory disease., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Psoriasis is a common chronic inflammatory condition, often beginning in childhood in approximately one-third of cases. It can be associated with various other autoimmune diseases such as rheumatoid arthritis, celiac disease, and thyroid disorders. However, its co-occurrence with Van Wyk Grumbach syndrome has not been described in the pediatric population. This syndrome, resulting from untreated hypothyroidism, is characterized by early puberty and ovarian cysts., Observation: A 15-year-old adolescent with a diagnosis of psoriasis since the age of 9 presented with chronic constipation and headaches. She exhibited early puberty (menarche at 9 years) and academic regression. Clinical examination revealed growth retardation and arterial hypertension. Hormonal analyses revealed primary hypothyroidism : Free Thyroxine (FT4)=7pmol/mL(9- 20 pmol/l), Thyroid Stimulating Hormone (TSH)=200 mIU/mL( 0,4 - 5 mUI/ml.). The ultrasound and scintigraphic appearance were suggestive of thyroiditis. Additionally, she experienced menstrual irregularities and pelvic pain. Radiological exploration revealed a left ovarian cyst. The diagnosis of Van Wyk Grumbach syndrome was established due to early puberty, hypothyroidism, and polycystic ovary. Treatment with l-thyroxine led to stabilization of blood pressure and hormonal levels. Her height remained below the target adult height., Conclusion: Assessment of thyroid function appears necessary in pediatric patients with psoriasis. Early hormonal replacement therapy for hypothyroidism may alleviate the symptoms of Van Wyk Grumbach syndrome and mitigate its impact on stature.

Ovarian cysts in adolescents are typically managed conservatively given the low rate of malignancy and the cysts typically regress over time. We present a case of a 14 year-old female with large bilateral adnexal cysts causing ureteral obstruction which was successfully treated with surgical resection and ensuring maximum preservation of ovarian tissue., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Prader-Willi syndrome (PWS) is a genetic disorder involving multiple systems, with an incidence of about 1/10000-25000. Ovarian torsion (OT) is not commonly found in children. Ovarian cyst acts as one of the primary factors resulting in OT. While ovarian cyst torsion with Prader-Willi Syndrome has not been reported before., Case Presentation: A 12-years old female was admitted to Emergency Department of our hospital with the chief complaint of abdominal pain. The outcomes of physical examination revealed the height of 150 cm, weight of 103 kg, BMI of 45.77 kg/m 2 . The patient manifested the special facial features, an obese body, with the abdomen distended into a spherical shape. The fat accumulation in the abdomen significantly embarrassed the palpation. The abdominal CT scan indicated a huge cystic mass in the abdominal cavity, sized about 138 mm × 118 mm. According to medical history, the patient was born with low crying and hypotonia, who has developed the uncontrollable eating behavior since 3-years old. These abnormalities led to a speculation of PWS syndrome, so a genetic test was performed and finally confirmed it, concluding a torsion of ovarian cyst with PWS. With the multidisciplinary consultation, a careful treatment strategy containing the control of blood pressure and blood sugar, coenzyme Q10 was administrated to nourish the myocardium and the application of Growth Hormone was developed. All the above preoperative treatments have brought great benefits to patients. Thus promising the successful completion of operation. The postoperative follow-up till now indicated that the abdominal incision was well healed, without operative complications., Conclusions: This may be the first case report. In the treatment of ovarian cyst torsion, PWS syndrome requires fully consideration, as the latter can lead to multisystem abnormalities, especially the relation to perioperative management, and even fatalities. Genetic testing should be conducted early when PWS was suspected, accompanied with adequate preparation for the perioperative period, the follow-ups of patients should be maintained for a long time after surgery., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Background: In comparison with the general population, women with bleeding disorders are more prone to develop obstetrical and gynecological problems. However, no comprehensive evaluation has investigated the prevalence of hemorrhagic ovarian cysts (HOCs) in rare bleeding disorders (RBDs). In this study, we sought to determine the prevalence of HOCs in a large cohort of Iranian patients with RBDs., Methods: A total of 210 symptomatic patients suspected of HOCs with RBD were included. The median age of the study population was 24 years. Patients were diagnosed with fibrinogen disorders (n = 7, 3%), factor (F) II (n = 4, 2%), FV (n = 28, 13%), FVII (n = 4, 2%), FX (n = 6, 3%), FXIII (n = 122, 58%), combined FV and FVIII (n = 8, 4%), Glanzmann's thrombasthenia (n = 10, 5%), and von Willebrand disease (VWD) type 3 (n = 21, 10%)., Results: Following further clinical and ultrasound examinations of these 210 patients, 68 (32.4%) were confirmed with a diagnosis of HOCs. Of which, FXIII deficiency with 46 cases (67.6%), followed by VWD type 3 (6 cases, 8.8%) showed the highest number. Other coagulation defects associated with HOCs were including fibrinogen deficiency (n = 2, 3%), FII (n = 2, 3%), FV (n = 4, 6%), FVII (n = 2, 3%), FX (n = 1, 1.5%), combined FV and FVIII (n = 2, 3%), and Glanzmann's thrombasthenia (n = 3, 4.5%)., Conclusion: This study found a high prevalence of HOCs in patients with RBDs, indicating the importance of early diagnosis and optimal management of obstetric and gynecological complications in these patients., Competing Interests: Conflict-of-interest disclosure The authors declare no conflicts of interest relevant to this manuscript., (Copyright © 2023. Published by Elsevier Ltd.)

Fetal ovarian torsion is quite a rare event during the antenatal period and usually seen because of an ovarian cyst complication. In this case report, we present a case of fetal ovarian torsion without any ovarian cyst or underlying detectable causes. A 27-year-old primigravid woman with no significant past medical history had a routine prenatal ultrasound at 30 weeks' gestation. The ultrasound showed abdominal ascites and a 47×42-cm intraabdominal solid diffuse mass at the left side under the stomach. Doppler examination showed no blood flow on the mass. Paracentesis was performed, cytological examination reported no abnormality. Based on these findings, the diagnosis was thought to be fetal ovarian torsion. There is lack of consistent recommendations to guide the prenatal and the postnatal management of cases with in-utero diagnosis of ovarian torsion. A "wait-and-see" policy is usually preferred, as in our case., Competing Interests: The authors declare that they have no conflict of interest., (Thieme. All rights reserved.)

Background: Acute epiploic appendagitis is a rare differential diagnosis of unclear or acute abdomen., Aim: To describe - by means of a scientific case report - the extraordinary diagnosis of acute epiploic appendagitis along with contained diverticulitis and incarcerated herniation of the greater omentum into the hernial sac of a former trocar site (medical history, significant for laparoscopic ovarian cyst removal) in a 29-year-old female based on experiences obtained in the successful clinical case management, and on selective references from medical scientific literature., Case Summary: Medical history: A 29-year-old female was admitted with abdominal pain in the lower left quadrant. She reported a laparoscopic ovarian cyst removal 3 years prior. Physical examination of the abdomen revealed tenderness in the lower left quadrant without a palpable mass.Leading diagnoses were found using transabdominal ultrasound and confirmed by an abdominal CT scan; namely, incarcerated trocar hernia, diverticulitis of sigmoid colon, and acute epiploic appendagitis. Therapeutic approach was comprised of an explorative laparoscopy (because of the incarcerated hernia), adhesiolysis, removal of a tip of the greater omentum out of the hernial sac, closure of the hernial orifice, and removal of an unclear, inflamed, and bloody fatty tissue from the wall of the descending colon ( histopathological investigation confirmed acute epiploic appendagitis). This was flanked by conservative treatment of diverticulitis of the sigmoid colon.Further clinical course was uneventful, with discharge on the 3 rd postoperative day with favorable long-term outcome, characterized by no further complaints for 15 months., Discussion: Acute epiploic appendagitis is an inflammatory, usually self-limiting condition of the epiploic appendages of the colon. It typically manifests with abdominal pain in the lower left quadrant. Imaging is an important diagnostic tool to determine whether the patient has, in fact, acute epiploic appendagitis, so recognizing the characteristic oval lesions with the surrounding inflammation and central fat attenuation on CT, as well as the hyperechoic oval lesions with a hypoechoic peripheral band on ultrasound images is crucial. Nevertheless, it is often overlooked in patients and confused with other differential diagnoses, such as appendicitis or diverticulitis. Although the condition appears infrequently, it is essential to be proficient in the diagnostic evaluation, as a misdiagnosis may lead to unnecessary treatment and even surgical intervention., In Conclusion: , the patient was initially diagnosed with an incarcerated abdominal hernia, and therefore subsequently underwent surgery. The inflamed epiploic appendage was discovered in laparoscopic exploration, removed, and confirmed through the histopathology report. This is an approach to be performed with great caution so as not to 1. : misinterpret an inflamed diverticula or covered perforation of it as well as not 2. : overlooking a peritoneal tumor lesion., Competing Interests: The authors declare that they have no conflict of interest., (Thieme. All rights reserved.)

Hyperreactio luteinalis is a benign, pregnancy-related condition with cystic enlargement of the ovaries and elevated androgen. However, only one-third of patients manifest as maternal virilisation and rarely does it cause fetal virilisation. Here, we report a virilised baby girl born to a virilised mother because of hyperreactio luteinalis. This case illustrates our management to maternal and fetal virilisation., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Rationale: Anti-glomerular basement membrane (anti-GBM) disease during gestation is sparse and even rarer when combined with bilateral large corpus luteum cysts. In this case, we report a case of anti-GBM disease in the early stage of pregnancy with ruptured newly formed bilateral large corpus luteum cysts., Patient Concerns: A 24-year-old female was initially diagnosed with anti-GBM disease. During treatment, abdominal distention and vaginal bleeding successively staged. The results of the first gynecological ultrasound and abdominal CT were negative., Diagnosis: Based on the dynamic imaging change of the ovaries, the elevated human chorionic gonadotropin (hCG) and sex hormones, and the pathological findings, a diagnosis of anti-GBM disease with rupture of the newly formed bilateral corpus luteum cysts during early pregnancy was considered., Interventions: The patient was treated with corticosteroids, plasma-exchange along with intensive hemodialysis. Then, to confirm the diagnosis, laparoscopic debulking of bilateral ovarian cysts and curettage were performed., Outcomes: After treatment, the anti-GBM antibody titer declined and the condition of the patient was still stable 2 months following discharge., Lessons: As clinicians, we should be aware that even if the first imaging tests are negative, the relevant indicators should be reviewed dynamically based on the condition of the patients. Additionally, this case raised the question of whether anti-GBM disease was associated with pregnancy and giant corpus luteum cysts, which needs further investigations., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)

Purpose: Hemoperitoneum caused by ovarian cyst rupture may necessitate intervention. The literature is lacking in descriptions of CT findings that help guide patient management. The purpose of this study is to consider CT findings associated with a need for intervention (surgical or interventional radiology management) versus conservative treatment (observation, pain management, and blood transfusions)., Methods: Two radiologists retrospectively and independently reviewed 103 CTs of pre-menopausal women who presented with acute hemoperitoneum related to ruptured ovarian cysts between January 2010 and January 2019. The following imaging features were assessed: ovarian cyst characteristics, sentinel clot, contrast extravasation, and hemoperitoneum size. Findings were correlated with patient demographics, clinical parameters, and management with surgery/interventional radiology procedure (intervention group) versus conservative management (conservative group)., Results: Of the 103 patients with hemoperitoneum from cyst rupture, 16% (n = 16) required intervention, and 84% underwent conservative treatment (n = 87). Length of stay (p = .008) was higher in the intervention group. Statistically significant CT findings in the intervention versus conservative group included (p-value reader 1/p-value reader 2) greatest AP dimension of hemoperitoneum (p = .001/p = 0.02), posterior cul-de-sac AP dimension (p = 0.03/p = .006), total cul-de-sac AP dimension (p = .002/p = .007), and number of spaces with hemoperitoneum (p = .01/p = .02). There was good to excellent inter-reader agreement for these findings (ICC 0.68-0.91). Active contrast extravasation was significant for one reader (p = .02) with poor inter-reader agreement (ICC 0.36). In utilizing ROC curves, thresholds of 107 mm (greatest axial AP dimension of hemoperitoneum) yielded a sensitivity and specificity of 0.81 and 0.62 for reader 1 and 0.69 and 0.55 for reader 2; 45 mm (posterior cul-de-sac AP dimension) yielded a sensitivity and specificity of 0.75 and 0.63 for reader 1 and 0.94 and 0.49 for reader 2; 70 mm (total cul-de-sac AP dimension) yielded a sensitivity and specificity of 0.75 and 0.64 for reader 1 and 0.75 and 0.50 for reader 2; and greater than 5 spaces yielded a sensitivity and specificity of 0.75 and 0.58 for reader 1 and 0.69 and 0.70 for reader 2., Conclusion: CT findings associated with intervention in hemoperitoneum due to ovarian cyst rupture include size of hemoperitoneum, number of abdominopelvic spaces with hemoperitoneum, and contrast extravasation., (© 2022. The Author(s), under exclusive licence to American Society of Emergency Radiology (ASER).)

Endometriosis is characterized by the growth of endometrial-like tissue outside the uterus. It affects many women during their reproductive age, causing years of pelvic pain and potential infertility. Its pathophysiology remains largely unknown, which limits early diagnosis and treatment. We characterized peritoneal and ovarian lesions at single-cell transcriptome resolution and compared them to matched eutopic endometrium, unaffected endometrium and organoids derived from these tissues, generating data on over 122,000 cells across 14 individuals. We spatially localized many of the cell types using imaging mass cytometry. We identify a perivascular mural cell specific to the peritoneal lesions, with dual roles in angiogenesis promotion and immune cell trafficking. We define an immunotolerant peritoneal niche, fundamental differences in eutopic endometrium and between lesion microenvironments and an unreported progenitor-like epithelial cell subpopulation. Altogether, this study provides a holistic view of the endometriosis microenvironment that represents a comprehensive cell atlas of the disease in individuals undergoing hormonal treatment, providing essential information for future therapeutics and diagnostics., (© 2022. The Author(s), under exclusive licence to Springer Nature Limited.)

Endometriotic ovarian cysts are one of the more common gynecological disorders found in reproductive-aged and infertile women. The aim of this review is to summarise information regarding the effect of surgical treatment of endometrioma on ovarian reserve. In women with endometrioma ovarian reserve is decreased compared to similarly aged healthy women and surgical management techniques cause an additional reduction. Evidence suggests that laparoscopic ovarian cystectomy via stripping is the preferable surgical technique for management of endometrioma, compared with excisional/ablative techniques, in the fields of pain improvement, spontaneous pregnancy rates, and ovarian cyst recurrences. Ablation techniques, combined technique and three-step approach demonstrate a less decline in anti-Müllerian hormone postoperatively. A successful operation involves not only removal of ovarian pathology, but also maintenance of ovarian function and future reproductive potential. Patients should be counselled about the risks of surgery and the management plan should be individualised to patient's symptoms and reproductive goals.

Background: Ovarian cysts represent a common condition among women. Epidemiologic studies are inconsistent in determining if women with cysts are more likely to develop endometrial cancer (EC) regardless of overweight/obesity. We investigated the combined role of cysts and body mass index (BMI) on EC risk., Methods: We pooled data from three case-control studies conducted in Italy and Switzerland on 920 women with EC and 1700 controls. The prevalence of cysts was 5% among both cases and controls, with 63% of cases being overweight/obese. We estimated odds ratios (ORs) and 95% confidence intervals (CIs) using logistic regression models, adjusting for potential confounders. We conducted stratified analyses according to BMI, and estimated the interaction between cysts and BMI; we carried out additional analyses according to age at diagnosis of cysts., Results: Overall, history of cysts was not associated to EC (OR=1.27, 95% CI=0.82-1.97, P = 0.29). Normal weight women reporting cysts had an increased risk of EC (OR=2.49, 95% CI=1.31-4.74), while no such effect was found among overweight/obese women (OR=0.65, 95% CI=0.36-1.18; P for interaction=0.004). The association was limited to women below 65 years of age and was stronger in those who reported cysts at age 48 or older., Conclusions: Cysts appeared to be a risk factor for EC in lean women but not in overweight/obese ones; these results are consistent with an effect of cysts and obesity on EC along common pathways., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Competing Interests: Conflict of Interest None declared.

Small bowel obstruction is a common surgical emergency and frequent cause of hospitalization. Internal hernias account for less than 6% of all small bowel obstruction cases. Less frequently, hernias through the broad ligament of the uterus can occur and account for only 4-7% of total internal hernia cases. We report a case of a small bowel hernia through broad ligament of the uterus in a young female. Multiple diagnostic modalities suggested a ruptured ovarian cyst as the most probable cause for her abdominal pain. However, her symptoms were much more severe than an ovarian cyst would normally produce. Therefore, a diagnostic laparotomy was performed, which found a small intestine hernia through the left broad ligament of the uterus. The diagnosis of intestinal hernias, specifically through the broad ligament, is often delayed due to the infrequent occurrence, varied presentation, and difficulty of confirmation on computed tomography (CT) scan. Surgery is the gold standard for the diagnosis and treatment of internal hernias. This article draws attention toward a rare and potentially life-threatening cause of abdominal pain.

The aim of the study was to determine the risk factors for surgery in patients with hemoperitoneum caused by corpus luteum cyst rupture. A retrospective review of medical records of 155 patients diagnosed with hemoperitoneum caused by corpus luteum cyst rupture was conducted between January 2010 and March 2015. The patients were divided into two groups: surgical and conservative management. The differences in characteristics between the two groups were compared. The indicators that determine the need of a surgery at the initial visit were also compared between the two groups. Initial hemoglobin level was lower (11.3 ± 1.4 g/dL vs. 12.2 ± 1.2 g/dL; p = 0.007) in the surgery group. There were significant differences in posterior cul-de-sac (PCDS) fluid collection depth (6.2 ± 2.5 cm vs. 4.5 ± 1.6 cm, p = 0.000), total fluid collection depth (8.4 ± 1.8 cm vs. 6.5 ± 2.1 cm, p = 0.000), single deepest pocket depth (6.7 ± 2.2 cm vs. 5.1 ± 1.5 cm, p = 0.006), liver-dome fluid (78.9% vs. 35.6%; p = 0.002), and estimated intrapelvic bleeding amount (325 ± 250 cc vs. 206 ± 146.5 cc, p = 0.002). The extravasation over grade 2 was more often in surgery group (68.4% vs. 30.1%; p = 0.001). PCDS fluid collection depth, the presence of liver-dome fluid, and the severity of contrast extravasation through ultrasonography and computed tomography are good indicators for determining the management of hemoperitoneum resulting from corpus luteum cyst rupture in healthy women., (© 2021. The Author(s).)

Research Question: What are ovarian stimulation cycle outcomes and acceptance rates of an oocyte accumulation programme in young women with benign ovarian tumour (BOT)?, Design: Retrospective cohort study conducted at the Academic Assisted Reproductive Technology and Fertility Preservation Centre, Lille University Hospital, between January 2016 and December 2019. The number of metaphase II oocytes per cycle and per patient after accumulation were evaluated. Two groups were identified for the analysis: endometrioma ('endometrioma') and dermoid, mucinous or serous cyst ('other cysts')., Results: A total of 113 fertility-preservation cycles were analysed in 70 women aged 27.9 ± 4.8 years. Almost all women had undergone previous ovarian surgery before fertility preservation (89%). Mean anti-Müllerian hormone levels before ovarian stimulation was 12.5 ± 8.7 pmol/l. A total of 6.4 ± 3.4 oocytes were retrieved, and 4.3 ± 3.4 metaphase II (MII) oocytes were vitrified per cycle. All agreed to the oocyte accumulation programme and all underwent at least one cycle. To date, 36 (51%) patients achieved two or three fertility- preservation cycles. After accumulation, 7.0 ± 5.23 MII oocytes were vitrified per patient. No difference was found in ovarian response and oocyte cohort between the 'endometrioma' and 'other cysts' groups. Questionnaires completed after oocyte retrieval revealed abdominal bloating and pelvic pain in most patients, with no difference according to the type of cyst. No serious adverse events occurred., Conclusions: Oocyte accumulation should be systematically offered to young women with BOT irrespective of histological type, as it seems to be well-tolerated. Long-term follow-up is needed to assess the efficiency of oocyte accumulation to optimize the chances of subsequent pregnancies., (Copyright © 2021 Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved.)

Background: Management of ovarian torsion has evolved toward ovarian preservation regardless of ovarian appearance during surgery. However, patients with torsion and an ovarian neoplasm undergo a disproportionately high rate of oophorectomy. Our objectives were to identify factors associated with ovarian torsion among females with an ovarian mass and to determine if torsion is associated with malignancy., Methods: A retrospective review of females aged 2-21 y who underwent an operation for an ovarian cyst or neoplasm between 2010 and 2016 at 10 children's hospitals was performed. Multivariate logistic regression was used to assess factors associated with torsion. Imaging data were assessed for sensitivity, specificity, and predictive value in identifying ovarian torsion., Results: Of 814 girls with an ovarian neoplasm, 180 (22%) had torsion. In risk-adjusted analyses, patients with a younger age, mass size >5 cm, abdominal pain, and vomiting had an increased likelihood of torsion (P < 0.01 for all). Patients with a mass >5 cm had two times the odds of torsion (odds ratio: 2.1; confidence interval: 1.2, 3.6). Imaging was not reliable at identifying torsion (sensitivity 34%, positive predictive value 49%) or excluding torsion (specificity 72%, negative predictive value 87%). The rates of malignancy were lower in those with an ovarian mass and torsion than those without torsion (10% versus 17%, P = 0.01). Among the 180 girls with torsion and a mass, 48% underwent oophorectomy of which 14% (n = 12) had a malignancy., Conclusions: In females with an ovarian neoplasm, torsion is not associated with an increased risk of malignancy and ovarian preservation should be considered., (Copyright © 2021 Elsevier Inc. All rights reserved.)

We present a case of a giant ovarian cyst in a 20-year-old woman who presented atypically at our Emergency Department with left-sided back pain followed by acute left leg swelling. Blood tests showed significantly raised C-Reactive Protein and D-Dimer. CT-Abdomen-Pelvis demonstrated a large mass in the region of the right ovary with suspicious heterogeneous filling defects in the left external iliac vein, confirmed as a left-sided deep-vein thrombosis on ultrasound Doppler. MRI revealed the lesion to be cystic and the deep venous thrombosis was treated with twice-daily Clexane. Prior to removal of the cyst, an Inferior Vena Cava Filter was placed to reduce thromboembolic risk. The cyst was resected without complication and the postoperative period was uneventful. This case occurred while face-to-face services were limited by COVID-19 and illustrates the need for robust systemic measures to safeguard patients against the emergency sequelae of insidious gynaecological pathology., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Most adnexal masses are benign, incidental findings of pregnancy which resolve spontaneously. They may present clinically due to haemorrhage, rupture, torsion and mass effect. Aetiological classification includes ovarian benign, ovarian malignant, non-ovarian, gynaecological, non-ovarian non-gynaecological and an additional subset of pathologies unique to pregnancy. Ultrasound is the first-line imaging modality for the evaluation of adnexal masses. This may be supplemented with magnetic resonance imaging. Tumour markers support evaluation of malignant potential, but interpretation of results in pregnancy is challenging. Surgical intervention requires consideration of gestation, lesion characteristics and presence of complications. Laparoscopy is preferred owing to shorter operative time, quicker recovery and resultant lower thrombotic risk. Post-viability, fetal wellbeing and assessment must be considered. Management of the pregnancy may include cardiotocography, steroids, non-teratogenic antibiotics and tocolytics. In rare cases, particularly related to malignancy, termination of pregnancy may be required to enable immediate management where there are concerns for maternal wellbeing.

Background: Adnexal torsion in pregnancy is often associated with functional adnexal cysts, especially in pregnancies conceived by ovulation induction (OI) or in-vitro fertilization (IVF). During laparoscopy for adnexal de-torsion, drainage of the functional cysts can be attempted, although this procedure may cause bleeding., Objectives: To investigate the characteristics of ovarian torsion in pregnancy associated with functional cysts and to compare the rate of torsion recurrence following de-torsion alone versus cyst drainage., Methods: All cases of surgically diagnosed adnexal torsion occurring during pregnancy between January 2007 and April 2019 in our department were retrospectively analyzed. The cases of torsion associated with presumed functional ovarian cysts were selected. The rate of recurrent torsion during the same pregnancy was compared for de-torsion alone versus de-torsion and cyst aspiration., Results: Of the 113 women who experienced adnexal torsion during pregnancy, 71 (67.0%) of torsion cases were caused by presumed functional ovarian cysts. Among women with torsion of functional ovarian cysts, the rate of torsion recurrence was significantly higher in patients who underwent de-torsion alone (n=28) compared to women who underwent aspiration and drainage of the ovarian cysts (n=43) (14.3% vs. 0, P = 0.021). There were no cases of intra- or post-operative bleeding in the study cohort., Conclusions: Functional ovarian cysts are the most common adnexal pathology encountered in pregnant women with torsion. Intra-operative cyst aspiration and drainage may reduce the risk of recurrent torsion. Further multi-center studies are required to validate our data prospectively.

Background: Carnett's sign (CAR) and Closed Eye sign (CE) have been suggested for use in the emergency department setting in the management of abdominal pain. The present study sought to determine the sensitivity/specificity of CAR and CE for pathological CT findings as a primary outcome and for subsequent hospital admission or surgical intervention as secondary outcomes in a community emergency department setting., Methods: A convenience sample of adults (≥18 y) presenting with acute (<48 h) nontraumatic and non-postoperative abdominal pain determined by treating provider to warrant CT imaging were eligible for enrollment. Treating providers completed a datasheet describing physical examination findings prior to CT imaging., Results: 320 patients were enrolled. 245/320 (76.5%) of enrolled patients had findings on CT Imaging. CAR+ was recorded in 145 and CAR- in 175 patients. CE+ was in 187 and CAR- in 133 patients. Sensitivity and specificity of CAR- for hospital admission was 42.2% and 38.9% and for surgery-44.8% and 43.1%. Sensitivity and specificity of CE- for hospital admission was 28% and 51.6% and for surgery-25.9% and 55%. CAR+ patients were more likely to be admitted or undergo surgery as compared to CAR-. CE+ patients were more likely to be admitted or undergo surgery as compared to CAR-. There were no differences in frequency of pathological CT findings between CAR+ and CAR- or CE+ and CE- patients., Conclusion: CAR and CE are neither sufficiently sensitive nor specific for use in the emergency department setting. CT findings were equally likely in CAR+ and CAR- patients. CT Findings were also equally likely in CE+ and CE- patients., Competing Interests: Declaration of competing interest None., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Study Design: Cross-sectional comparative study., Objectives: Evaluate prevalence and clinical relevance of an underlying pathology in painful adolescent idiopathic scoliosis (AIS) patients after a non-diagnostic history, physical examination and spinal X-ray using Magnetic Resonance Image (MRI) as diagnostic tool. Discrepancies regarding indications of routine MRI screening in painful AIS patients are multifactorial. Few studies have investigated relationship and practical importance of painful AIS with an underlying pathology by MRI., Method: A total of 152-consecutive AIS patients complaining of back pain during a 36-month period were enrolled. All patients underwent whole-spine MRI after a non-diagnostic history, physical examination and spinal X-ray. Underlying pathologies were reported as neural and non-neural axis abnormalities based on MRI reports. Variables such as sex, age, constant or intermittent pain, night pain, back pain location (thoracic or lumbar pain), Cobb-angle and follow-up were evaluated as clinical markers to predict presence of underlying MRI pathologies., Results: The presence of an underlying pathology was found by MRI in 54 painful AIS patients (35.5%). Isolated syringomyelia was the only neural axis abnormality found in 6 patients (3.9%). Non-neural axis abnormalities (31.6%) were composed by: 32 herniated nucleus pulposus, 5 vertebral disc desiccation, 4 ovarian cysts, 3 renal cysts, 2 sacral cysts, and 2 vertebral hemangiomas. There was no association with gender, age of presentation, initial coronal Cobb angle and follow up; with presence of an underlying pathology. Lumbar pain location was identified as an adequate clinical marker that correlated with presence of an underlying pathology (p = 0.01)., Conclusions: Prevalence of underlying pathologies diagnosed by MRI in painful AIS was found high (35.5%), but it's clinical relevance and implication are debatable. The use of MRI did not affect orthopedic management of painful AIS patients who showed an underlying pathology. A thorough evaluation must be performed by clinicians; and discussed with patients and family prior to undergo further imaging management., Level of Evidence: Level III.

The aim of this study was to investigate the effects of endometrioma (OMAs) size and bilaterality on ovarian reserve. The patients with OMA were determined by ultrasonographic examination. Fifty patients with unilateral OMA (Group A), 30 patients with bilateral OMA (Group B), and 60 women without ovarian cysts (Group C) were included in this study. AMH levels were measured, and antral follicle count (AFC) was determined. The mean serum AMH levels were significantly lower in Group B than Groups C and A, and were significantly lower in Group A than Group C. There was a significant correlation between serum AMH level and OMA size in Group A ( R  = -.372, p  = .008). OMAs per se appear to be associated with damage to the ovarian reserve. Increased OMA size is related to decreased AMH levels in patients with OMA. Bilateral OMAs have a more destructive effect on ovarian reserve.IMPACT STATEMENT What is already known on this subject? Previous Studies have demonstrated the effect of surgery on ovarian reserve but there have been contradictory findings reported about the effects of OMAs per se on serum AMH levels and it has not been clear what the relation between OMAs size and AMH levels is, if any. What the results of this study add? In this study, we found decreased AMH levels in patients with OMA. The results showed significant negative correlation between OMA size and AMH levels. The patients with bilateral OMAs had lower AMH levels than the unilateral ones. What the implications are of these findings for clinical practice and/or further research? Increasing OMA size might be harmful to ovarian reserve. Further studies should be done to evaluate whether increasing the size of the OMA is associated with a progressive decline in ovarian reserve and to better clarify the role of the OMAs per se or of laparoscopic surgery in the determination of damage to the ovarian reserve.

Context: We previously reported the first female with a causative ESR1 gene variant, who exhibited absent puberty and high estrogens. At age 15 years, she presented with lower abdominal pain, absent breast development, primary amenorrhea, and multicystic ovaries. The natural history of complete estrogen insensitivity (CEI) in women is unknown., Objective: The purpose of this report is to present the neuroendocrine phenotype of CEI, identify potential ligands, and determine the effect of targeted treatment., Design: We have characterized gonadotropin pulsatility and followed this patient's endocrine profile and bone density over 8 years. Seventy-five different compounds were tested for transactivation of the variant receptor. A personalized medicine approach was tailored to our patient., Setting: Academic medical center., Patient or Other Participants: A 24-year-old adopted white female with CEI., Intervention(s): The patient was treated with diethylstilbestrol (DES) for approximately 2.5 years., Main Outcome Measure(s): Induction of secondary sexual characteristics., Results: Luteinizing hormone (LH) pulse studies demonstrated normal pulsatile LH secretion, elevated mean LH, and mildly elevated mean follicle-stimulating hormone (FSH) in the presence of markedly increased estrogens. DES transactivated the variant ESR1 in vitro. However, DES treatment did not induce secondary sexual characteristics in our patient., Conclusions: Treatment with DES was not successful in our patient. She remains hypoestrogenic despite the presence of ovarian cysts with a hypoestrogenic vaginal smear, absent breast development, and low bone mineral mass. Findings suggest additional receptor mechanistic actions are required to elicit clinical hormone responses., (© Endocrine Society 2020. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Endometriosis is a chronic benign gynecological disease with symptoms that can severely impact quality of life and well-being. Women affected by endometriotic ovarian cyst could have associated infertility problems. Infertility affects 30% to 50% of women with endometriosis. Women with endometriosis are at risk of decreased ovarian reserve, due to the disease pathophysiologic mechanisms. Generally, infertility management include surgical procedure (usually with minimally invasive approach) and ovulation induction with intrauterine insemination or in vitro fertilization. Fertility preservation technologies also include oocyte or embryo freezing and ovarian tissue cryopreservation. Approach to patients with endometriotic cysts still remains controversial, and a multidisciplinary approach is a key factor to achieve the best outcome with appropriate patient counselling. Such management by a multidisciplinary team is a key factor in achieving the successful outcome.

Background: Endometriosis is a risk factor for ovarian cancer. Endometriosis-associated ovarian cancer (EAOC), most commonly clear cell carcinoma, is believed to develop from ovarian endometrial cysts. In this study, we reviewed published cases of EAOC considered to have developed from endometrial cysts, and focused on the observation period., Methods: We searched for articles published since January 2000 that reported cases of ovarian cancer thought to have originated from endometrial cysts using PubMed, Web of Science, and Ichushi-Web. The period from the start of follow-up of the endometrial cyst to the diagnosis of ovarian cancer was calculated., Results: Seventy-nine cases were identified from 32 articles. The median period from the diagnosis of endometrial cysts to the diagnosis of ovarian cancer was only 36 months. Approximately 75% of cases developed into cancer within 60 months and most cases developed within 120 months., Conclusion: Our results suggest that clinically detectable cysts subsequently diagnosed as ovarian cancer might already have contained cancer cells. Therefore, the mechanism of EAOC development needs to be re-examined and appropriate management guidelines need to be developed.

The case of a 36-yr-old woman with a pituitary adenoma who was found to have bilateral ovarian masses is reported. The right ovary was removed, measured 15 cm in maximum dimension, and contained multiple cysts which on microscopic examination had the typical morphology of follicle cysts. The left ovary was grossly similar intraoperatively. Subsequent excision of the pituitary adenoma was followed ∼3 mo later by a return to normal size of the left ovary. The case represents an example of multiple luteinized follicle cysts, analogous to the phenomenon seen occasionally in pregnancy, but with a different clinical background. Periodic documentation of this phenomenon is present in the literature, predominantly the clinical literature with limited pathologic documentation of the nature of the process in many reports. As pertains to the evaluation of follicle cysts encountered during pregnancy the differential diagnosis is with a cystic granulosa cell tumor of either adult or juvenile types, more likely the latter. The cyst lining is identical to that of standard follicle cysts and contrasts with the immature mitotically active nuclei seen in a juvenile granulosa cell tumor. That neoplasm also usually shows follicular differentiation typically absent in follicle cysts. Pathologists should be aware of the rare occurrence of luteinized follicle cysts in patients with a pituitary adenoma to enable correct intraoperative and standard pathologic evaluation.

We outline the narrative of a 28-year-old woman who initially presented to the emergency department with vomiting, diarrhoea, abdominal pain and fever. Blood tests revealed significantly raised inflammatory markers and acute renal failure. Initially, this was attributed to gastroenteritis due to a recent foreign travel, but further investigations and radiological imaging revealed a large right ovarian dermoid cyst with a significant amount of free intra-abdominal fluid and small bowel dilation. She underwent laparotomy, which revealed a spontaneously perforated right ovarian dermoid cyst resulting in generalised purulent peritonitis and small bowel obstruction due to bowel adherence at the perforation site. Meticulous adhesiolysis, right salpingo-oophorectomy and extensive peritoneal lavage were performed, with a good postoperative recovery. Spontaneous perforation of an ovarian dermoid cyst, without an associated torsion, is extremely rare, but it should be considered in cases of peritonitis and bowel obstruction of unclear cause with a concomitant finding of a dermoid cyst., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To introduce an effective approach for excision of ovarian endometrioma by "water injection"-assisted laparoscopy treatment., Design: Step-by-step video explanation of the surgical procedure with still pictures and surgical video clips to demonstrate the detailed technique, approved by the Shengjing Hospital of China Medical University., Setting: Hospital., Patients: A 26-year-old young woman diagnosed with a 6 cm in diameter right ovarian cyst, who endured 5 years of dysmenorrhea., Interventions: The "water injection"-assisted laparoscopic excision of ovarian endometrioma consists of five steps: rupture the ovarian endometrial cyst and remove the "chocolate fluid;" inject the "water" (diluted vasopressin solution) into the interface between endometrioma and ovarian parenchyma; stop injecting until the solution overflow; separate the endometrioma away from the ovarian parenchyma; and suture the ovary., Main Outcome Measures: Value and feasibility of "water injection"-assisted laparoscopic excision of ovarian endometrioma., Results: The "water injection"-assisted laparoscopic excision of ovarian endometrioma was feasible and effective. In the follow-up period, the patient did not report any symptom of dysmenorrhea; and the sex hormone and antimüllerian hormone tests reached to normal levels., Conclusion: Our surgical approach demonstrated several noteworthy advantages. After "water injection", the endometrioma and ovarian parenchyma was easily distinguished and separated. The approach avoided normal ovarian tissue destruction during endometrioma separation. The utilization of diluted vasopressin solution might decrease bleeding of ovarian wound. Considering its simplicity of realization, our surgical approach should be promoted to more reproductive-age patients., (Copyright © 2019 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Acute hemoperitoneum (AHP) in early gestation is commonly treated via laparotomy. A ruptured corpus luteum (CL) cyst is a rare cause of AHP in pregnancy. This case report describes a 33-year-old, hemodynamically stable G2/P1 who presented at 5+5 gestational weeks with an acute abdomen due to ruptured CL cyst (7 cm). Emergent laparoscopy was performed. After evacuation of 1 L of hemoperitoneum, an atraumatic hemostasis was obtained without diathermy by use of hemostatic matrix (Floseal ® ). The ovary was reformed with an absorbable suture under preservation of CL. The postoperative recovery was uncomplicated. The hemoglobin drop was 2.8 g/dl. Further pregnancy course was uneventful. A healthy baby (2860 g) was delivered vaginally at 38+3 weeks of gestation. CONCLUSION: Laparoscopic approach to AHP in early pregnancy is suitable. CL preservation is feasible by use of atraumatic hemostatics., Competing Interests: The authors declare that they have no conflict of interest., (© Georg Thieme Verlag KG Stuttgart · New York.)