What Is Ovarian Remnant Syndrome?
When ovarian tissue is left behind after a bilateral salpingo-oophorectomy (BSO), whether or not a hysterectomy was performed, the disease is known as ovarian remnant syndrome (ORS). Pelvic pain, or pelvic mass, is the subsequent effect of this leftover ovarian tissue. Rarely, if one or both ovaries are removed for endometriosis (tissue that normally lines the uterus grows outside the uterus), there may be microscopic endometriosis tissue inadvertently left behind. This tissue might regenerate and resume hormone production, regaining function. This can still happen years after the first procedure.
A history of endometriosis, pelvic adhesive disease, many prior operations, and pelvic inflammatory illness are risk factors linked to partial ovary removal and the subsequent development of ORS. Pelvic pain is the most typical symptom of ovarian remnant syndrome. A pelvic mass or no sign of menopausal symptoms following surgery are less common signs.
After having both ovaries removed surgically, the patient might still be releasing hormones, and there could have been residual ovarian tissue if symptoms of menopause were not felt. In addition to endometriosis-like symptoms, some individuals with ovarian remnant syndrome may experience painful sex and bowel or urine problems. The percentage of individuals with ovarian remnant syndrome who do not exhibit any symptoms is unknown, but it is conceivable.
What Causes Ovarian Remnant Syndrome?
When ovarian tissue is not completely removed during ovarian excision surgery, ovarian residual syndrome results. Patients with endometriosis, inflammatory disease of the pelvis, pelvic adhesive disease, or those who have had difficult or repeated surgery are more likely to have it. The risk of ovarian remnant syndrome can also be raised by intraoperative hemorrhage, anatomical anomalies (i.e., ovaries situated in unexpected places), inexperienced or subpar surgeons, and inadequate surgical technique. Scar tissue called pelvic adhesions can cause organs to adhere to one another and result in various issues. It is common to find pelvic adhesions on the bladder, uterus, and ovaries. Because there is a higher chance that ovarian tissue will become embedded in adjacent organs, pelvic adhesions increase the likelihood of ovarian residual syndrome by complicating and making the full excision of all ovarian tissue more difficult. Individuals with a history of surgery or endometriosis are more likely to develop pelvic adhesions.
What Are Histological Findings of Ovarian Remnant Syndrome?
Histologically, in a small number of patients, ovarian residual tissue was associated with a corpus luteum and endometriosis. The diagnosis of an encapsulated borderline mucinous tumor was made after a frozen section. An examination using a frozen piece showed a benign serous cyst free of any signs of cancer.
How Is Ovarian Remnant Syndrome Diagnosed?
A complete history, clinical symptoms, vaginal cytology, abdominal ultrasonography, hormonal study, and exploratory laparotomy are among the variables that go into making a diagnosis.
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Physical Examination: The patient will exhibit serosanguinous vaginal discharge and vulvar swelling upon physical examination. If not, they will be healthy and vibrant. However, in a patient with ORS, these indications will not be present during anoestrus; therefore, the lack of clinical indicators does not rule it out.
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Abdominal Ultrasound: Abdominal ultrasonography can help determine the presence of residual ovarian tissue. However, this option might not be available in circumstances with restricted resources. The size of the remaining tissue, the stage of the oestrus cycle (a set of recurring physiological changes induced by reproductive hormones in females), and the examiner's experience all affect how effective the treatment is. For example, false identification of remaining ovarian tissue may result from the existence of a suture granuloma at the ligation site.
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Vaginal Cytology: Vaginal exfoliative cytology can be used, much like with a physical examination, to help diagnose ORS. Variations in estrogen blood levels influence the vagina's epithelial layer, which gets ready for mating. The transition of cells from parabasal (small cells with large nuclei) and intermediate (larger cells with a "fried egg" look) to keratinized, epithelial cells, also known as superficial cells, occurs when blood estrogen levels are rising, such as during proestrus and oestrus.
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Sex Hormone Serology: Another diagnostic technique is to show that important hormones are present in the blood. Several hormones can be tested. However, their applicability is restricted.
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Progesterone: The corpus luteum produces progesterone after ovulation. For serum P4 to confirm the presence of ovarian tissue, the female must be either pregnant or in dioestrus (phase of the cycle dominated by P4 secretion).
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AMH, or Anti-Müllerian Hormone: AMH should not be present in the bloodstream after total ovarian excision. Nonetheless, AMH expression is not present in the corpus luteum but only in the ovarian follicle's granulosa cells. As a result, an ovarian remnant mostly made up of luteal tissue may not produce enough AMH to be seen in the bloodstream. As a result, a negative outcome needs to be handled carefully.
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Responsive Serology Testing: Gonadotropin hormone-releasing hormone (GnRH) injections can be used for responsive serology testing. Serum samples can then be used to measure the levels of P4 or luteinizing hormone (LH). This is usually an expensive choice.
How to Prevent and Treat Ovarian Remnant Syndrome?
Surgical methods, including excision of all pelvic adhesions, are required to minimize and avoid this problem when performing oophorectomy. To remove ovaries, the retroperitoneal technique creates a safety buffer around the ovary to achieve total removal. While this reduces the likelihood of ovarian remnant syndrome, it does not rule it out entirely. Remaining ovarian tissue removal surgery is a complicated procedure with a high risk of surgical complications. It is best left to a surgeon with extensive laparoscopic surgical competence. Treatment can also be carried out concurrently with a biopsy, in which case the surgeon extracts any remaining ovarian tissue in the same operation. Through a laparoscopic procedure, this is finished. Those with a high risk of ovarian cancer, a pelvic mass, or developing symptoms are the main candidates for treatment. The likelihood of ovarian cancer developing from the residual ovarian tissue is quite low. Hormonal therapy to reduce ovarian function may be used as a treatment if surgery is not an option.
Conclusion:
After a woman has had an oophorectomy (surgical removal of the ovary) in the past, they develop ovarian residual syndrome (ORS). Ovarian remnant syndrome is an uncommon disorder with an unpredictable incidence that may develop following a prior bilateral salpingo-oophorectomy. A minimally invasive method may be safe and successful if the same surgical principles are followed. Ovarian residual tissue carries a low risk of cancer; hence, surgical removal is the recommended course of action. The development of robotic laparoscopy technology may make it easier for patients with ovarian remnant syndrome to undergo the exact and comprehensive dissection that is necessary.
