Adnexal torsion in a postmenopausal woman on tamoxifen

Abstract

The authors describe the case of a postmenopausal woman who presented with sudden-onset abdominal pain and vomiting, found to be caused by a torted haemorrhagic ovarian cyst. The case highlights the occurrence of ovarian cyst formation and endometrial stimulation in patients treated with tamoxifen.A 56-year-old woman presented to the accident and emergency department with sudden onset of left iliac fossa pain and vomiting. The pain was constant and non-radiating. She had associated vomiting of recently eaten food, but no fever and no history of diarrhoea. She had had a left mastectomy and radiotherapy fi ve years previously for intraductal adenocarcinoma of the breast.The breast cancer was weakly oestrogen-receptor positive and progesterone-receptor negative. She had been on tamoxifen for more than four years. This had been changed to an aromatase inhibitor (letrozole) two weeks before presentation.She had no history of postmenopausal bleeding. Examination revealed a normal pulse rate, blood pressure and temperature. Her abdomen moved with respiration and was soft but tender in the left iliac fossa with no palpable mass. A pelvic ultrasound scan revealed a small axial uterus. The size of the right ovary was 16 × 8 × 12mm; the right adnexa had a thickwalled cyst of 90 × 60 × 67mm. It had homogeneous low-level echoes (Figure 1) and appeared to have a thick septum across the superior pole. The left ovary was not identifi ed. Free fl uid was noted posterior to the cyst.Her temperature remained normal. Full blood count, electrolytes and urea were normal. Cancer antigen (CA-125), carcino-embryonic antigen (CEA) and liver function tests were also requested. She was admitted for pain relief and had improved by the next day, when she was allowed home to await the results of the serum cancer markers and to have a computerised tomography (CT) scan arranged. She was due to be followed up in the gynaecology outpatient clinic two weeks later.

Ovarian Torsion in a Postmenopausal Woman: A Case Report and Review of Literature

“…Cohen et al [ 3 ] in their study reported that diagnosis to surgery timing was significantly longer (24 hours vs. 6 hours) in postmenopausal women when compared with premenopausal women. Various other studies have also reported a delay of 6 hours–6 months from initial presentation to definite management in this age group [ 3 5 6 7 8 9 11 13 ]. Ultrasound with doppler studies of ovarian vessels is usually first investigation ordered to support the diagnosis.…”

“…In the study by Cohen et al [ 3 ] continuous dull aching pain was the most common symptom present in postmenopausal women whereas premenopausal women mostly presented with acute abdominal pain. Left iliac fossa pain, right inguinal pain with phlank pain, persistent backpain radiating to right groin are also mentioned as presenting complaints in this age group in some of the previous studies [ 6 7 8 ]. Ovarian torsion compromises the blood supply to the ovaries leading to ovarian necrosis and hence can affect fertility in young women of childbearing age, needing aggressive management in terms of laparoscopy or laparotomy with de-torsion of the affected ovary.…”

“…Eitan et al [ 5 ] in their study reviewed charts of 27 postmenopausal women with adnexal torsion and found that malignancy was found in around 22% of cases. Nausea, vomiting, acute abdominal pain and peritonitis are the usual presentation with which women with ovarian torsion generally present [ 1 3 4 5 6 7 8 9 10 11 12 13 14 15 ]. However in postmenopausal women typical symptoms of ovarian torsion may not be always present.…”

“…Laparoscopy or emergency laparotomy with ovarian de-torsion with or without oophorectomy is usually the management of choice though more conservative approach is also acceptable in benign lesions. Since the risk of malignant adnexal masses are more common in this age total abdominal hysterectomy with bilateral salpingo-ophrectomy is also widely practiced [ 3 4 5 6 7 8 9 10 11 12 13 14 15 ].…”