M E D iC A L
JOURNAL
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G Y N E C O L O G 'l
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O ID G Ib I~ L '
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S a lim W e h b a , C e s a r E d u a r d o F e r n a n d e s , J o s e A r n a ld o S o u z a F e r r e ir a , L u c ia H e le n a A z e v e d o , R o g e r io B o n a s s i M a c h a d o , J a c q u e lin e L e m e L u n a r d e lli, S o n ia R o lim R o s a L im a , V a ld e m a r I w a m o t o
T ra n sv a g in a l u ltra so n o g ra p h y a sse ssm e n t o f o v a ria n
v o lu m e s
in
p o stm e n o p a u sa l w o m e n
Clinic of Endocrine
Gynecology and Climacterium
at the College of
Me.dical Sciences of the Santa Casa of Siio Paulo - Siio Paulo, Brazil
T h e a u th o rs e v a lu a te d o v a ria n v o lu m e s b y tra n s v a g in a l u ltra s o n o g ra p h y a t d iffe re n t p e rio d s a fte r m e n o p a u s e . N in e ty e ig h t p o s tm e n o -p a u s a l w o m e n w ith a n a v e ra g e a g e o f 5 1 .9 y e a rs a n d a o n e - to e ig h t-y e a r -p o s tm e n o -p a u s a l p e rio d w e re s tu d ie d . T h e c o n tro l g ro u p c o n s is te d o f 4 0 w o m e n d u rin g m e n a c m e w ith a n a v e ra g e a g e o f 3 1 .8 y e a rs , w h o w e re a ls o s u b m itte d to tra n s v a g in a l u ltra s o n o g ra p h y to e v a lu a te o v a ria n v o lu m e . T h e re w a s n o s ig n ific a n t d iffe re n c e b e tw e e n rig h t a n d le ft o v a ria n v o lu m e s in th e s tu d y g ro u p s . T h e re w a s a s ig n ific a n t d e c re a s e in m e a s u re a n d s ta n d a rd d e v ia tio n s o f th e v o lu m e s a fte r th e firs t y e a r o f m e n o p a u s e (m e a n v o lu m e - 2 .2 :t0 .9 c m3) w h e n c o m p a re d to th e c o n tro l g ro u p (m e a n v o lu m e - 6 .3 :t2 .0 c m3) , fo llo w e d b y a s lo w a n d g ra d u a l s h rin k in g a fte r th is p h a s e . D e c re a s e in o v a ria n v o lu m e b e c a m e s ig n ific a n t a fte r th e fo u rth p o s tm e n o p a u s a l y e a r. T ra n s v a g in a l u ltra s o n o g ra p h y d e m o n s tra te d g re a t im p o rta n c e a s a n in v e s tig a tiv e m e th o d o f o v a ria n d is e a s e s in p o s tm e n o p a u s a l w o m e n .
U N IT E R M S : O v a ry . U ltra s o n o g ra p h y . M e n o p a u s e .
IN T R O D U C T IO N
O
v a r ia nto ~ if f ic u ltc a n c e rd e te c tio n .is a n im p o r ta n ta n d d ia g n o s isc a u s e o f d e a tho f its i~ itia ld u e. le s I O n s . T h e p r o g n o s I s f o r w o m e n w h o a r e 1 0 a n
a d v a n c e d s ta g e o f th e d is e a s e r e m a in s p o o r , w ith a s u r v iv a l
r a te o f 1 5 p e r c e n t a f te r a p e r io d o f 5 y e a r s ; w h ile w o m e n
in s ta g e I o f th e d is e a s e h a v e a m u c h b e tte r p r o g n o s is ,
w ith a s u r v iv a l r a te o f 9 5 p e r c e n t in 5 y e a r s .'
T h e d if f ic u lty in in itia lly d ia g n o s is in g o v a r ia n c a n c e r
h a s b e e n a ttr ib u te d to its p o o r c lin ic a l p r e s e n ta tio n in s ta g e s
I a n d I I , a n d to th e a lm o s t im p o s s ib le d e te c tio n o f o v a r ia n
e n la r g e m e n ts in p o s tm e n o p a u s a l w o m e n b y b im a n u a l
p e lv ic e x a m in a tio n . T h e r e f o r e , it is im p e r a tiv e to d e v e lo p
a d e q u a te d e te c tio n m e th o d s , w h ic h w o u ld u n a r g u a b ly h a v e
a g r e a t im p a c t o n s u r v i v a l r a te s , e s p e c ia lly in
A d d r e s s f o r c o r r e s p o n d e n c e : S a lim W e h b a
R u a C a n a r io , 1 1 3 5 -I n d ia n 6 p o lis S a o P a u lo / S P - B r a s il - C E P 0 4 5 2 1 - 0 0 5
p o s tm e n o p a u s a l w o m e n , in w h o m th e in c id e n c e o f o v a r ia n
c a n c e r is h ig h e r .2
U ltr a s o n o g r a p h y h a s b e e n u s e d in p o s tm e n o p a u s a l
w o m e n f o r d e te c tio n o f o v a r ia n e n la r g e m e n ts a n d .
n e o p la s ic le s io n s .3 T r a n s v a g in a l a s s e s s m e n t, a r e c e n tly
d e v e lo p e d u ltr a s o n o g r a p h y te c h n iq u e , a llo w s f o r b e tte r
v is u a liz a tio n o f th e o v a r y th a n c o n v e n tio n a l a b d o m in a l
u ltr a s o n o g r a p h y , a n d s e e m s m o r e e f f ic ie n t in d e te c tin g
o v a r ia n tu m o r s .
I t is a k n o w f a c t th a t o v a r i a n s i z e d e c r e a s e s
p r o g r e s s iv e ly th r o u g h o u t m e n o p a u s e . T h is s h r in k in g is
m o s t e v id e n t in th e o v a r ic a n c o r tic a l, a s a c o n s e q u e n c e o f
th e a c e n tu a te d d e c r e a s e in th e g r o w th a n d m a tu r a tio n o f
f o llic le s .4 O b lite r a te a r te r io la r s c le r o s is a n d c o r tic a l f ib r o s is
a ls o c o n tr ib u te to th e d e c r e a s e in o v a r ia n s iz e .s A s a
c o n s e q u e n c e , o v a r ia n w e ig h t d e c r e a s e s 3 0 p e r c e n t,
a c c o r d in g to B lo c k . 6 'I w a m o to e t a l. a s s e s s e d o v a r i a n
v o lu m e b y a b d o m in a l u ltr a s o n o g r a p h y a n d o b s e r v e d a
r e g r e s s iv e c u r v e th a t a p p e a r s a f te r m e n o p a u s e .?
S in c e tr a n s v a g in a l u ltr a s o n o g r a p h y is m o r e a c c u r a te
in e v a lu a tin g th e o v a r ia n v o lu m e , in th is s tu d y w e e v a lu a te d
th e o v a r ia n v o lu m e o f w o m e n a t d if f e r e n t p e r io d s a f te r
1 1 5 3
m e n o p a u se , in o rd e r to e sta b lish n o rm a l p a ra m e te rs o f o v a ria n v o lu m e in th e p o stm e n o p a u sa l p e rio d .
th e first y e a r, th e d iffe re n c e in o v a ria n v o lu m e o n c e a g a in b e c a m e sig n ific a n t a fte r th e fo u rth y e a r, a s d e m o n stra te d b y th e v a ria n c e a n a ly sis a n d in d ic a te d b y a stra ig h t lin e .
T a b le 2
A v e ra g e a n d s ta n d a rd d e v ia tio n o f o v a ria n v o lu m e s
in th e c o n tro l a n d s tu d y g ro u p s . T a b le 1
A v e ra g e v o lu m e o f rig h t a n d le ft o v a rie s in th e
c o n tro l a n d s tu d y g ro u p s .
O v a rie s (c m3 )
L e ft
6 .5 :t2 .2
2 .4 :t0 .7 R ig h t
6 .3 :t2 .0
2 .2 :t0 .9
O v a ria n V o lu m e (R O - c m3 )
6 .3 :t2 .0
2 .2 :t0 .9 * N
4 0
98
N4 0
92
2
A V E R A G E V O L U M E R IG H T O V A R Y (C M ')
1 0
* K ru s k a ll-W a llis te s t
p > 0 .0 5 R O : rig h t o v a ry G ro u p
C o n tro l
S tu d y G ro u p
C o n tro l
S tu d y
W e stu d ie d 9 8 w o m e n d u rin g m e n o p a u se w ith a n a v e ra g e a g e o f 5 1 .9 y e a rs, a n d a 1 - to 8 -y e a r p e rio d o f m e n o p a u se .
W o m e n o v e r 4 0 y e a rs o ld , w ith a n a m e n o rrh e a p e rio d o f a t le a st o n e y e a r a n d h ig h F S H le v e ls, w e re c o n sid e re d p o stm e n o p a u sa l. !!.9R a c e a n d n u m b e r o f g e sta tio n s w e re n o t c o n sid e re d . A ll p a tie n ts p re se n te d n o rm a l c lin ic a l a n d la b o ra to ria l c o n d itio n s. P a tie n ts w ith p re v io u s g y n e c o lo g ic a l su rg e rie s, a n d th o se w ith p e lv ic m a sse s (d e te c te d e ith e r c lin ic a lly o r e c o g ra p h ic a lly ) w e re e x c lu d e d . N o p a tie n t w a s u n d e rg o in g h o rm o n a l re p la c e m e n t th e ra p y .
C o n tro l g ro u p s c o n siste d o f tra n sv a g in a l u ltra so n o g ra m s o f 4 0 c lin ic a lly n o rm a l w o m e n d u rin g m e n a c m e (a g e 2 0 -4 0 y e a rs, m e a n : 3 1 .8 y e a rs) tre a te d a s o u tp a tie n ts a t th e D e p a rtm e n t o f O b ste tric s a n d G y n e c o lo g y o f th e C o lle g e o f M e d ic a l S c ie n c e s o f th e S a n ta C a sa o f S a o P a u lo .
U ltra so n o g ra p h y w a s p e rfo rm e d w ith a T o sh ib a S A L -3 8 D a n d a m e c h a n ic a l e n d o v a g in a l se c to r tra n sd u c e r o f 5 .0 M H z . O v a rie s w e re a sse sse d in th re e p la n e s a n d th e ir siz e c a lc u la te d w ith th e sim p lifie d e llip tic fo rm u la : le n g th x h e ig h t x d e p th x 0 .5 2 3 .1 0
T h e o v a rie s a n d v e sse ls w e re id e n tifie d in a ll c a se s a n d d id n o t sh o w a n y te x tu re o r su rfa c e a lte ra tio n s. S ta tistic a l a n a ly sis w a s d o n e b y th e t te st w ith c o u p le d sa m p le s; th e K ru sk a ll- W a llis te st fo r in d e p e n d e n t sa m p le s; a n d a re g re ssio n a n a ly sis o f v a ria n c e .
P A T IE N T S A N D M E T H O D S
o
C O N T R O L 2 3 4 5 6 7 8 o u +
P O S T M E N O P A U S A L P E R IO D (Y E A R S )
R E S U L T S
-- A V E R A G EA V E R A G E ::l: S .D .
T h e a v e ra g e v o lu m e s o f rig h t a n d le ft o v a rie s fo r c o n tro l a n d stu d ie d g ro u p s a re liste d in T a b le I. T h e re w a s n o sig n ific a n t d iffe re n c e b e tw e e n rig h t a n d le ft o v a ria n v o lu m e s. T h e re fo re , w e u se d ra n d o m ly , th e a v e ra g e rig h t o v a ria n v o lu m e o f b o th stu d y g ro u p s fo r a n a ly sis.
A fte r c o m p a rin g th e rig h t o v a ria n v o lu m e o f b o th g ro u p s, a sig n ific a n t d iffe re n c e c o u ld b e n o te d in re la tio n to th e a v e ra g e a n d sta n d a rd d e v ia tio n o f b o th g ro u p s (T a b le 2 ). T h is d iffe re n c e w a s p re se n t in th e first y e a r a fte r m e n o p a u se a n d is sh o w n in C h a rt 1 .
O v a ria n v o lu m e in re la tio n to p o stm e n o p a u sa l p e rio d is sh o w n in C h a rt 2 a n d T a b le 3 . A fte r a sh a rp d e c re a se in
C h a rt 1 - A v e ra g e v o lu m e a n d s ta n d a rd d e v ia tio n o f rig h t o v a ry a t m e n a c m e (c o n tro l) a n d a fte r m e n o p a u s e .
D IS C U S S IO N
U ltra so n o g ra p h ic stu d y o f th e fe m a le p e lv is is a n in v a lu a b le m e th o d o f g e n ita l a sse ssm e n t a fte r m e n o p a u se . A b d o m in a l p e lv ic u ltra so n o g ra p h y w a s first u se d in e a rly d e te c tio n o f o v a ria n c a n c e rll a n d e n d o m e tria l th ic k n e ss.1 2
W E H B A , S .; F E R N A N D E S , C .E .; F E R R E IR A , J .A .S . e t a l. - T ra n s v a g in a l u ltra s o n o g ra p h y a s s e s s m e n t o f o v a ria n v o lu m e s in p o s tm e n o p a u s a l w o m e n
1154
Chart 2 -
V o lu m e o f rig h t o v a ry in re la tio n to p o s tm e n o p a u s a l p e rio d .V O L U M E R O ( C M ')
5
The recently introduced transvaginal ultrasonography has im proved im age resolution through higher frequency transducers and proxim ity to the pelvic organs, w ithout the lim itations of the abdom inal technique. 1 3 H igh frequency
(5-7.5 M H z) endovaginal transducers produce clear im ages that are easier to interpret, and m ay effectiveley com plem ent the routine bim anual pelvic exam .1 4
Establishing the lim its of m easurem ent of ovarian volum e for each period after m enopause is of great im portance. W ith such, increases in ovarian volum es or the appearance of anom alous im ages w ould require other m ethods offering a better investigation.l u 5
In our study, there w as no significant difference betw een right and left ovaries. H ow ever, w e noted a significant decrease in ovarian volum es betw een the studied groups that began in the first year after m enopause. These findings coincide w ith the m orphorologic studys of postm enapausal ovaries.4
•1 6 W e w ould also highlight that,
after the initial decrease in ovarian size, the shrinking slow s dow n until the fourth year, w hen it becom es significant, as dem onstrated by the regressive analysis of ovarian volum e and postm enopausal period.
M alignant tum ors of the ovary have a significantly elevated frequency am ongst postm enopausal w om en over
O v a r ia n V o lu m e
( R O - c m3)
2 .6 :t0 .8 2 .5 :t1 .1 2 .4 :t0 .8 2 .1 :t1 .1 * 1 .7 :t0 .4 * 1 .5 :t0 .9 * 1 .5 :t0 .3 * 1 .8 :t0 .6 * N
P e r io d a fte r m e n o p a u s e
1 1 5
2 2 2
3 1 9
4 11
5 1 0
6
4
7 6
8 a n d u p 1 1 * K r u s k a ll- W a llis te s t p > 0 .0 5 R O : r ig h t o v a r y
Table 3
Average and standard deviation of ovarian volumes
according to period after menopause
50 years 0ld.2Sm all tum ors (diam eter <5.0 cm ) are rarely detected palpably during a bim anual pelvic exam ination. B JO R K H O EM & SILLFV ESW A R report that 31 percent of Stage I ovarian carcinom as presented a diam eter below 5.0 cm , and that survival rates for granulosa tum ors of this size w as 100 percent; 1 7 w hile in those w ith diam eters
betw een 5-15cm it w as 57 percent. IX
In the past few years, m uch has been discussed about the role of ultrasonography in ovarian cancer detection. A ccording to V A N N A G ELL et aI.,19.20 ovaries m ay be visualized transvaginally in 95 percent of the cases during m enacm e and in m ore than 85 percent of the postm enopausal cases. The sam e authors, in a study of 1300 asym ptom atic postm enopausal w om en, detected 33 abnorm al ovaries, of w hich 2 w ere cancers in an early stage.
O ur results show that the ovarian volum e before m enopause can be predicted. Therefore, the routine use of transvaginal ultrasonography in clim acteric w om en assum es an im portant role in finding volum e and structure m odifications, and could reduce in m ortality through early diagnosis.
> 8
8 7 6 5 4
3
P O S T M E N O P A U S A L P E R IO D ( Y E A R S )
R V : R E G R E S S IO N A P P L IE D T O V A R IA N C E O F
R IG H T O V A R IA N V O L U M E
2
a
*p<0.05 3 4
2
1155
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a s s e s s m e n t o f o v a ria n v o lu m e s in p o s tm e n o p a u s a l w o m e n
