Tubo-ovarian abscesses in postmenopausal women: gynecological malignancy until proven otherwise?

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Abstract

Objective: To investigate the incidence of gynecological malignancy in menopausal women who develop tubo-ovarian abscesses (TOAs), and to address the differences in presentation and underlying pathology between premenopausal and postmenopausal women with TOAs. Study design: In a retrospective study we included 93 patients with a diagnosis of a TOA and compared a premenopausal group (group 1) with a postmenopausal group (group 2). Results: Group 1 included 76 (82%), and group 2 17 (18%) patients. Abdominal pain and pyrexia >38 °C were present in 93 and 74% cases of group 1, and in 71 and 41% cases of group 2 (P=0.016 and 0.019, respectively). Irregular vaginal bleeding and gross ascites were significantly more frequent in group 2. With respect to benign additional pathology we found no differences between the two groups. On the contrary a significant association between TOAs in menopause and malignancy was established. In 8 (47%) postmenopausal cases a concomitant gynecological malignancy was found including a variety of cancers. Conclusion: Postmenopausal women presenting with TOAs, should be thoroughly investigated to exclude a concomitant pelvic malignancy. Conservative treatment of TOAs has no place during the menopause.

Introduction

Tubo-ovarian abscesses (TOAs) are a common consequence of acute salpingitis in women of reproductive age. It has been reported that 34% of patients with acute genital tract infections develop this complication [1]. Risk factors for the development of a tubo-ovarian abscess in this age group include a low socioeconomic status, multiple sexual partners, a past history of pelvic inflammatory disease (PID), and intrauterine contraceptive device (IUCD) use [2], [3]. Treatment of TOAs in women wishing to conserve their reproductive capacity should initially be medical, leaving surgical management for those patients who respond poorly to antibiotics, or those who develop life threatening complications such as rupture of the abscess [4], [5], [6].

Despite a wealth of information concerning management of TOAs in women of reproductive age, there are only a handful of literature reports addressing the problem of tubo-ovarian abscesses in postmenopausal women. In this age group development of a TOA seems to be associated frequently with serious pathology of the genital tract including co-existing malignant tumors, and the decision to treat such a patient medically or even with conservative surgery may not be a safe option [7], [8]. We conducted this retrospective study firstly to investigate the incidence of gynecological malignancy in menopausal women who develop tubo-ovarian abscesses (TOAs), and secondly to address possible differences in clinical presentation, underlying pelvic pathology, and other predisposing factors between premenopausal and postmenopausal women who develop TOAs.

Section snippets

Materials and methods

We conducted a thorough search in the operating theatre records of our Institution covering the time period between January 1996 and July 2002, to identify all patients who were operated for a diagnosed tubo-ovarian abscess. We then reviewed reports on histology specimens from these patients and performed an additional computer search in our pathology department to identify patients with a histological diagnosis of a tubo-ovarian abscess, who underwent surgery for a different indication.

Results

Through this combined search we identified a total of 93 patients with a surgical and/or a histological diagnosis of tubo-ovarian abscess. Among those, 76 (82%) were premenopausal and 17 (18%) were postmenopausal. Mean patient age was 39 years (range: 17–78). Most important patient characteristics are summarized in Table 1.

Eight patients in the premenopausal group and one in the postmenopausal group had a history of IUCD use. The device was in situ at the time of TOA diagnosis in six cases

Comment

During the last 2 years we managed several consecutive menopausal patients who presented with symptoms of a TOA, and a preoperative diagnosis, or a strong suspicion of a coexisting malignancy of the reproductive organs. This association appeared very strong indeed, and for this reason we expanded our search covering a longer time period to identify the true incidence of gynecological cancer in postmenopausal patients who develop TOAs.

TOAs represent a rather unusual entity in postmenopausal

References (14)

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