Barriers to care for women with low-grade endometrial cancer and morbid obesity: a qualitative study.

OBJECTIVE: Obesity is a major risk factor for low-grade endometrial cancer. The surgical management of patients with obesity is challenging, and they may face unique barriers to accessing care. We completed a qualitative study to understand the experiences of low-grade endometrial cancer patients with morbid obesity, from symptom onset to diagnosis to surgery. DESIGN: Semi-structured interviews were performed with endometrial cancer patients with morbid obesity (body mass index (BMI) >40 kg/m2) referred for primary surgery. Transcribed interviews were coded line-by-line and analysed using an interpretive descriptive approach that drew on labelling theory to understand patients' experiences. Thematic sufficiency was confirmed after 15 interviews. SETTING: Two tertiary care centres in Toronto, Ontario, Canada. PARTICIPANTS: Fifteen endometrial cancer patients with a median age of 61 years (range: 50-74) and a median BMI of 50 kg/m2 (range: 44-70) were interviewed. RESULTS: Thematic analysis identified that (1) both patients and providers lack knowledge on endometrial cancer and its presenting symptoms and risk factors; (2) patients with morbid obesity are subject to stigma and poor communication in the healthcare system and (3, 4) although clinical, administrative, financial, geographic and facility-related barriers exist, quality care for patients with morbid obesity is an achievable goal. CONCLUSIONS: Improved education on the prevention and identification of endometrial cancer is needed for both patients and providers. Delivery of cancer care to patients with morbid obesity may be improved through provider awareness of the impact of weight stigma and establishing streamlined care pathways at centres equipped to manage surgical complexity.

Rates and Technique for Oophoropexy in Pediatric Ovarian Torsion: A Single-Institution Case Series.

STUDY OBJECTIVE: Ovarian torsion (OT) is uncommon, but can result in loss of reproductive function. Traditionally managed using adnexectomy, torsed adnexae are now being conserved, increasing the potential for recurrent OT. As a result, some experts suggest oophoropexy (OP) to prevent recurrence. We report on a series of 11 patients who underwent OP. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: A retrospective case series was conducted from 2004 to 2013 to identify patients younger than the age of 18 years with OT. From this, data for patients with OP were extracted for detailed review. RESULTS: We identified 97 patients with OT; 6 of 97 (6.2%) had recurrent OT. The rate of recurrence was higher (14.8%, 4/27) in the group with torsion without an adnexal mass. Eleven of 97 patients (11.3%) underwent OP. The mean age of patients with OP was 8.8 years. Nine patients had normal adnexae at initial torsion. Five of 11 had OP during their initial procedure. OP was most commonly performed for long utero-ovarian ligaments (n = 6), recurrence (n = 4), or bilateral OT (n = 2). Eight of 8 patients with follow-up ultrasound imaging after torsion showed at least 1 marker of normal ovarian function. One of 11 patients (9%) had a recurrence of OT of an oophoropexied ovary. There were no complications due to the OP portion of the procedure. CONCLUSION: In our series of OT, a small percentage of patients underwent prophylactic OP. Recurrence might still occur after OP. It seems reasonable to offer OP to patients at higher risk of recurrent OT although level 1 evidence is lacking. Future research should focus on techniques and long-term outcomes of OP.

Simulated impact of pelvic MRI in treatment planning for pediatric adnexal masses.

BACKGROUND: There are no studies on utility of MRI in management of pediatric adnexal masses. OBJECTIVE: To determine the diagnostic and therapeutic impact of pelvic MRI in adnexal masses in children and adolescents. MATERIALS AND METHODS: We included 32 females age 18 years and younger who had adnexal masses and who underwent both pelvic ultrasound (US) and MRI. A radiologist retrospectively reviewed US and MR images and created a standard radiologic report for each patient. In a prospective theoretical fashion, two pediatric gynecologists reviewed the clinical data and US report for each patient and indicated conservative versus surgical management; in surgical cases the options were laparoscopy versus laparotomy, midline versus Pfannenstiel incision, and oophorectomy versus cystectomy. Subsequently, the gynecologists were presented the MRI report and were asked to indicate their treatment options again. A binomial test was conducted to determine the effect of adding MRI findings to the management plan. RESULTS: The addition of MRI significantly changed management in 10 of 32 patients (P=0.0322), with a change in surgical versus conservative treatment in 5, a change in laparotomy vs. laparoscopy in 2, and a change from oophorectomy to cystectomy along with change in incision in 3 cases. This was based on additional information provided by MRI regarding the nature of the mass in 8 cases and origin of the mass in 2 cases. CONCLUSION: Preoperative pelvic MRI findings might change the surgical management of pediatric patients with adnexal masses, so it is a valuable addition to the conventional workup in the clinical management.

Müllerian agenesis and ovarian torsion. A case report and review of literature.

A case report of a premenarcheal patient with an ovarian torsion and müllerian agenesis is presented. An 11-year-old prepubertal girl presented with severe left lower quadrant abdominal pain and mild rebound. A computed tomography showed a normal appendix; an ultrasound showed a left ovary measuring 3 x 2 cm with multiple 0.5-mm simple cysts. A diagnostic laparoscopy showed the left ovary tube to be twisted, but the uterus was absent, and the right ovary and tube were not visualized in the appropriate location; instead, a right adnexal structure was buried in the right sidewall. The ovary was untwisted and fixed to the pelvic sidewall. Chromosomes were 46,XX, and her hormonal evaluation was normal. Ovarian torsion and müllerian agenesis are rarely reported. An association between the lax attachment of the adnexa and torsion may be a contributing factor in this condition.

Ruptured hemorrhagic cyst in an undescended ovary.

The authors report on a patient with an uncommon congenital anomaly of bilateral undescended ovaries and tubes. She presented with an acute abdomen at 13 years of age. A computed tomography scan showed a cystic mass suspicious for congenital intestinal duplication. At the time of laparoscopy, she was found to have a bicornuate uterus and bilateral undescended ovaries with a ruptured right hemorrhagic ovarian cyst. This case shows that although a ruptured ovarian cyst can occur in such malpositioned organs, it can pose difficult diagnostic challenges. Suppression of the ovaries with the combined oral contraceptive pill may help to prevent further ovarian cyst development.

Premenarchal recurrent periclitoral abscess: a case report.

BACKGROUND: Periclitoral abscesses in premenarchal girls is a serious condition and can have negative implications for future reproductive health. Recurrent periclitoral abscess in premenarchal girls is rare. CASE: An 11-year-old, premenarchal girl presented complaining of dysuria, vulvar swelling, pain and erythema of the clitoral hood and a similar episode 12 months previously. Intravenous antibiotics and local measures resulted in spontaneous drainage of the abscess. On day 3 the area was healing, and the patient was discharged on oral antibiotics and sitz baths. At her 6-month follow-up, she had a normal clitoral hood without tenderness or erythema. CONCLUSION: Broad-spectrum antibiotics and local measures may prevent surgical treatment and potential associated reproductive morbidity.