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2018 | July-December | Volume 6 | Issue 2

EDITORIAL

Syeda Batool Mazhar

Premature Ovarian Insufficiency: Is it te Same as Menopause?

[Year:2018] [Month:July-December] [Volume:6] [Number:2] [Pages:1] [Pages No:0 - 0]

PDF  |  DOI: 10.5005/jsafoms-6-2-iv  |  Open Access |  How to cite  | 

Original Article

Uma Jain, Ruchi Kalra, Shikha Ghanghoria, Dilip Jain

Study of Usefulness of Endometrial Pipelle Biopsy Procedure in an Endometrial Sampling of Abnormal Uterine Bleeding

[Year:2018] [Month:July-December] [Volume:6] [Number:2] [Pages:5] [Pages No:83 - 87]

Keywords: Pipelle procedure,Abnormal utrerine bleeding, Endometrial biopsy

PDF  |  DOI: 10.5005/jp-journals-10032-1145  |  Open Access |  How to cite  | 

Abstract

Introduction: Abnormal bleeding from uterus is a commonly encountered complaint in gynecological practice. As per the National Health Portal report of India (2017) prevalence of AUB is 17.9%. A Gynae Endocrine Society of India (GESI) initiative in collaboration with Endocrine Committee of Association of Obstetrics and Gynecologists of India recommended that endometrial aspiration is preferred procedure for taking endometrial sample for histopathology examination in place of Dilatation and curettage. D&C should not be the procedure of choice for endometrial assessment. Methodology: A retrospective analysis was done of the abnormal uterine bleeding (AUB) cases who underwent endometrial biopsy using pipelle procedure. The duration of study was from January 2016 to December 2017 at the Private Hospital Clinic of Shivpuri, Madhya Pradesh. Those women who had complaints of AUB were included and as per the recommended protocol for AUB management by GESI required endometrial sampling. Case records of patients those who had undergone endometrial biopsy by pipelle procedure were analyzed. The procedure was “successful” if the cervical os was negotiated successfully and even if after three attempts failed to negotiate cervix it was a “failure.” Result: Of the total 230 cases attempted for pipelle procedure, 227 cases (98.69%) were successful. The 98% cases the sample obtained was satisfactory. 41.40% of cases were in the age group of 30-40 years. Maximum cases (44.49%) were para 3. Rural cases were 78.41% of the total cases. The presenting symptoms majority were menometorrhagia (49.33%). Histopathology reports were negative for malignancy (60.79%). Hyperplasia without atypical (12.33%) positive suspicious for malignant tumor (0.44%) atrophic endometrium (4.40%) endometrits (9.69%). Conclusion: Pipelle biopsy procedure is a simple, easy, patient friendly technique to obtain endometrial biopsy on the outpatient basis without need of patient admission and anesthesia

Original Article

Peeyusha W Rajani, Annie Rajaratnam

Histopathological Evaluation of Endometrium in Perimenopausal Women with Fibroids

[Year:2018] [Month:July-December] [Volume:6] [Number:2] [Pages:3] [Pages No:88 - 90]

Keywords: Abnormal uterine bleeding, Endometrial thickness, Leiomyoma, Perimenopausal women

PDF  |  DOI: 10.5005/jp-journals-10032-1146  |  Open Access |  How to cite  | 

Abstract

Background: Steroid hormones causes functional and structural changes in endometrium throughout each menstrual cycle. Uterine leiomyomas being dependent on steroid growth hormones for their growth and maintenance account for more than 75% of the benign tumors in females of childbearing age group. Formation of fibroids hence is a common response to this pathologic state. The aim of our study was to correlate endometrial histopathology in perimenopausal women with fibroids presenting as abnormal uterine bleeding (AUB-L). Materials and methods: Fifty women of perimenopausal age, presenting with abnormal uterine bleeding, wherein the uterus revealed leiomyoma were studied. Endometrial thickness was measured using vaginal or pelvic ultrasonography. Endometrial biopsy was taken, and the samples were sent for histopathological examination. Ten asymptomatic normal women of similar age group were taken as controls. Results: Uterine size was nonsignificantly increased in a peri-menopausal woman with fibroid. The average size of fibroid was 3.10 to 3.24 cm. Mean endometrial thickness with fibroid was significantly higher as compared to normal females of similar age group. Conclusion: Presence of fibroid was associated with an increase in endometrial thickness in perimenopausal women, along with a small change in uterine size.

Original Article

Amita Ray

Comparing the Diagnostic Accuracy of Symptom Index and the Risk of Malignancy Index with Histopathological Outcomes in Adnexal Masses

[Year:2018] [Month:July-December] [Volume:6] [Number:2] [Pages:6] [Pages No:91 - 96]

Keywords: Tests of diagnostic accuracy,Adnexal mass, Risk of malignancy index 1, Symptom index

PDF  |  DOI: 10.5005/jp-journals-10032-1147  |  Open Access |  How to cite  | 

Abstract

Aim: Accurate identification of the nature of an adnexal mass can ensure optimum management and with this aim in mind we applied tests of diagnostic accuracy to the symptom index (SI) and the risk of malignancy index 1 (RMI-1) separately and in combination to differentiate between benign and malignant adnexal masses in women admitted for surgery at three different medical college institutions in India. This was done to frame a referral policy for women with adnexal masses, facilitate triaging and for counseling the woman and her family. Methods: All the participants were given a survey to complete based on which the participants were either SI positive or negative. Ultrasonographic parameters and CA-125 levels were used to calculate the RMI for each participant. Using Histopathology as the gold standard we compared the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive and negative likelihood ratios and diagnostic accuracy of the SI and RMI separately and in combination. Results: When compared to the SI the RMI rates higher in all tests of diagnostic accuracy. Sensitivity (SI—41.4% RMI—77.8%) Specificity(SI—73.24%, RMI—80.6%), PPV(SI—38.71% RMI—60.0%), NPV(SI—75.36% RMI—90.6%) and diagnostic accuracy (SI—64% RMI—79.8%) diagnostic accuracy does not improve when the tools are combined. Conclusion: The RMI can be used as a triaging tool and also for framing a referral policy for adnexal masses. For counseling patients with adnexal masses, the RMI through a better option than the SI does not have a good positive or negative likelihood ratio to either rule out or rule in a diagnosis of malignancy in individual cases. Clinical significance: Menopausal status, CA-125, and ultrasound features are much more predictive of the nature of an adnexal mass when compared to symptoms making RMI a better tool for triaging and referral and counseling women with adnexal masses

Original Article

Vijaya Srinivasan, Sadasiva P Meenakshi, Koramadai S Mouleeswaran, Gopalakrishnan V Praveen, Tom Michael

Changing Trends in the Epidemiology of Cervical Cancer in Upper Middle Class Women

[Year:2018] [Month:July-December] [Volume:6] [Number:2] [Pages:6] [Pages No:97 - 102]

Keywords: Cervical cancer, Postmenopausal bleeding, Postparity, Socioeconomic status

PDF  |  DOI: 10.5005/jp-journals-10032-1148  |  Open Access |  How to cite  | 

Abstract

Introduction: Changing trends in the epidemiology of cervical cancer are reported from developing countries, but the new factors are not well documented, especially socioeconomic (SE) status. Aim: To study the prevalence and factors associated with cervical cancer in upper middle SE class women from a tertiary care hospital in Chennai, South India. Materials and methods: This is a case–control study of cases with cervical cancer and twice the number of asymptomatic controls, among women who underwent papanicolaou (PAP) smear test during 2009 to 2015. Results: Of the 3,536 PAP smears examined, 48 (1.36%) had cervical cancer and 96 age- and year-matched controls were selected for the cases. The mean (± standard deviation, SD) age of cases was 51.3 (± 12.7) years and controls was 51.7 (± 12.7) years (p not significant, NS). Over 90% of both groups underwent surgical sterilization and had long married lives. The median parity of cases and controls was 2. Parity was 3 or more in 22 (44.9%), compared with 27 (28.1%) in controls (p < 0.05; relative risk, RR: 1.6 and 95% confidence interval, CI: 1.3–1.9). Among all the cases, 23 (48.0%) were asymptomatic. More than half, 28 (58.3%), of the cases and 50 (52.1%) of the controls had attained menopause (p = NS). About 7 (25%) of these cases reported postmenopausal bleeding (PNB). Conclusion: Among the PAP smears tested, high prevalence (1.36%) of cervical cancer was noted. The associated factors were age >50 years, median parity of 2, history of PNB, and a long duration of sexual exposure. Nearly half the cases were asymptomatic, highlighting the need for routine screening of all postmenopausal women.

Original Article

Deepthi Ravindranath, Sivasundari , Onimi Syamala

Evaluation of Predictive Value of Swede Score

[Year:2018] [Month:July-December] [Volume:6] [Number:2] [Pages:3] [Pages No:103 - 105]

Keywords: Cin, Colposcopy, Swede score

PDF  |  DOI: 10.5005/jp-journals-10032-1149  |  Open Access |  How to cite  | 

Abstract

Objective: The predictive value of colposcopy is not as reliable as it was presumed. The Reid colposcopic index is a prevalently used scoring system which was devised to standardize the colposcopic assessment and to predict the histology. The Swede score formulated by Strander et al. in 2005 is a simple scoring system which includes five variables also including the size of the lesion. This study aims to validate the accuracy of the Swede score in the prediction of high-grade lesions (CIN-II or higher). Methods: The evaluation was carried out in the Department of Obstetrics and Gynecology at Sri Ramachandra Medical College between January 2015 and July 2015. Seventy-nine patients who attended the gynecology outpatient department who underwent colposcopy and guided biopsy were included. The participating colposcopists were well trained. Swede score was calculated for each patient after colposcopy and noted. It was then evaluated with the final histopathology after either colposcopic biopsy or excisional cervical biopsy. Since it was not a research study and it was an evaluation, the management of patients was not influenced by the Swede score. Results: Whenever the final diagnosis of cervical lesions was CIN-II or higher, our study showed that the Swede score had 71% sensitivity, 95% specificity, 77% positive predictive value and 94% negative predictive value. Conclusion: The specificity for a score of 8 or more was 95%, therefore higher scores within the system may more accurately predict high-grade lesions. Swede score is a valid simplified scoring system in accurately predicting high-grade lesions.

RESEARCH ARTICLE

Jyoti Jaiswal, Anand Jaiswal

A Study on Relationship of Endometrial Thickness and Abnormal Uterine Bleeding in Perimenopausal Women

[Year:2018] [Month:July-December] [Volume:6] [Number:2] [Pages:6] [Pages No:106 - 111]

Keywords: AUB, Endometrial thickness, Perimenopause

PDF  |  DOI: 10.5005/jp-journals-10032-1150  |  Open Access |  How to cite  | 

Abstract

Aims and objectives: To study the possible relationship between abnormal uterine bleeding (AUB) and endometrial thickness in perimenopausal women. Materials and methods: A prospective observational study conducted on 60 cases of AUB in perimenopausal age (41–55 years) group. Results: Institutional incidence of AUB in general and AUB in perimenopausal age was 10.7% and 29.38% respectively. Maximum cases were para 3 and of age 41–45 years (78.33%). Cases presented with irregular and heavy menstrual bleeding (76.66%). About one-third (33.33%) of the study subjects were suffering from severe and life-threatening anemia due to AUB. 90% study subjects required a blood transfusion, maximum of them were transfused preoperatively. As per PALM-COEIN classification, maximum cases had leiomyoma (41.66%) as a structural cause of AUB followed by malignancy and hyperplasia (33.33%). Majority of cases (45%) presenting with AUB had an endometrial thickness between 6–9 mm. Mean endometrial thickness was maximum in cases of AUB M that is 10.33 mm followed by AUB-L 7.56 mm, and AUB-A 7.2 mm. Majority of cases (70%) with ET 9 mm or less were having mild to moderate blood loss. Majority of cases with severe blood loss higher endometrial thickness; half subjects had ET >10 mm, and few had ET 16 to 21 mm. Cafeteria approach for choosing the management line was given. Most of the perimenopausal cases preferred the surgical line of management (83.33%) over medical method (13.33%) despite counseling. Conclusion: Endometrial thickness of more than 7 mm remains a common feature with estrogen-dependent conditions like fibroid, adenomyosis, hyperplasia, and malignancy even during perimenopause. Clinical Significance: AUB in perimenopause needs vigilant surveillance, and endometrial thickness may be a relevant tool for it.

RESEARCH ARTICLE

Parvathavarthini Krishnamoorthy, Nandhini Balakrishnan, Geetha Prasad

Association of Endometrial Thickness with Histopathological Pattern of Endometrium with Postmenopausal Bleeding

[Year:2018] [Month:July-December] [Volume:6] [Number:2] [Pages:5] [Pages No:112 - 116]

Keywords: Endometrial pathology, Endometrial thickness, Observational study, Postmenopausal bleeding, Ultrasound

PDF  |  DOI: 10.5005/jp-journals-10032-1151  |  Open Access |  How to cite  | 

Abstract

Aim: To compare the endometrial thickness with the results of the biopsy and assess the usefulness of endometrial thickness as an indicator of underlying pathology. Materials and methods: Endometrial thickness measured by ultrasound of 61 patients with postmenopausal bleeding were compared with histopathology of endometrial biopsy. Age of presentation, the duration between menopause and postmenopausal bleeding, parity, associated symptomsand association of risk factors for endometrial hyperplasia and carcinoma were analyzed. Results: The mean age of patients with menopausal bleeding was 52 years, and that of endometrial cancer was 63.7 years. About one-third of cases with postmenopausal bleeding had hyperplasia and one-tenth was diagnosed as carcinoma. The minimum thickness of endometrium was 6 mm in patients with hyperplasia with a mean of 14.3 ± 5.4 mm, and it was 12 mm in the case of carcinoma with a mean of 20 ± 6.4 mm. Mean thickness of atrophic endometrium was 7.4 ± 3.5 mm. None of the cases with less than 4 mm endometrial thickness had either hyperplasia or cancer. Conclusion: Ultrasound can be considered as an early diagnostic evaluation tool for patients with postmenopausal bleeding in predicting endometrial hyperplasia and carcinoma which could prevent un-warranted operation in patients with a thin endometrium. Clinical significance: Thickened endometrium is a predictor of endometrial hyperplasia and cancer.

RESEARCH ARTICLE

Febia Erfiandi, Tita H Madjid, Mulya NA Ritonga, Herman Susanto, Hadi Susiarno

Effects of Tofu Consumption on Menopause Symptoms and Equol Level [7-Hydroxy-3-(4-Hydroxyphenyl) Chroman]

[Year:2018] [Month:July-December] [Volume:6] [Number:2] [Pages:5] [Pages No:117 - 121]

Keywords: Equol, Isoflavones, Menopause symptoms, Phytoestrogens, Tofu

PDF  |  DOI: 10.5005/jp-journals-10032-1152  |  Open Access |  How to cite  | 

Abstract

Background: Improvements in both health and welfare in Indonesia have increased the life expectancy; thus, the number of women who experience menopause period would be increasing. Menopause symptoms resulting from estrogen deficiency often cause problems, such as menstrual cycle changes, hot flushes, dyspareunia, urethritis, incontinence, urgency, frequent micturition, insomnia, or sexual dysfunction. This symptom happened since perimenopause age. Phytoestrogens and their metabolites, equol, binds to estrogen receptors and induce biological effects resembling estrogen. The most important content of phytoestrogens is isoflavones. Isoflavones could be found in foods or drinks that contain soya (soybeans), such as tofu. Equol, a bacterial metabolite, and the only hormonally active daidzein metabolite is a good predictor to determine the degree of menopause symptoms. This was an experimental study with pre and post design. Aim: The aim of this study was to determine the effect of regular tofu consumption for three months on the symptoms of menopause and excreted human urinary equol level. Subjects were perimenopause women (n = 25) that were interviewed using questionnaire guidance of menopause rating scale (MRS). Urine samples were analyzed using high-performance liquid chromatography (HPLC). Results The result showed that regular tofu consumption significantly affected menopause symptoms and equol level (p value <0.05). Method: This was an experimental study with pre- and post- design. Subjects were perimenopause women (n = 25) that were interviewed using questionnaire guidance of menopause rating scale (MRS). Urine samples were analyzed using high performance liquid chromatography (HPLC). Conclusion: Research concluded there was a decrease in the degree of menopause symptoms and increased equol level in perimenopause women after consuming tofu regularly for 3 months. Clinical significance: Results can be an alternative choice besides hormonal drugs that we used regularly to decrease menopause symptoms.

CASE REPORT

Indra Bhati, Sobika Rana

A Rare Variety of Vulval Carcinoma-verrucous Carcinoma: A Case Report

[Year:2018] [Month:July-December] [Volume:6] [Number:2] [Pages:3] [Pages No:122 - 124]

Keywords: Aquamous cell cancer, Postmenopausal women, Vulval carcinoma

PDF  |  DOI: 10.5005/jp-journals-10032-1153  |  Open Access |  How to cite  | 

Abstract

Verrucous carcinoma of the vulva is a rare subtype of squamous cell cancer and tends to appear as a slowly growing wart with good overall prognosis. Most commonly affects elderly, postmenopausal women. Here, we present a case concerning an 85 years old postmenopausal woman on follow up after punch biopsy suggesting Bowenoid papulosis of the vulva. The treatment decided was only surgical. A review of the literature shows the rarity of this lesion of the female genital tract.

CASE REPORT

Mayuri Ahuja, Archana Mehta, Vikram Singh, Shehla Jamal, Neerja Goel

Outlander of the Bladder: The Hidden Copper Intrauterine Device

[Year:2018] [Month:July-December] [Volume:6] [Number:2] [Pages:2] [Pages No:124 - 125]

Keywords: Cystoscopy, Intrauterine device, Ultrasonography

PDF  |  DOI: 10.5005/jp-journals-10032-1154  |  Open Access |  How to cite  | 

Abstract

Intrauterine contraceptive devices have been in use for many years. Although perforation of the uterus by an intrauterine device (IUD) is not uncommon (9.6 per 1000 insertions), intravesical migration with the secondary stone formation is a rare condition. We report a case of a 46-year-old late perimenopausal woman being treated for urinary complaints for six months which on USG turned out to be Copper T encrusted with secondary calculus formation managed successfully by cystoscopic retrieval.

CASE REPORT

Mayanglambam R Devi, Helen Kamei, Paikhomba Kharibam, Sylvia Keisham, Sunita Haobam

Diagnostic Predicament of Cystic Degenerated Uterine Leiomyoma Presenting as Ovarian Cyst: A Case Report

[Year:2018] [Month:July-December] [Volume:6] [Number:2] [Pages:3] [Pages No:126 - 128]

Keywords: Cystic degeneration, Leiomyoma, Ovarian cyst

PDF  |  DOI: 10.5005/jp-journals-10032-1155  |  Open Access |  How to cite  | 

Abstract

A large degenerated fibroid may give a false impression of other abdominal gynecological abnormalities like in our case of a 46-year-old para 3, living 3 (P3L3) woman presented to our hospital with the complaint of distension of abdomen since last ten years. The increase in the size of the abdomen was slow initially, but it increased rapidly in last one month. She complained of right abdominal pain for the last one month along with difficulty in breathing and constipation. Abdomen examination revealed a huge abdominopelvic mass and a provisional diagnosis of the ovarian cyst was made clinically. Computed tomography (CT) scan showed a very large cystic lesion arising from the pelvis filling up the abdominal cavity. We planned for laparotomy and proceed. Intraoperatively, a giant cyst occupying the whole abdomen identified and control suction done with removal of ~5 liters of straw-colored fluid. The cyst was found to have adhered to the mesentery and also attached to the fundal area of the uterus. The cyst was severed from the uterus by clamping and cutting the pedicle of the cyst. Uterus and bilateral ovaries were looking normal. Total abdominal hysterectomy with bilateral salpingo-oophorectomy done. Cyst separated from guts and excised. Feeding vessels were from the mesenteric artery. Histopathological examination showed the features of leiomyoma with cystic degeneration. Leiomyoma with cystic degeneration is the rare secondary changes. But they can cause a diagnostic dilemma by mimicking huge ovarian cyst.

CASE REPORT

Mriganka M Saha, Joydeep Neogi, Madhukar Harani, Arabinda Majumder, Soumyabrata Mitra

Removal of Massive Ovarian Tumor Weighing 35.4 kg in a Tertiary Care Hospital: A Case Report

[Year:2018] [Month:July-December] [Volume:6] [Number:2] [Pages:3] [Pages No:129 - 131]

Keywords: Tumor,Massive, Ovarian

PDF  |  DOI: 10.5005/jp-journals-10032-1156  |  Open Access |  How to cite  | 

Abstract

Massive ovarian tumors are rarely encountered in our clinical practices and the most common reason is ignorance about the pathology and its sequences. Many complications are associated with it starting from the preoperative, intraoperative and postoperative period. Here we are reporting a case of massive bilateral ovarian tumor weighing 35.4 kg (weighted after removal). She underwent a successful operation and discharged from the hospital on tenth postoperative day. Histopathology examination has revealed papillary serous cystadenocarcinoma of one ovary and borderline mucinous tumor of another ovary.

CASE REPORT

BC Manjula

A Rare Case of “Large Twisted Dermoid Cyst” in an 82-year-old Lady with Diverticulitis and Septicemia: A Case Report

[Year:2018] [Month:July-December] [Volume:6] [Number:2] [Pages:3] [Pages No:132 - 134]

Keywords: Diverticulitis, Septicemia, Twisted dermoid cyst

PDF  |  DOI: 10.5005/jp-journals-10032-1157  |  Open Access |  How to cite  | 

Abstract

Dermoid cyst is a germ cell tumor. Eighty percent occurs during reproductive years. One to two percent undergoes malignant transformation. This is a case of a large dermoid cyst ovary measuring 10 × 12 cm in an 82-year-old lady who complained of acute on chronic pain abdomen associated with constipation. CT scan revealed a heterogeneous mass replacing ovary. Emergency laparoscopy done revealed a large collection of pus in peritoneal cavity filling POD and extending up to the subhepatic region with massively distended bowel loops. The right ovary was torted 3.5 times. To the best of our knowledge, this is the only case described in the literature of torsion ovary in a lady above the age of 80 years with diverticulitis managed laparoscopically.

CASE REPORT

Prashanthi Damodharan, Usha Vishwanath, Priyanka Mehta, S Gouthaman, K Sriram

A Rare Case of Endometrial Adenocarcinoma with Renal Clear Cell Carcinoma

[Year:2018] [Month:July-December] [Volume:6] [Number:2] [Pages:4] [Pages No:135 - 138]

Keywords: Endometrial adenocarcinoma, Leptin, Peroxisome proliferators activators receptor gamma, Renal clear cell carcinoma

PDF  |  DOI: 10.5005/jp-journals-10032-1158  |  Open Access |  How to cite  | 

Abstract

Patients diagnosed with cancer have a lifetime risk of developing another de novo malignancy. The incidence of two primaries in the same patient is an extremely rare condition, and there are no specific guidelines for management. There are less than ten reported cases of coincidental renal cell cancer in a patient with endometrial cancer. In a woman who presented with postmenopausal bleeding with endometrial carcinoma, an incidental primary renal cell carcinoma was diagnosed and treated successfully by a multidisciplinary team of gynecologists, oncosurgeon, urologist, radiologist, pathologist, and a medical oncologist. We are reporting this case due to its rarity and clinical interest. A high index of clinical suspicion would go a long way in the management of such tumors.

CASE REPORT

Tjokorda GA Pemayun, I Nyoman G Budiana

A Rare Case of Extensive Degeneration in Bilateral Ovarian Fibroma Mimicking Large Ovarian Cystadenoma

[Year:2018] [Month:July-December] [Volume:6] [Number:2] [Pages:3] [Pages No:139 - 141]

Keywords: Cystic degeneration, Ovarian fibroma, Ultrasound

PDF  |  DOI: 10.5005/jp-journals-10032-1159  |  Open Access |  How to cite  | 

Abstract

Aim: To describe a rare variant of ovarian fibroma. Background: Ovarian fibroma is a rare entity, but is the most common solid ovarian tumor. Most of these tumors are solid, and most commonly mistaken with uterine fibroid. In rare cases, they may show a mix of solid-cystic components. Case description: In this case report, we present a rare case of bilateral ovarian fibroma with extensive cystic degeneration, appearing as predominantly cystic adnexal mass on ultrasound. Conclusion: A rare condition with extensive degeneration may be impossible to distinguish with the ovarian epithelial tumor. Thus, ultrasound finding of a cystic lesion should not be used to exclude an ovarian fibroma. Established Facts: Ovarian fibromas are mostly solid, and may sometimes appear as a mixed solid-cystic mass on ultrasound. A unilocular cystic lesion on ultrasound usually excludes this tumor. Novel insights: Extensive degenerations of ovarian fibroma are extremely rare and may cause the tumor to appear as the cystic adnexal mass. When ultrasound examination shows a predominantly cystic lesion, a careful evaluation should be done, before excluding ovarian fibroma

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