The ovaries are part of the female reproductive system. Women have two ovaries, one on each side of the uterus. Each ovary is about the size and shape of an almond.

The ovaries produce and store a woman's eggs. During ovulation, an ovary releases an egg. If that egg is fertilized by a sperm, a pregnancy can occur. Ovaries also make the female hormones estrogen and progesterone. When a woman goes through menopause, her ovaries stop making those hormones and releasing eggs.

Problems with the ovaries include

• Ovarian cancer
• Ovarian cysts and polycystic ovary syndrome
• Primary ovarian insufficiency
• Ovarian torsion, a twisting of the ovary

The ovaries are paired, oval-shaped organs measuring approximately 2-4 cm in diameter that lie on the posterior wall of the pelvis lateral to the uterus. They are supported by the suspensory ligaments, the ovarian ligament, and the broad ligament. The ovaries produce and expell ova (eggs) and function as glands that produce reproductive hormones.

The fallopian tubes are a pair of slender ducts, approximately 10 cm long with fingerlike projections adjacent to the ovary (fimbriae) through which ova pass from the ovaries to the uterus in the female reproductive system.

In females, the peritoneum, which includes the omentum and pelvic and abdominal viscera, lines the anterior (front) and posterior (back) surfaces of the uterus. It is more commonly a site of metastasis than of primary cancer.

Anatomical Structures Related to the Ovaries

• Ovary
• Medial surface
• Lateral surface
• Free border
• Mesovarial margin
• Tubal extremity
• Uterine extremity
• Oviduct (fallopian tube)
• Opening of fallopian tube
• Infundibulum of fallopian tube
• Fimbriae of fallopian tube
• Ovarian fimbria
• Ampulla of fallopian tube
• Isthmus of fallopian tube
• Uterine part of fallopian tube
• Uterine opening of fallopian tube

What is primary ovarian insufficiency (POI)?

Primary ovarian insufficiency (POI), also known as premature ovarian failure, happens when a woman's ovaries stop working normally before she is 40.

Many women naturally experience reduced fertility when they are about 40 years old. They may start getting irregular menstrual periods as they transition to menopause. For women with POI, irregular periods and reduced fertility start before the age of 40. Sometimes it can start as early as the teenage years.

POI is different from premature menopause. With premature menopause, your periods stop before age 40. You can no longer get pregnant. The cause can be natural or it can be a disease, surgery, chemotherapy, or radiation. With POI, some women still have occasional periods. They may even get pregnant. In most cases of POI, the cause is unknown.

What causes primary ovarian insufficiency (POI)?

In about 90% of cases, the exact cause of POI is unknown.

Research shows that POI is related to problems with the follicles. Follicles are small sacs in your ovaries. Your eggs grow and mature inside them. One type of follicle problem is that you run out of working follicles earlier than normal. Another is that the follicles are not working properly. In most cases, the cause of the follicle problem is unknown. But sometimes the cause may be:

• Genetic disorders such as Fragile X syndrome and Turner syndrome
• A low number of follicles
• Autoimmune diseases, including thyroiditis and Addison disease
• Chemotherapy or radiation therapy
• Metabolic disorders
• Toxins, such as cigarette smoke, chemicals, and pesticides

Who is at risk for primary ovarian insufficiency (POI)?

Certain factors can raise a woman's risk of POI:

• Family history. Women who have a mother or sister with POI are more likely to have it.
• Genes. Some changes to genes and genetic conditions put women at higher risk for POI. For example, women Fragile X syndrome or Turner syndrome are at higher risk.
• Certain diseases, such as autoimmune diseases and viral infections
• Cancer treatments, such as chemotherapy and radiation therapy
• Age. Younger women can get POI, but it becomes more common between the ages of 35-40.

What are the symptoms of primary ovarian insufficiency (POI)?

The first sign of POI is usually irregular or missed periods. Later symptoms may be similar to those of natural menopause:

• Hot flashes
• Night sweats
• Irritability
• Poor concentration
• Decreased sex drive
• Pain during sex
• Vaginal dryness

For many women with POI, trouble getting pregnant or infertility is the reason they go to their health care provider.

What other problems can primary ovarian insufficiency (POI) cause?

Since POI causes you to have lower levels of certain hormones, you are at greater risk for other health conditions, including:

• Anxiety and depression. Hormonal changes caused by POI can contribute to anxiety or lead to depression.
• Dry eye syndrome and eye surface disease. Some women with POI have one of these eye conditions. Both can cause discomfort and may lead to blurred vision. If not treated, these conditions can cause permanent eye damage.
• Heart disease. Lower levels of estrogen can affect the muscles lining the arteries and can increase the buildup of cholesterol in the arteries. These factors increase your risk of atherosclerosis (hardening of the arteries).
• Infertility.
• Low thyroid function. This problem also is called hypothyroidism. The thyroid is a gland that makes hormones that control your body's metabolism and energy level. Low levels thyroid hormones can affect your metabolism and can cause very low energy, mental sluggishness, and other symptoms.
• Osteoporosis. The hormone estrogen helps keep bones strong. Without enough estrogen, women with POI often develop osteoporosis. It is a bone disease that causes weak, brittle bones that are more likely to break.

How is primary ovarian insufficiency (POI) diagnosed?

To diagnose POI, your health care provider may do:

• A medical history, including asking whether you have relatives with POI
• A pregnancy test, to make sure that you are not pregnant
• A physical exam, to look for signs of other disorders which could be causing your symptoms
• Blood tests, to check for certain hormone levels. You may also have a blood test to do a chromosome analysis. A chromosome is the part of a cell that contains genetic information.
• A pelvic ultrasound, to see whether or not the ovaries are enlarged or have multiple follicles

How is primary ovarian insufficiency (POI) treated?

Currently, there is no proven treatment to restore normal function to a woman's ovaries. But there are treatments for some of the symptoms of POI. There are also ways to lower your health risks and treat the conditions that POI can cause:

• Hormone replacement therapy (HRT). HRT is the most common treatment. It gives your body the estrogen and other hormones that your ovaries are not making. HRT improves sexual health and decreases the risks for heart disease and osteoporosis. You usually take it until about age 50; that's about the age when menopause usually begins.
• Calcium and vitamin D supplements. Because women with POI are at higher risk for osteoporosis, you should take calcium and vitamin D every day.
• In vitro fertilization (IVF). If you have POI and you wish to become pregnant, you may consider trying IVF.
• Regular physical activity and a healthy body weight. Getting regular exercise and controlling your weight can lower your risk for osteoporosis and heart disease.
• Treatments for associated conditions. If you have a condition that is related to POI, it is important to treat that as well. Treatments may involve medicines and hormones.

Polycystic ovary syndrome (PCOS) happens when a woman's ovaries or adrenal glands produce more male hormones than normal. PCOS causes cysts (fluid-filled sacs) to grow on the ovaries. Symptoms include

• Irregular menstrual periods
• Infertility
• Pelvic pain
• Excess hair growth on the face, chest, stomach, or thighs
• Weight gain
• Acne or oily skin
• Patches of thickened skin

Women with PCOS are at higher risk of diabetes, metabolic syndrome, heart disease, and high blood pressure.

PCOS is more common in women who have obesity, or have a mother or sister with PCOS. To diagnose PCOS, your health care provider may do a physical exam, pelvic exam, blood tests, and an ultrasound.

There is no cure, but diet, exercise, and medicines can help control the symptoms. Birth control pills help women have normal periods, reduce male hormone levels, and clear acne. Treatments for infertility caused by PCOS may include medicines, surgery, and in vitro fertilization (IVF).

The ovaries are part of the female reproductive system. They produce a woman's eggs and make female hormones. Ovarian cysts are fluid-filled sacs in or on an ovary. They usually form during ovulation, when the ovary releases an egg. They are usually harmless and go away by themselves. Most women have them sometime during their lives.

Most ovarian cysts are small and don't cause symptoms. Women may not find out that they have them until they have a pelvic exam. If there are symptoms, they may include

• Pressure
• Bloating
• Swelling
• Pain in the lower abdomen, on the side where the cyst is

If your health care provider finds a cyst, you may be able to wait to see if it gets bigger. You may need surgery if you have pain, are past menopause, or if the cyst does not go away. If a cyst bursts or causes bleeding, you should get medical help right away. Birth control pills can help prevent new cysts.

Rarely, ovarian cysts can become cancerous. This risk increases as you get older.

A health problem that involves ovarian cysts is polycystic ovary syndrome (PCOS). Women with PCOS can have high levels of male hormones, irregular or no periods, and small ovarian cysts.

What is ovarian cancer?

Cancer is a disease in which abnormal cells in the body grow out of control and form a tumor. Ovarian cancer is a cancerous tumor that forms in the tissues of an ovary. The ovaries are a pair of female reproductive glands that make eggs and female hormones.

What are the types of ovarian cancer?

There are a few different types of ovarian cancer. The most common type is epithelial cancer. It begins in the cells that cover the ovary.

There are also two related types of epithelial cancer that can spread to the ovaries:

• Fallopian tube cancer forms in the tissue lining a fallopian tube. The fallopian tubes are a pair of long, slender tubes on each side of the uterus. The uterus is the female reproductive organ where a baby grows during pregnancy.
• Primary peritoneal cancer forms in the tissue lining the peritoneum. Your peritoneum is a tissue lining that covers the organs in the abdomen (belly).

These two cancers are similar to ovarian cancer, and they have the same treatments. So some medical experts also consider those two types as ovarian cancer.

Some other rarer types of ovarian cancer are malignant germ cell tumors and stromal tumors.

What causes ovarian cancer?

Ovarian cancer happens when there are changes (mutations) in the genetic material (DNA). Often, the exact cause of these genetic changes is unknown.

Most ovarian cancers are caused by genetic changes that happen during your lifetime. But sometimes these genetic changes are inherited, meaning that you are born with them. Ovarian cancer that is caused by inherited genetic changes is called hereditary ovarian cancer.

There are also certain genetic changes that can raise your risk of ovarian cancer, including changes called BRCA1 and BRCA2. These two changes also raise your risk of breast and other cancers.

Besides genetics, your lifestyle and the environment can affect your risk of ovarian cancer.

Who is more likely to develop ovarian cancer?

Certain people are more likely to develop ovarian cancer. They include those who:

• Have a family history of ovarian cancer in a mother, daughter, or sister
• Have inherited changes in the BRCA1 or BRCA2 genes.
• Have certain other genetic conditions, such as Lynch syndrome
• Have endometriosis
• Took hormone replacement therapy
• Are overweight or have obesity
• Are tall
• Are older, especially those who have gone through menopause

What are the symptoms of ovarian cancer?

Ovarian cancer may not cause early signs or symptoms. By the time you do have signs or symptoms, the cancer is often advanced.

The signs and symptoms may include:

• Pain, swelling, or a feeling of pressure in the abdomen or pelvis
• Sudden or frequent urge to urinate (pee)
• Trouble eating or feeling full
• A lump in the pelvic area
• Gastrointestinal problems, such as gas, bloating, or constipation

How is ovarian cancer diagnosed?

To find out if you have ovarian cancer, your health care provider:

• Will ask about your medical history, including your symptoms
• Will ask about your family health history, including relatives who have had ovarian cancer
• Will do a physical exam, including a pelvic exam
• Will likely do imaging tests
• May do blood tests such as a CA-125 blood test

Often the only way to know for sure that you have ovarian cancer is by having a biopsy of the tissue. A biopsy is done during surgery to remove the tumor.

What are the treatments for ovarian cancer?

Treatments for ovarian cancer may include:

• Surgery to remove as much of the cancer as possible
• Chemotherapy
• Targeted therapy, which uses drugs or other substances that attack specific cancer cells with less harm to normal cells

Your provider may suggest that you have genetic testing to look for the gene changes that raise the risk for ovarian cancer. Knowing whether or not you have the gene change may help your provider decide on your treatment plan.

The ovaries are the female gonads. Paired ovals, they are each about 2 to 3 cm in length, about the size of an almond. The ovaries are located within the pelvic cavity, and are supported by the mesovarium, an extension of the peritoneum that connects the ovaries to the broad ligament. Extending from the mesovarium itself is the suspensory ligament that contains the ovarian blood and lymph vessels. Finally, the ovary itself is attached to the uterus via the ovarian ligament.

The ovary comprises an outer covering of cuboidal epithelium called the ovarian surface epithelium that is superficial to a dense connective tissue covering called the tunica albuginea. Beneath the tunica albuginea is the cortex, or outer portion, of the organ. The cortex is composed of a tissue framework called the ovarian stroma that forms the bulk of the adult ovary. Oocytes develop within the outer layer of this stroma, each surrounded by supporting cells. This grouping of an oocyte and its supporting cells is called a follicle. The growth and development of ovarian follicles will be described shortly. Beneath the cortex lies the inner ovarian medulla, the site of blood vessels, lymph vessels, and the nerves of the ovary. You will learn more about the overall anatomy of the female reproductive system at the end of this section.

Suspension or cessation of OVULATION in animals or humans with follicle-containing ovaries (OVARIAN FOLLICLE). Depending on the etiology, OVULATION may be induced with appropriate therapy.

Ovarian torsion, which affects females of all ages, is a gynecological emergency. It refers to a complete or partial rotation of the adnexal supporting organ, resulting in ischemic changes in the ovary. Torsions more commonly involve both the ovary and fallopian tube, and there are fewer cases of isolated torsion involving either one (one in 1.5 million women). Torsion involving paratubal or paraovarian cysts has also been found. Early diagnosis and surgery are essential to protect ovarian and tubal function and prevent severe morbidity.

Evaluation and diagnosis

On clinical presentation, the first approach to a patient is a medical history and physical examination. The medical history should include any recent diagnosis of an adnexal mass, recurrent abdominal pain, and low-grade fever. The physical examination should include a search for a pelvic mass or pain. Laboratory evaluation should include serum human chorionic gonadotropin, a hematocrit, white blood cell count, and electrolyte panel.

There is no serum marker for a diagnosis of adnexal torsion. Several serum markers can hint at an adnexal tumor type. Serum human chronic gonadotropin can reveal pregnancy or an ovarian germ cell tumor. CA-125 may indicate a malignant ovary tumor or endometrioma. Some studies have found an association between an increased level of serum interleukin-6 and ovarian torsion, although further research such as oxidative stress during ovarian torsion is needed.

Imaging studies are the most important when evaluating a pelvic mass. Ultrasonography is the first-line diagnostic assessment. A torsed ovary may be rounded and enlarged compared with the contralateral ovary, because of edema or vascular and lymph engorgement. An ultrasound can easily distinguish an ovarian mass by its components, location, density, Doppler flow, and size. There can be decreased or absent Doppler flow in the vessels of a torsed ovary. One prospective study reported that Doppler flow has high sensitivity and specificity; another retrospective study showed low sensitivity and high specificity in the diagnosis of ovarian torsion. It is not the gold standard for diagnosis, but it is a good tool. Two other studies suggested that a whirlpool sign is highly sensitive for ovary torsion. The whirlpool sign shows a twisted vascular pedicle, and a Doppler sonogram reveals circular vessels within the mass. However, further study on the diagnosis of ovarian torsion is necessary to determine the usefulness of this sign in ovary torsion.

Magnetic resonance imaging (MRI) is expensive but helpful in diagnosing ovarian torsion if findings on ultrasound are equivocal. MRI can demonstrate the components of a mass in more detail than an ultrasound. Computed tomography (CT), however, is not typically used in ovary torsion because of radiation and density, but patients with acute abdominal or pelvic pain need to undergo CT to exclude diagnoses such as appendicitis, diverticulitis, and others.

Finally, direct visualization is needed for a definitive diagnosis of ovary torsion. Hence, the diagnosis needs to be surgical proven for early rescue of ovary function.

Management

The gold standard to treat ovary torsion is surgery, and this is also the only way to confirm the torsion. There are two surgical methods, laparoscopy and laparotomy. A laparoscopic approach has become a popular procedure. However, if cancer of the ovary or fallopian tube is suspected, a laparotomy should be done. While performing the surgery, it is necessary to assess ovarian viability and preserve its function. The only way to determine the viability of a torsed ovary during surgery is by gross visual inspection. In the conventional view of point, dark and enlarged ovaries may have vascular and lymphatic congestion, and may seem nonviable. However, multiple studies have suggested that even those black or blue-like ovaries may retain ovarian function following detorsion. Postoperative follow-up with ultrasound showed over 80% of patients had normal follicular development after detorsion. Animal study showed that there may not be total occlusion of the artery in ovarian torsion even with venous and lymphatic congestion. In recent years, the mainstay of the treatment for ovarian torsion has been surgical evaluation and preserving ovarian function. There are many ways to perform the surgery and detorsion and ovarian conservation are almost always recommended now rather than salpingo-oophorectomy. An ovarian cystectomy is often performed for a benign ovarian mass. If malignancy is highly suspected, a salpingo-oophorectomy is needed. According to many observational studies, detorsion is associated with preserved ovarian function. The earlier the approach to torsion, the higher is the chance to preserve function. An animal study showed that necrosis might develop after occlusion of ovarian vessels for 36 h or longer. After the symptoms have developed, ovarian conservation reportedly decreases with time. No evidence suggests that detorsion increases adverse events postoperatively. Management in pregnant women is similar to that in nonpregnant patients, and laparoscopic surgery is safe for torsion in pregnant women. Neonates with ovarian torsion often present with irritability and the condition can be treated with laparoscopic surgery.

Prevention of recurrence

There is a risk of recurrence after detorsion, but the incidence and causes are unknown. According to recent research, several methods can be used to decrease the risk of recurrence. One method is suppression of ovarian cysts by oral contraceptives . Another method is an oophoropexy. However, both approaches lack long-term follow-up and systematic study.

Conclusion

Although the diagnosis of ovarian torsion is difficult and challenging, careful analysis of presenting symptoms (such as sudden onset of lower abdominal pain) is very critical. Pelvic ultrasonography can provide information on ovarian cysts. Once ovarian torsion is suspected, surgery is the mainstay of diagnosis and treatment. Ovarian cystectomy, oophorectomy, or conservative treatment with detorsion can be the treatment of choice.

Articles from Tzu-Chi Medical Journal are provided here courtesy of Wolters Kluwer/Medknow Publications

Authors Ci Huang, Mun-Kun Hong, and Dah-Ching Ding

Inflammation of the OVARY, generally caused by an ascending infection of organisms from the endocervix.

Hormone replacement therapy restored bone mineral density to normal in young women with primary ovarian insufficiency (POI). The findings provide important treatment information for women with POI and their physicians.

Spontaneous POI affects 1 in 100 women by age 40. With no apparent cause, the ovaries of affected women don’t work normally. They stop regularly releasing eggs and produce low levels of reproductive hormones, including estradiol (a type of estrogen) and testosterone (a predominantly male hormone that is also produced by women in smaller amounts). Women with POI have hot flashes, fertility problems, and irregular or no menstrual cycles. They also have reduced bone mineral density, which can lead to osteoporosis and bone fractures.

Hormone replacement therapy regimens have been well studied and optimized to improve bone health in postmenopausal women. But there has been limited research on the effects of these therapies in younger women. A team led by Drs. Vaishali B. Popat and Lawrence M. Nelson of NIH’s Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) tested the effects of hormone replacement therapy on bone health in young women with POI. The trial was done at NIH’s Clinical Center in Bethesda, Maryland.

The team enrolled 145 women with POI between the ages of 18 and 42. The women were randomly assigned to 2 groups. One received an estradiol patch, progestin pills, and a testosterone patch. The other received an estradiol patch, progestin pills, and an inactive placebo patch. The researchers used bone density scans of the hip and lower spine to measure the effects of the regimens. For comparison, the scientists also measured bone mineral density in an untreated group of 70 women with normal ovarian function. Results were published online on June 6, 2014, in the Journal of Clinical Endocrinology & Metabolism.

Both hormone treatment regimens led to increases in bone mineral density at 3 years. When the study began, women with POI had significantly lower hip and spine bone mineral density levels than those in the control group. By the study’s end, bone density measures in both treatment groups had increased to the same level as the women without POI.

The group receiving a testosterone patch didn’t gain further benefits over those with a placebo patch. Studies with a greater number of women would be needed to learn whether testosterone replacement might benefit women with POI, the researchers note.

“While hormone replacement therapy’s effect on bone mineral density has been studied in postmenopausal women, there is limited research on the effects of this therapy in younger women,” Popat says.

“This study showed that not only could hormone treatment reduce the rate at which women with POI lose bone mineral density, but it could actually restore bone density to normal levels,” Nelson adds.