Ovarian Remnant Syndrome

Someone asked me to write about ovarian remnant syndrome. This is actually a pretty simple thing in concept, but can be difficult to treat in some cases. What happens is that some ovaries get stuck down to the pelvic sidewall, sometimes from endo, sometimes from other things. Underneath the ovary on the sidewall (under the peritoneum) are lots of "dangerous" structures like the ureter and lots of big blood vessels and nerves that intimidate most gynecologists. Because they don't want to risk damage to these structures, some docs prefer to leave a little bit of ovarian tissue on the sidewall rather than dissect the ovary and attached peritoneum off the pelvis in order to remove the entire ovary. Sometimes this little bit of ovary has enough cells that it continues to be metabolically active enough to make hormones and form cysts. Oftentimes there are adhesions over the remnant of ovarian tissue that get stretched when the cysts form, thereby causing pain. The simple answer to this problem is to remove the remnant of ovary. The real life issues that make this a little more challenging are twofold. First, in order to diagnose a condition, one must first think of that condition. Most GYNs think that if the ovary was removed, it can't cause any more problems, so when a patient presents with right sided pelvic pain and previously had their right ovary removed, the doc starts trying to think of other things that can cause right sided pain (appendix, fibroids, gallbladder, etc). Oftentimes they're right to think of these other sources of pain. But, if the investigative workup into other causes of pain leads nowhere, then what? It's sad but true, I've seen GYNs remove the right ovary in patients with left sided pain "because the left ovary is already gone". Crazy. Ovarian remnant syndrome isn't all that common, but it certainly needs to be in the list of things thought about in patients with persistent unilateral pain after removal of that adnexa (tube and ovary). The second reason that these can be difficult problems to deal with is because some patients have incredibly dense adhesions of bowel and omentum over the top of the remnant of ovary. This can lead many surgeons to leave the abdomen before finishing the job (can you say "cut and run"?). One example of this is a patient I had in Hawaii. She had multiple surgeries by her previous GYN and a couple by me, eventually resulting in removal of both ovaries and her uterus. At the last surgery she had the worst bowel adhesions I've ever seen before or since. Imagine a kettle full of sausage, then pour Elmer's glue all over them, mix it up, and let it harden. The last thing I wanted to do was reoperate on this poor girl, but she kept having a recurrent fluid collection in her right pelvis that caused her pain. We tried everything to suppress it (OCPs), drain it via ultrasound guidance, and nothing worked. Finally before I left I agreed to go back in to remove this cystic structure. We finally did succeed in finding it, under 6 layers of bowel adhesions, and after making a couple holes in the bowel (and fixing them) guess what the path report showed? Ovarian tissue. The good news is that she finally recovered from her surgery, and now has no more pain from that cyst. The take home message is that even if you do figure out what's going on, these cases can be extremely difficult, time consuming, and risky. I knew what I would find, so the patient was prepared, but it's not always that obvious before the surgery starts. The take home message from this is that as surgeons specializing in pelvic pain, we have to be prepared for anything. We also have to be prepared to think of anything, even if it seems unlikely. Too often I see doctors try to make the operation they know how to do fit the patient. This results in removal of things that don't need to be removed, or worse, a "peek and shriek", where the scope is placed, they take a look around, and then promptly run away because they don't have the tools (skill, experience, ego small enough to ask someone with more of the first 2 than they have to help them) to do the job right. When I evaluate a patient with pain, I go through an algorithm in my head and evaluate every aspect of the pelvis. Ovaries, tubes, uterus, bladder, bowel, upper urinary tract, pelvic floor muscles, abdominal muscles, pelvic girdle/spine/orthopedic issues, upper abdominal causes, nerves, muscles, infections, masses; and on and on. When only the 1st 3 and the last 2 are considered, you miss a lot. I don't want to be like the politicians - only having scripted answers regardless of the questions. I close with the Robin Williams quote "politicians are like diapers. They should be changed often, and for the same reason."
Take care, and have a good week or 2 or 3. I'll be off for the next few weeks, but don't worry. I'll be back. Leave me all your good ideas for what to write about so I won't have to think too hard the week I come back.
Dr. Mos