Epidemiology of Ovarian Masses among teenagers in Mansoura University Hospitals

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Research

HJOG 2025, 24 (2), 143-159| doi: 10.33574/hjog.0594

Asmaa Abdellatif Mohamed Badr1, Sherin Mohammed Refaey Farag2, Nasser Sameh El-Lakkany3, Mohamed Hassan Hussien3, Alaa Wageh Osman4, Ahmed A Elgaml5

1Specialist of Obstetrics and Gynecology, Mansoura university Hospitals, Mansoura, Egypt
2Specialist of Obstetrics and Gynaecology, Ain Shams University, Cairo, Egypt
3Professor of Obstetrics and Gynecology, Faculty of Medicine, Mansoura University, Mansoura, Egypt
4Assistant Professor of Obstetrics and Gynecology, Faculty of Medicine – Mansoura University, Mansoura, Egypt
5Assistant Lecturer of Obstetrics and Gynaecology, Ain Shams University, Cairo, Egypt

Correspondence: Asmaa Abdellatif Mohamed Badr, Mansoura University Hospital, Department of Obstetrics and Gynecology, Mit Khamis WA Kafr Al Mougi, 7650030, Egypt, e-mail: karimabdel2013@outlook.com

Abstract

Background: The estimated prevalence for ovarian masses in the pediatric and adolescent age is 2.6 cases out of 100,000 each year. Clinical Symptoms might be a helpful tool in the diagnosis of ovarian masses despite their non-specificity and overlapping between different ovarian masses. The basic principles for managing ovarian masses in teenagers should be to define mass major characteristics, to manage functional cysts conservatively by avoiding any unnecessary surgery for them and to rule out malignancy.

Objective: To analyze epidemiology of ovarian masses in teenagers admitted at Mansoura University Hospitals.

Methods: This cross-sectional study has been carried out in the department of obstetrics and gynecology at Mansoura University Hospitals throughout the period 2018. The study included 76 patients aged between thirteen and nineteen years with a diagnosis of ovarian mass by ultrasonography or CT or MRI, those patients below the age of thirteen and those above the age of nineteen were excluded from the study.

Results: During the study period, 76 patients were diagnosed with ovarian masses. The age of patients ranged from 13 to 19 years (median, 16.63±2.2 years). Many patients underwent more than one diagnostic procedure owing to the varied nature of presented symptoms; however, pelvic ultrasound was most commonly performed. Accuracy of diagnosis by ultrasound was (89.8%); accuracy of diagnosis by MRI was (87.5%) while CT was not accurate in the case performed in it, which pathology turned out to be hemorrhagic infarction of the ovary. CA125 was done in 20 cases and its level raised in 2 cases, one turned out to be benign neoplasm (cystadenofibroma) and the other case was malignant neoplasm (immature teratoma). Alpha-fetoprotein (AFP) was done in 11 patients, and the level raised in only one of them histopathology of which turned out to be immature teratoma. LDH was done in 6 patients, and its level raised in 4 of them including 2 benign neoplasms, their histopathology turned out to be mucinous cystadenoma and fibrothecoma and 2 malignant neoplasms, their pathology turned out to be dysgerminoma and granulosa cell tumor. ALP was done in 3 patients and its level raised in two of them, one turned out to be benign neoplasm (cystadenofibroma) and the other case was malignant neoplasm (immature teratoma). B-HCG was done in 9 patients, and none of them had a rise. CEA was done in 4 patients, and none of them had a rise.

Conclusion: Adolescents benefit from conservative management of ovarian cysts because ovarian cysts are more likely to be benign. If surgical approach is mandatory, the aim should be preservation ovarian tissue in order to preserve fertility and allow normal pubertal development. Detorsion of the torsed ovary is the ideal procedure even if the ovary appears necrotic. The laparoscopic approach is effective and safe for managing benign adnexal masses in adolescents.

Keywords: Ovarian Masses, teenagers

Introduction

A teenager, or teen, is a young person whose age falls within the range from 13 -19 years old (1). The incidence of ovarian masses has been rated at 2.6 cases per 100,000 girls every year (2). They are the most common genital tract tumors in teenagers (3).

Ovarian masses are classified as functional cysts, benign tumors and malignant tumors. (57.9%) of females below the age of 21 who underwent surgical procedures for ovarian masses had been diagnosed with an ovarian cyst (4).

Ovarian masses have many presentations involving abdominal pain, abdominal enlargement, and palpable abdominal mass, precocious puberty, nausea and vomiting (5,6). It has been demonstrated that cysts in adolescents are frequently linked to menstrual cycle irregularities (7). Palpable abdominal mass is the most frequent presentation of ovarian cysts in prepubertal females(5). Gynecologist should suspect ovarian torsion whenever the patient complains of sudden onset of severe abdominal pain, nausea, vomiting or fever (8).

The diagnostic modality of choice for ovarian masses in teenagers is ultrasonography with the use of endovaginal probe beings favored in mature patients who can tolerate the examination (9). MRI or CT could be used for additional knowledge about the nature and extent of ovarian mass (9).

Tumor markers are indicated if ovarian masses are suspicious for a malignant nature, complex or solid. Germ cell tumors are the most common malignant ovarian tumor in adolescents, which is completely distinct from elderly women (4). Tumor markers involve CA-125, alpha fetoprotein, serum beta-HCG, estradiol, inhibin B, and lactate dehydrogenase (9), their levels raise in only (6.5%) of benign ovarian masses and (54%) of ovarian malignancies, yet they could be useful in  diagnosis of a germ cell tumor (5).

Adolescents diagnosed with ovarian masses are mostly managed by surgical approach which may compromise future fertility, due either to removal of the ovary or due to adhesions formation(10, 11).

Aim of the work

The aim of this study is to analyze epidemiology of ovarian masses in teenagers admitted at Mansoura University Hospitals.

Patients & methods

This cross-sectional study has been carried out in the department of obstetrics and gynecology at Mansoura University Hospitals throughout the period 2018. The study included 76 patients aged between thirteen and nineteen years with a diagnosis of ovarian mass by ultrasonography or CT or MRI by the same radiologist for consistency of results, those patients below the age of thirteen and those above the age of nineteen were excluded from the study.

If an ovarian lesion has at least one of these features by diagnostic radiological methods, it can be confidently considered malignant: irregular solid tumor, irregyular multilocular-solid mass>10 cm in diameter, >4 papillary structures, ascites and high Doppler signal (color score 4)

Every patient has been analyzed for demographic profiles, initial symptoms, preoperative radiologic findings, operative approach, surgical procedure and pathology findings.

The clinical profiles were analyzed in terms of age at time of diagnosis, residence (urban, rural), parity, menstrual history (premenarcheal, postmenarcheal), sexual history,  history of operation (ovarian cystectomy, appendectomy, cesarean section),  initial symptoms (abdominal Pain, abdominal enlargement, nausea and vomiting, fever), complications (torsion, rupture, hemorrhage), preoperative radiologic findings, mass diameter (cm) and side on ultrasound, tumor markers if done (cancer antigen [CA] 125, alpha fetoprotein [AFP], β-human chorionic gonadotropin, Alkaline phosphatase, lactate dehydrogenase, carcinoembryonic antigen) and management (conservative, surgical).

Those patients who were managed surgically have been analyzed as regard to operative approach (laparoscopy, laparotomy), operation method (emergency, elective), operator (assistant lecturer, lecturer and professor) and histopathology findings (frozen histopathology if done, definitive histopathology). The surgical procedures performed were categorized as ovarian cystectomy, detorsion and ovarian cystectomy, unilateral salpingo-oophorectomy and total abdominal hysterectomy and bilateral salpingo-oophorectomy.

The study was approved by the local ethical committee and parental consent obtained, with patient confidentiality was preserved.

Statistical analysis

Data were fed to the computer and analyzed using IBM SPSS software package version 22.0. Qualitative data were described using number and percent. Quantitative data were described using median (minimum and maximum) for non-parametric data and mean, standard deviation for parametric data after testing normality using Kolmogrov-Smirnov test / Shapiro-Wilk test. The proper statistical analyses were applied. Significance of the obtained results was judged at the (0.05) level.

The sample size (76 cases) represented well the population at risk considering the low prevalence of ovarian masses in adolescents. The duration of study period(2018), in relation to data collection,   was sufficient to capture seasonal or yearly variation.

Results

During the study period, 76 patients were diagnosed with ovarian masses. The age of patients ranged from 13 to 19 years (median, 16.63±2.2 years). (6.6%) of patients were premenarcheal and (93.4%) of patients were postmenarcheal, (64.5%) of which had regular menstruation while (28.9%) had irregular menstruation and (26.3%) of patients were sexually active. (44.7%) of patients had urban residence while (55.3%) had rural residence (Table 1).

The most common presenting symptom was abdominal pain (89.5%). Other initial symptoms were abdominal enlargement (7.9%), nausea and vomiting (11.8%), fever (6.6%) and (10.5%) of patients were asymptomatic. Ovarian masses were right sided in (53.9%) of cases, left sided in (40.8%) of cases and bilateral in (5.3%) of cases. Mass diameter median (Range) was 7.0 (3.0-29.0) cm. As regard to surgical history, (9.2%) of patients had history of ovarian cystectomy, (7.9%) had previous cesarean section and (7.9%) had undergone appendectomy. (50%) of ovarian masses were managed conservatively while (50%) were surgically removed (Table 2).

57 (25.0%) of ovarian masses were complicated, 10 (13.2%) were complicated by hemorrhage, 6 (7.9%) were complicated by torsion and 3 (3.9%) were complicated by rupture and internal hemorrhage (Table 3).

Many patients underwent more than one diagnostic procedure owing to the varied nature of presented symptoms; however, pelvic ultrasound was most commonly performed. The preoperative radiologic reports were available for all patients and included findings from 59 ultrasonography images, 1 computed tomography, and 16 magnetic resonance images. The median (range) size of ovarian masses was 7.0 (3.0-29.0) cm by ultrasound. Accuracy of diagnosis by ultrasound was (89.8%); accuracy of diagnosis by MRI was (87.5%) while CT was not accurate in the case performed in it, which pathology turned out to be hemorrhagic infarction of the ovary. Doppler ultrasound was performed in 10 cases of ovarian torsion and it was accurate in diagnosis of (90%) of them (Table 4).

Surgery was performed in 38 (50%) patients, 24 (63.2%) of operations were elective and (36.8%) were emergent because of either torsion or rupture of ovarian cysts and internal hemorrhage. According to surgical approach, laparotomy was done for 28 (73.7%) cases and 10 (26.3%) of operations were done by laparoscopy. The procedures performed were ovarian cystectomy for 20 (52.6%) patients, salpingo-oophorectomy for 15 (39.5%) patients, detorsion for 2 (5.3%) and total abdominal hysterectomy and bilateral salpingo-oophorectomy for one (2.6%) patient. The ovaries were preserved in 60 (78.9%) patients (Table 5).

Figure 1. Dermoid ovarian cyst in a 15‐years old teenager.

11 (14.5%) of lesions were non-neoplastic, 3 (27.3 %) of which were corpus luteal cysts, 2 (18.2%) were follicular cysts, 2 (18.2%) were simple serous cysts, 2 (18.2%) were endometriotic ovarian cysts, 1(9.1%) was mesothelial cyst and 1(9.1%) was ovarian edema by histopathology. Benign neoplastic tumors represented (34.2%) of all lesions, including 4 (30.8%) mature cystic teratomas (i.e., dermoid cysts), 4 (30.8%) cystadenofibromas, 2 (15.4%) mucinous cystadenomas, 2 (15.4%) serous cystadenomas and 1 (7.7%) fibrothecoma. Only 4 patients (10.5%) had a malignant neoplastic tumor, two of which were immature teratoma, one patient had dysgerminoma while the other one had granulosa cell tumor. The patient with dysgerminoma was also turner syndrome 45 X0, had congenital anomalies in heart (ventricular septum defect) and underwent surgery for septum closure. Laparotomy in this case revealed streak gonads, so total abdominal hysterectomy and bilateral salpingo-oophorectomy was done. Frozen histopathology was done for 7 cases, only 2 of the 3 benign tumors were correctly diagnosed by frozen histopathology and 3 of the 4 malignant lesions were correctly diagnosed by frozen histopathology. Overall frozen accuracy was (57.1%) among studied cases (Table 6 and table 7).

Figure 2. Bilateral benign multilocular serous cystadenoma in a 14‐years old teenager.

Ovarian torsion occurred in 12 (31.6%) patients in this study, (50%) of ovarian torsion cases were caused by ovarian cysts, 3 (50%) of them were simple serous cysts, 2 (33.33%) were hemorrhagic cysts and one cyst (1.66%) was mature cystic teratoma on histopathology. All 12 patients presented with abdominal pain, nine of which also presented with nausea and vomiting and five patients had fever. All patients underwent emergency laparotomy; salpingo-oophorectomy was done in 10 (83.3%) patients while only 2 (16.7%) patients had detorsion and ovarian cystectomy, respectively (Table 8).

CA125 was done in 20 cases and its level raised in 2 cases, one turned out to be benign neoplasm (cystadenofibroma) and the other case was malignant neoplasm (immature teratoma). Alpha-fetoprotein (AFP) was done in 11 patients, and the level raised in only one of them histopathology of which turned out to be immature teratoma. LDH was done in 6 patients, and its level raised in 4 of them including 2 benign neoplasms, their histopathology turned out to be mucinous cystadenoma and fibrothecoma and 2 malignant neoplasms, their pathology turned out to be dysgerminoma and granulosa cell tumor. ALP was done in 3 patients and its level raised in two of them, one turned out to be benign neoplasm (cystadenofibroma) and the other case was malignant neoplasm (immature teratoma). Β-HCG was done in 9 patients, and none of them had a rise. CEA was done in 4 patients, and none of them had a rise (Table 9 and table 10).

Of the group with benign tumors which represented (13%) of all patients, 5 (38.5%) patients were below the age of 15 years and 8 (61.5%) patients were above the age of 15 years. 4( 30.8%) patients were not sexually active while 9 (69.2%) patients were sexually active, all of them were nullipara. 6 (46.2%) patients had urban residence while 7 (53.8%) patients had rural residence. 3 (23.1%) patients were premenarcheal while 10 (76.9%) were postmenarcheal, 7 of them had regular menstruation while 3 of them had irregular menstruation. Mass diameter median (range) of benign ovarian masses was 10.0(5.0-29.0) cm by ultrasound.  6 (46.2%) of them were right sided, 5 (38.5%) of them were left sided while 2(15.4%) of them were bilateral. All patients with benign ovarian masses presented with abdominal pain, 2 (15.4%) patients presented with abdominal enlargement, 1 (7.7%) patient presented with nausea and vomiting and 1 (7.7%) patient presented with fever. Only one patient with benign ovarian mass which was complicated by torsion underwent detorsion and ovarian cystectomy, the pathology turned out to be mature cystic teratoma. 10 (76.9%) patients underwent ovarian cystectomy and 2(15.4%) patients underwent salpingo-oophorectomy, definitive histopathology for one of them turned out to be cystadenofibroma complicated by torsion. Frozen histopathology was done for the other one and revealed atypical spindle cell proliferation (malignant) while definite histopathology turned out to be fibrothecoma (benign). Frozen histopathology was done for 3 patients, frozen was accurate in 2(66.7%) of cases (Table 11).

Of the group with malignant tumors which represented 4% of all patients, 1(25.0%) patient was below the age of 15 years and 3(75.0%) patients were above the age of 15 years. All patients were not sexually active. 1(25.0%) patient had urban residence while 3 (75.0%) patients had rural residence. 1(25.0%) patient was premenarcheal while 3 (75%) patients were postmenarcheal, two of them had regular menstruation while the other one had irregular menstruation. Mass diameter median (range) of malignant ovarian masses was 15.5 (10.0-20.0)cm by ultrasound.  3 (75.0%) of them were right sided and the other one (25.0%) was left sided. All patients with malignant ovarian masses presented with abdominal pain and 2 (15.4%) patients presented with abdominal enlargement. 2 (50.0%) patients underwent salpingo-oophorectomy, 1 (25.0%) patient underwent ovarian cystectomy and 1 (25.0%) patient underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy. Frozen histopathology was done for all 4 patients and it was accurate in 3 (75.0%) of cases (Table 11).

(18.4%) of ovarian masses were recurrent, 3 (21.4%) patients were below the age of 15 years and 11(78.6%) patients were above the age of 15 years. 10 (71.4%) patients were not sexually active while 4 (28.6%) patients were sexually active, all of them were nullipara. 7 (50.0%) patients had urban residence and 7(50.0%) patients had rural residence. 2 (14.3%) patients were premenarcheal while 12 (85.7%) were postmenarcheal, 7(50.0%) of them had regular menstruation while the other 5(35.7%) patients had irregular menstruation. Mass diameter median (range) of recurrent ovarian masses was 7.0(5.0-20.0) cm by ultrasound. 8  (57.1%) of recurrent ovarian masses were right sided and 6 (42.9%) of them were left sided. All patients with recurrent ovarian masses presented with abdominal pain, 2 (14.3%) patients presented with abdominal enlargement and 1 (7.1%) patient presented with nausea and vomiting. 4 (28.6%) recurrent ovarian masses were complicated, 3 of them were  complicated by intracystic hemorrhage while only one recurrent ovarian mass was complicated by internal hemorrhage. 6 (42.9%) recurrent ovarian masses were managed conservatively and 8 (57.1%) patients underwent surgical operations. 6 (75.0%) patients underwent ovarian cystectomy, 1 (12.5%) patient underwent salpingo-oophorectomy and 1 (12.5%) patient underwent total abdominal hysterectomy and bilateral salpingo- oophorectomy. Histopathology of recurrent ovarian masses turned out to be follicular cyst in (12.5%) of cases, simple serous cyst in (12.5%) of cases, mature cystic teratoma in (12.5%) of cases, corpus luteum cyst in (12.5%) of cases, mucinous cystadenoma in (12.5%) of cases, serous cystadenofibroma in (12.5%) of cases, immature teratoma in (12.5%) of cases and dysgerminoma in (12.5%) of cases (Table 12 and table 13).

Discussion

The estimated prevalence for ovarian masses in the pediatric and adolescent age is 2.6 cases out of 100,000 each year (3). However, they provoke nervousness for both the patient and her household and they pose a notable challenge in management. In accordance with the study done by Kim et al. (12) where the mean age was 17.1 years, the mean age of our study population was 16.63±2.2 years. (93.4%) of adolescents included in our study were postmenarcheal, concurrent with other studies (13, 14).

Functional cysts predominate in postmenarcheal females secondary to hormonal changes at puberty (104); they result from failure of ovulation or ovarian follicles persistence (9). Functional cysts could also be symptomatic with hemorrhage inside cyst, cyst rupture, torsion, and enlargement. In our study, (50%) of simple ovarian cysts were managed conservatively as simple cysts greater than 3 cm need to be managed conservatively with month to month ultrasounds to verify regression (15), they resolve spontaneously through 3 menstrual cycles.

Based on our study, the most common presenting symptom was abdominal pain (89.5%) then abdominal enlargement followed (7.9%), which was similar to previous findings that reported abdominal pain and a palpable mass in (70%) and (35.7%) of females with ovarian masses, respectively (4). Other symptoms were nausea and vomiting (11.8%), fever (6.6%) and (10.5%) of ovarian cysts were detected incidentally. Tenderness might also be a symptom of rupture, hemorrhage or torsion of ovarian masses (16). Adnexal masses in adolescents are more likely to be benign (17); however, analysis of signs and symptoms cannot demonstrate nature of masses.

All patients were preoperatively assessed by ultrasound as ultrasound is well known to be the gold standard in evaluating an adnexal mass (5,18,19).The mean diameter of adnexal masses was 7 cm, similar findings were reported in other studies as well (13,20). The sensitivity of ultrasound in diagnosing a benign adnexal mass in this study was (89.8%) which was comparable to the study done by marret that showed the sensitivity of ultrasound to be (80%) (20). However both benign and malignant tumors can appear cystic, solid ovarian masses recognized by using ultrasound were more likely to be malignant (21).  In our study 4 of the 7 solid ovarian masses recognized with the aid of ultrasound had been malignant.

Computed tomography (CT) or magnetic resonance (MR) imaging could be carried out to attain additional information, such as the mass nature and mass extent (9); in our study MRI accuracy was (87.5%).

(60%) of all ovarian neoplasms in teens and kids are of germ cell origin and one-third of these reported to be malignant (22).  In our study only (28.9%) of ovarian tumors had germ cell origin and (36.4%) of them were malignant.

Ovarian masses risk of malignancy in teens has been estimated around (19%), with a range from (2 to 59%) with variations due to referral bias (specialized pediatric oncologist or not) and ages of studied adolescents (23), which is consistent with our study where (10.5%) of all ovarian masses had been malignant. (66.6%) of malignant tumors were germ cell tumors and (33.3%) were sex cord stromal tumors. The most frequent malignant ovarian germ cell tumor is dysgerminoma (22,24). In our study immature teratoma was the most frequent malignant germ cell tumor representing (50%) of all germ cell tumors.

Sex cord-stromal tumors had been uncommon and represented approximately (5.3%) of all ovarian tumors, fibroma accounted for approximately (50%) of sex cord-stromal tumors which was consistent with other studies (25, 26).

Epithelial ovarian tumors are rare in teenagers and mostly occur in the period after menarche and are extremely rare prior to menarche (27,28). In our study epithelial tumors were found in (15.8%) of patients and all were benign.

As CA 125 has limited specificity in adolescence (18), AFP, b-HCG, lactate dehydrogenase, alkaline phosphatase and carcinoembryonic antigen were assessed additionally. Tumor markers could be a useful resource in diagnosis of a germ cell tumor but they have been stated to be elevated in only (54%) of malignant ovarian tumors and (6.5%) of benign tumors (5). In our study CA125 level raised in (50%) of malignant tumors, LDH level raised in (66.7%) of malignant tumors and AFP level raised in (33.3%) of malignant tumors.

In distinguishing patients with benign disease from those with malignancy, It has been found that age was not useful (P=0.62), whereas imaging traits, tumor size and tumor markers were crucial. Malignant tumors were more likely to be larger 15.5(10.0-20.0) cm in our analysis (p=0.09), which was comparable with preceding findings (29).

Fertility preservation requires rapid diagnosis and quick surgical interference in cases suspicious of ovarian torsion. Ovarian torsion represents (2.7%) of all kids who present with acute abdominal pain (30), it is most commonly caused by a benign ovarian cyst or teratoma. In fact, (97%) of torsions result from benign lesions (31). Ovarian cyst size has not been proven to correlate with an increased risk of ovarian torsion (31).

In our study, ovarian torsion represented (31.6%) of all patients who presented with acute abdominal pain, about (50%) of cases were caused by ovarian cysts, all of them were of benign nature, (50%) were simple serous cysts, (33.33%) were hemorrhagic cysts and (1.66%) were mature cystic teratoma on histopathology.

Ovarian torsions are more commonly to occur on the right side due to the protective impact of the sigmoid colon(32), while in our experience they were found equally on both sides. Oophorectomies had been used for treating ovarian torsion in the past for fear of possible embolization after detorsion. Up to now, thromboembolic events have not occurred in the gonadal veins of young females during detorsion (33). The surgical approach should be as conservative as possible in order to keep future fertility; therefore, detorsion by laparoscopy or conventional surgery can be performed by puncturing a benign appearing cyst or cystectomy of a dermoid cyst in order to keep future fertility(32). In our experience, ovarian torsion had been reported in about (31.6%) of patients, salpingo-oophorectomy was performed in 10 (83.3%) of cases. Detorsion was performed for two (16.7%) cases, with no reported complications (i.e. embolization and infection). Salpingo-oophorectomy was performed for eight cases because the ovary was completely necrotic. Lately, detorsion has been encouraged even if the ovaries appear necrotic (34). In our study, oophoropexy has been done in one case after detorsion, it is possible that oophoropexy causes adhesions and future infertility via distortion of the ovary-fallopian tube relationship, and consequently, it should be discouraged. Detorsion via laparoscopy is the procedure of choice even if the ovary appears necrotic (35), it has been proven that ovary was well perfused in (88%) to (100%) of patients handled conservatively (36).

Ovarian masses in teens are treated conservatively in common, whether expectant, medical or surgical. The decision to use laparotomy or laparoscopy relies upon the laparoscopic skills of the treating gynecologist. Laparoscopy has been recommended for treating ovarian cysts, even those with large diameters as it is associated with satisfactory results and few complications (114). Laparoscopy could be used for diagnostic and therapeutic purposes with direct detorsion or oophorectomy in patients with complete ovarian necrosis (4,37), it has been proven to be a generally safe and beneficial alternative to laparotomy (38). On this study laparotomy was performed in (73.7%) of patients while laparoscopy was performed in (26.3%) of patients. However, the lapa-roscopic technique has limitations in large ovarian masses or if malignancy is suspected.

Limitations of the study

The main limitation of this study was  the effect of the single-center design and possible referral bias. The duration of one year affects its ability to fully explain variability in presentation and outcome. The limited sample size for analysis of uncommon outcomes, e.g., malignancy.

Conclusion

The risks of cyst rupture or torsion occur more commonly in ovarian cysts more than five cm in diameter and adolescents should be informed of the risks and advised to seek care immediately in case of new symptoms. Abdominal pain is the most common presenting symptom, teenagers should be referred to experienced gynecologist in order to achieve the best possible outcome and preserve fertility. Although ultrasound is the gold standard for diagnosis of ovarian mass, it could not determine the nature of the mass, tumor size and tumor markers are more helpful to distinguish between benign and malignant ovarian masses. The most common benign tumors are mature cystic teratoma and cystadenofibroma and germ cell tumors are the most common malignancy in adolescents. Adolescents benefit from conservative management of ovarian cysts because ovarian cysts are more likely to be benign. If surgical approach is mandatory, the aim should be preservation ovarian tissue in order to preserve fertility and allow normal pubertal development. Detorsion of the torsed ovary is the ideal procedure even if the ovary appears necrotic. The laparoscopic approach is effective and safe for managing benign adnexal masses in adolescents.

Future recommented studies

We recommend repeating this study with Multi-center design and clear unified referral protocols. Also, increasing the duration of the study to fully explain variability in presentation and outcome. Also, increasing the sample size for analysis will be more informative. 

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