Clinical Presentation of Ovarian Tumors

Ovarian malignancy is a serious disease affecting women of all ages, more so above 50 years, and they are still difficult to treat, partly because no truly effective therapy has yet been developed although presentation is often vague and non-specific, the symptoms are definitely present. It is important to recognize the symptoms so far, there is no test yet available, which is truly specific and suitable for screening and early detection of epithelial ovarian carcinoma. So, it is concluded that for prognosis and patient survival, early detection and treatment is mandatory.


Introduction
Ovarian tumor is one of the most common gynecological tumors seen in female although there are different types of ovarian tumor but epithelial ovarian cancer is the fifth most common cause of cancer death in women [1].In Pakistan, it is the 2 nd most common cause of death in women malignancies after breast tumor [2].
It is often called the "silent killer" because the disease is not often detected until it reaches an advance stage.Due to its anatomical location, such ovarian tumors may remain unnoticed for a long period of time [3] [4].Ovarian cancer usually affects the age of 65 years or older more frequently than younger women [1], they are not always malignant, but, the incidence of malignancy is about 15% -25% in different parts of the world [5].The incidence is high in North America and Europe as compared to Japanese [6].These tumors behave in diverse ways and are generally not detected until they get large size [7].Ovarian tumors may be cystic or solid in consistency.Most of the benign tumors are cystic but 80% of solid ovarian tumors are malignant [3] [8].
There are a number of risk factors associated with their origin.None of these has been yet proved except for age and parity [9].The relative risk for ovarian malignancy increases significantly after the age of 40 years [10].An early menarche and late menopause are associated with an increased risk [11].Use of oral contraceptive is associated with a reduced risk of benign ovarian neoplasma [12].Common symptoms include abdominal distension, abdominal and pelvic pain, and dyspepsia and also increased the frequency of urine [13].Family history of ovarian and breast cancer has strong link and considers as major risk factor for ovarian cancer [14] [15].One theory is that ovarian carcinoma arises from endometriosis; it is the presence of endometrial tissue rather than uterus [16].

Data Collection Procedure
Patients who had fulfilled the inclusion criteria were included in study; coming from OPD then informed consent was taken from patient.Details of the patient's symptoms were recorded on pre-designed Performa.Demographic profile including age, address, and parity was noted.A detail of symptoms was asked by researcher.
Symptoms which has been asked from patients include abdominal pain, abdominal mass and abdominal enlargement.Details of gastrointestinal symptoms like nausea, vomiting and urinary symptoms like increase in urinary frequency were asked.Constitutional symptoms including weight loss was asked.Then diagnosis is confirmed by ultrasound or laparotomy and histopathology.

Data Analysis
All the information has been entered in the proforma attached as annexure by the researcher and analyzed by using SPSS version 15.0.

Results
This case series study was conducted in the department of Obstetrics & Gynecology, Isra University Hospital, to determine the frequency of various clinical presentations of ovarian tumors by age and stage of disease.
Total 97 women with various clinical presentation of ovarian tumor were enrolled in this study based on inclusion & exclusion criteria.All the women were distributed and results are shown in the systemic order.

Discussion
Early diagnosis of ovarian cancer is challenge to gynecologist, mainly due to the fact that symptoms in early disease are vague and non-specific.Several studies have shown that women with ovarian cancer experience abdominal, GIT & constitutional symptoms, more as compared to those with benign tumors [17] [18].In my study, 19.6% patients were asymptomatic while the result of study conducted by Wasim T. shows that 11% patients were asymptomatic [3].Ovarian cancer is common in low parity & infertile women probably due to incessant ovulation theory.In my study, 48.5% women who had ovarian tumor were nullipara while 21% multipara.However in study conducted by khan I, at KEMU/Lady Willington hospital, 58.15% women who had ovarian tumor were multipara [19].In another population based case control study, Titus Ernstaff et al. found that risk of ovarian tumors was higher in multiparous [20], a woman which is comparable to results of my study.
Another study conducted by Naheed A. Malik shows the percentage of weight loss is 4%, these findings are similar to the present study [5].Delay in presentation is one of the big dilemmas with ovarian cancer & is responsible for high mortality associated with disease.Similar delays have been reported in other studies [21] [22].
In my study, 43% presented with ovarian tumor after 1 year of development of symptoms reason of delay were non-specific symptoms, inadequate health care system, omission of pelvic examination at presentation,

Conclusion
Ovarian tumor can affect peri-and postmenopausal women.The peak incidence is above 50 years of age.The women having history of malignancy in family should screen regularly specially in old age.So, it is concluded that for prognosis and patient survival, early detection and treatment is mandatory, which may reduce mortality.
There is need to increase awareness of population.Abdominal and pelvic bimanual examination should be carried out in every patient presenting with gynecological problem and appropriate investigations in post menopausal women in early period to diagnose the disease at an early stage.

Table 1 .
Frequency of age groups of study participants (n = 97).

Table 4 .
Frequency of various symptoms of study participants (n = 97).