1 Unit of Reproductive Medicine, Department of Obstetrics and Gynaecology, Clínica Las Condes and 2 Ares-Serono, Panamá 2121, 140 Martinez, Buenos Aires, Argentina
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Abstract |
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Key words: functional cysts/ovarian cysts/physiological cysts
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Introduction |
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For years, gynaecologists have prescribed oral contraceptives, containing a variety of oestrogen and progestin combinations, for the resolution of functional ovarian cysts (Vessey et al., 1987) and to distinguish between them and pathological cysts of the ovary (Spanos, 1973
). On the other hand, randomized controlled trials in women undergoing ovulation induction suggest that ovarian cyst resolution is not affected by oral contraceptives (Steinkampf et al., 1990
; Ben-Ami et al., 1993
), although both studies cited included not only functional cysts, but also pathological adnexal masses. Despite the results reported by the latter studies, the use of combined oestrogen and progestin preparations has become a common and accepted clinical practice in women having ovarian cysts in which the sonographic characteristics are benign (Lipitz et al., 1992
).
The purpose of the present study was to assess the spontaneous resolution of genuine functional ovarian cysts in women undergoing ovulation induction (cysts induced by ovarian stimulation), to determine whether the prescription of oral contraceptives has benefits over expectant management and to define the period of time necessary for the resolution of the cysts.
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Material and methods |
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Patients recruited for the study, except one who did not enter the randomization because of a previous history of gastric intolerance to oral contraceptives, were followed-up by transvaginal ultrasound for one or two cycles to verify the resolution of the ovarian cyst.
Assignment
After consent was obtained, 53 patients were randomized, either to have an expectant management for one cycle (group A: 27 women) or to receive oral contraception (ethinyl oestradiol 0.05 mg and levonorgestrel 0.25mg) for 21 days (group B: 26 women). Treatments were alternated every other week. A transvaginal ultrasound was repeated within the first 5 days of the next cycle, after women had their period following a spontaneous cycle or 3 weeks of oral contraceptive. If persistence of the cyst was observed, the patient had another cycle without any treatment and the ultrasound was performed again within the first 5 days of the next cycle.
Statistical analysis
As previous studies reported no differences between groups very similar to groups A and B (Steinkampf et al., 1990; Ben-Ami et al., 1993
), a sample size calculation was not conducted a priori. However, in order to detect the clinical relevance of the results, a statistical power calculation was performed (power test). Student's t-test was used to compare patients' characteristics,
2-test and Fisher's exact test, as appropriate, were used for statistical analysis and comparison between the group with and without oral contraceptives. The level of statistical significance was P < 0.05.
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Results |
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In group A, 19 of the 25 (76%) patients had a complete resolution of their cysts within the first cycle and in group B, 18 of the 25 (72%) women showed a complete resolution of their cysts when the ultrasound was performed after one cycle receiving oral contraception (Table I). Values in group A and B were not significantly different; however, the statistical power required to detect a significant difference between the groups, for 25 cases in each group, was only 5%. A total of 2500 cases in each group would be needed to increase this statistical power to 90%.
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Discussion |
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Moreover, all patients having persistent cysts had a complete resolution of the ovarian mass after one more cycle, without any treatment. This is in disagreement with the findings of Ben-Ami et al. (1993) and Steinkampf et al. (1990), who followed ovarian cysts after ovulation induction and found persistent cysts after 8 and 9 weeks respectively. Those patients underwent a laparoscopy and pathological adnexal masses, including endometriomas, hydrosalpinges, dermoid cysts and para-ovarian cysts were found, confirming that the initial findings did not correspond to functional cysts. This was not observed in the present study because an ultrasound was performed before starting with ovulation induction, confirming that both ovaries were normal, which seems to be a good practice in order to avoid wasting time with ovulation induction when patients need laparoscopy. Therefore, the results reported correspond to the resolution of functional cysts in women undergoing ovulation induction. However, as the number of patients included in this report is low, and the statistical power of the results obtained from the comparison between group A and B is only 5%, a larger number of cases is needed to obtain stronger and definitive clinical conclusions.
Although these results cannot be generalized to spontaneous cycles, it is likely that in women having normal ovulatory cycles, spontaneous resolution of functional cysts also occurs within 2 months of expectant management. After that period of time a laparoscopy should be performed if a persistent cyst is observed because of the high probability of finding a pathological rather than a functional cyst.
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Notes |
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References |
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De Wilde, R., Bordt, J., Hesseling, M. et al. (1989) Ovarian cystotomy. Acta Obstet. Gynecol. Scand., 68, 363364.[ISI][Medline]
Lipitz, S., Seidman, D.S., Menczer, J. et al. (1992) Recurrence rate after fluid aspiration from sonographically benign appearing ovarian cysts. J. Reprod. Med., 37, 845848.[ISI][Medline]
MacKenna, A. (1995) Contribution of the male factor to unexplained infertility: a review. Int. J. Androl., 18, 5861.[ISI][Medline]
Spanos, W.J. (1973) Preoperative hormonal therapy of cystic adnexal masses. Am. J. Obstet. Gynecol., 116, 551556.[ISI][Medline]
Steinkampf, M.P., Hammond, K.R. and Blackwell, R.E. (1990) Hormonal treatment of functional ovarian cysts: a randomized, prospective study. Fertil. Steril., 54, 775777.[ISI][Medline]
Vessey, M., Matcalfe, A., Wells, C. et al. (1987) Ovarian neoplasm's, functional cysts and oral contraceptives. Br. Med. J., 294, 15181520.[ISI][Medline]
Submitted on April 10, 2000; accepted on August 18, 2000.