{"paper_id":"14024fb0-474f-433f-b85a-f5c38ffa6b6e","body_text":"154\nThis is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International  \n(CC BY-NC-SA 4.0). License (http://creativecommons.org/licenses/by-nc-sa/4.0/)\nCASE REPORT\nDOI: https://doi.org/10.5114/pm.2021.109773\nMenopause Rev 2021; 20(3): 154-157\nIntroduction\nAbdominal and pelvic pain with an associated pelvic \nmass is a very common emergency situation. There is \nalways a management dilemma for most emergency \nphysicians regarding these patients. Physicians encoun-\nter difficulties in differentiating a potential surgical prob-\nlem such as torsion of an enlarged ovary and a non-sur-\ngical pathology such as uterine leiomyoma in a physical \nexamination. Different types of imaging examinations, \ne.g. ultrasonography (US), computed tomography (CT), \nand/or magnetic resonance imaging (MRI), are the gold \nstandard imaging tools used to differentiate pelvic mass-\nes in women presenting with abdominal and pelvic pain \nto the emergency department (ED) [1]. \nCase report\nA 46-year-old postmenopausal woman was admit-\nted to our ED with complaints of massive abdominal \ndistention which started gradually 30 days ago. She \nalso complained of difficulty in breathing and ambula-\ntion. There were no other gastrointestinal, gynecologi-\nAn enormous pelvic tumor in a 46-year-old woman with an elevated  \nserum CA 125 level, what lies beneath it? Investigation of uterine tumors  \nin postmenopausal women\nFrancesk Mulita, Elias Liolis, Dimitrios Kehagias, Levan Tchabashvili, Charalampos Kaplanis,  \nFotios Iliopoulos, Ioannis Perdikaris, Ioannis Kehagias \nDepartment of Surgery, General University Hospital of Patras, Rio, Greece \nAbstract\nAbdominal and pelvic pain with an associated pelvic mass is a very common emergency situation. There is \nalways a management dilemma for most emergency physicians regarding these patients. A 46-year-old post-\nmenopausal woman was admitted to our emergency department (ED) with complaints of massive abdominal \ndistention. Abdominal and pelvis magnetic resonance imaging (MRI) was performed, which revealed a huge \npelvic abdominal mass. All tumor markers were within normal limits. However, the ovarian cancer antigen  \n(CA 125) level was elevated. As there was a strong suspicion of malignancy, the patient underwent total ab-\ndominal hysterectomy with bilateral salpingo-oophorectomy. Her final histopathology report was suggestive  \nof uterine leiomyoma. Uterine leiomyomas are the most common benign uterine tumors in women. Surgical \ntreatment is the gold standard, especially for older women with severe symptoms and no desire for future fertil-\nity. Although the combination of a pelvic tumor and a high-level of CA 125 arouses suspicion of gynecological ma-\nlignancy, other benign conditions should always be considered in the differential diagnosis. There is limited evi-\ndence to support an association between elevated CA 125 levels and uterine fibroids so far. However, conditions \nsuch as the coexistence of adenomyosis and tumor size can affect the level of this marker in uterine fibroids.\nKey words: menopause, uterine tumor, CA 125, leiomyoma.\ncal, or urinary symptoms. The woman had a significant \npast medical history of hypertension. Her family history \nis negative for ovarian and breast cancer in first-degree \nrelatives. On physical examination, the patient’s abdo-\nmen was distended. Blood analysis revealed hemoglobin \nof 13.9 g/dL, 8280 leukocytes, and 226 000 platelets. All \ntumor markers were within normal limits. However, the \novarian cancer antigen (CA 125) level was 260.9 U/mL \n(normal range: 0–35 U/mL). Abdominal and pelvis MRI \nwas performed, which revealed a huge pelvic-abdom-\ninal mass measuring approximately 22 x 15 x 12 cm \n(Fig. 1 A, B, C). As there was a strong suspicion of ma-\nlignancy, the patient underwent total abdominal hys-\nterectomy with bilateral salpingo-oophorectomy. The \nenormous lobulated tumor weighing 6.7 kg had a thick \nwall with solid and cystic areas (Fig. 1 D). Her final his-\ntopathology report was suggestive of uterine leiomyo-\nma. The patient had no intra-operative or postoperative \ncomplications. On day 5 after the surgery, the patient \nwas discharged home. Three months following the \nsurgery, the CA 125 levels had regressed to the normal \nrange. The patient has since been symptom-free, and \nthe CA 125 levels have also remained normal.\nCorresponding author: \nDr. Francesk Mulita, Department of Surgery, General University Hospital of Patras, Rio, Greece ,  \ne-mail: oknarfmulita@hotmail.com\nSubmitted: 14.04.2021\nAccepted: 09.06.2021\n\nMenopause Review/Przegląd Menopauzalny 20(3) 2021\n155\nDiscussion\nMenopause is defined as the absence of menstrual \ncycles for at least twelve consecutive months, indicat-\ning the end of the reproductive age for women as they \nare not able to get pregnant naturally [2, 3] Menopause \nis a natural biological event, but the mean age can dif-\nfer between women and it can be affected by several \nparameters, e.g. nationality, diet, other diseases. Meno-\npause is also associated with hormonal changes. More \nspecifically, the levels of estrogen, progesterone, folli-\ncle-stimulating hormone (FSH), and other hormones are \naffected. Early menopausal transition causes fluctua-\ntions in estrogen but eventually its production declines \ncompletely (last post-menopause stage). The same pat-\ntern is observed for FSH and progesterone [2]. These \nhormonal changes are associated with various symp-\ntoms such as hot flushes, night sweats, etc. [4]. Studies \nalso have demonstrated a potential role of menopause \nonset with hormone-related cancers such as ovarian, \nendometrial, and breast cancer as late menopause \nmeans higher hormone levels for women and longer \nexposure to estrogens. According to one hypothesis, \nestrogens play a  mitogenic role but mitotic activity \nincreases the probability of DNA damage resulting in \na mutation that can lead to the transformation of en-\ndometrial cells and tumor formation [2, 3, 5]. Therefore, \na uterine tumor is a phenomenon usually observed in \npostmenopausal women. \nAbnormal uterine bleeding is the first sign that \nleads postmenopausal women to seek gynecological \nadvice. Bleeding may be due to a tumor, but many oth-\ner diseases also can cause it [6, 7]. Therefore, it is very \nimportant to proceed with the right diagnosis. The first \nstep is the physical examination that involves a pelvic \nexamination to check for lumps that should be further \nchecked. After that, the first tool that can be used is \nthe transvaginal ultrasound (TVUS), an imaging tech-\nnique in which the doctor inserts an ultrasound probe \ninto the vaginal canal to get images and to examine the \norgans of the female reproductive tract [6]. It has been \nobserved that TVUS has 97% sensitivity and 74% spec-\nificity for the detection of endometrial abnormalities \n[8]. If any abnormality is detected, the next step is to \nproceed with biopsy. During this procedure, a sample of \ncells is removed from the inside lining of the uterus and \nit is examined using a microscope. If the biopsy shows \nendometrial cancer, the appropriate treatment should \nbe given. However, if the biopsy is normal or non-diag-\nnostic, other techniques can be used to investigate the \ncause of bleeding. More specifically, color Doppler can \nbe used to differentiate between benign and malignant \npathologies, and saline contrast hysterosonography is \nFig. 1. A, B, C) magnetic resonance imaging images show 2 large subserosal fibroids arising from the anterior uterus, D) complete \nresection of the mass that weighed 6.7 kg and measured approximately 22 × 15 × 12 cm\nA\nC\nB\nD\n\nMenopause Review/Przegląd Menopauzalny 20(3) 2021\n156\na technique used to evaluate the uterine cavity of post-\nmenopausal women [6, 8]. Finally, hysteroscopy with \nbiopsy is used when the biopsy results are unclear or \nenough tissue cannot be removed. During this proce-\ndure, the doctor examines the inside of the cervix and \nuterus using a  hysteroscope that resembles a  small \nmicroscope [9]. It is also considered a  safe technique \nand it has 100% sensitivity and 97% specificity for the \ndetection of endometrial cancer [8].\nAs the most common symptom of a uterine tumor \nis abnormal uterine bleeding, it is very important to \ndifferentiate endometrial cancer at early stages from en-\ndometrial hyperplasia and endometrial polyps and also \nto differentiate advanced stages of cancer from uterine \nsarcoma or uterine lymphoma [10, 11]. Endometrial \nhyperplasia is an overgrowth of the endometrium which \nusually causes heavy or abnormal bleeding. Though  \nit can increase the risk of endometrial cancer, it is very \nimportant to diagnose it accurately in order to proceed \nwith the appropriate therapy. Therefore, an endometrial \nbiopsy is the best tool to differentiate hyperplasia from \ncancer [12]. Endometrial polyps are localized hyperplastic \novergrowths that occur in the endometrium, and their \nprevalence is higher among women with increasing age \n[13]. Most polyps are benign, in contrast with cancer \ntumors. Transvaginal US is usually the first tool for diag-\nnosis, but it seems that color Doppler is more effective in \ndistinguishing benign and cancerous tumors. However, \nthe gold standard is hysteroscopy with guided biopsy [8]. \nAnother disease that should be differentiated is uterine \nsarcomas, rare gynecologic tumors which are usually \ndiagnosed in postmenopausal women between 50 and \n70 years old. However, their diagnosis is extremely chal-\nlenging. Imaging tools are not very helpful to distinguish \nsarcoma from endometrial hyperplasia or carcinoma, but \nit seems that endometrial biopsy is the best choice [14]. \nFinally, uterine lymphomas usually cause uterine bleed-\ning and abdominal pain, but it is very important to distin-\nguish them from other diseases such as endometrial can-\ncer as they require different treatment options. Uterine \nlymphomas are rare malignancies (usually non-Hodgkin) \nof the female reproductive system and they are usually \ndiagnosed using laparoscopy and biopsy [15]. \nUterine leiomyomas (also known as fibroids) are \nthe most common uterine tumors in women. Although \nthe exact pathophysiology behind the development  \nof these benign tumors remains unclear, they common-\nly result in severe symptoms such as abnormal bleed-\ning, pelvic pain, pelvic masses, infertility, anemia, bulk \nsymptoms and obstetric complications [16, 17]. \nTreatment options mainly involve surgical inter -\nventions, but the choice of treatment is individualized \nbased on patient’s age, size and location of the lesions, \nseverity of the symptoms, and desire for future fertility. \nHysterectomy is the gold standard of leiomyoma treat-\nment, especially for women who do not wish to con-\nceive and/or women aged above 40–50 years, as it is \nimmediately curative of the symptoms and can prevent \ntheir recurrence [18]. Our patient underwent surgery,  \nas she was symptomatic and had completed having \nchildren. In addition, malignancy could not be excluded. \nCancer antigen is mostly  used as a  relatively spe-\ncific marker for ovarian cancer. According to the litera-\nture, the combination of a pelvic tumor and a high level  \nof CA 125 arouses suspicion of a gynecological malig-\nnancy, but other benign conditions such as menstrua-\ntion, endometriosis, and pelvic inflammatory diseases \nshould always be considered in the differential diag-\nnosis, particularly in pre-menopausal women [19–21]. \nAlthough there is limited evidence to support an as-\nsociation between elevated CA 125 levels and uterine \nfibroids, abnormally high levels have been reported in \na  small number of patients. Furthermore, coexistence \nof adenomyosis and tumor size can affect the level  \nof this marker in uterine fibroids. A large leiomyoma may \nbe responsible for CA 125 elevations through an indirect \nmechanism such as peritoneal irritation [22].\nConclusions\nUterine leiomyomas are the most common benign \nuterine tumors in women. Surgical treatment is the gold \n standard, especially for older women with severe symp-\ntoms and no desire for future fertility. Although the com-\nbination of a pelvic tumor and a high level of CA 125 \narouses suspicion of a gynecological malignancy, oth-\ner benign conditions should always be considered in \nthe differential diagnosis. There is limited evidence  \nto support an association between elevated CA 125 lev-\nels and uterine fibroids so far. However, conditions such  \nas coexistence of adenomyosis and tumor size can af-\nfect the level of this marker in uterine fibroids.\nAcknowledgement\nInformed consent was obtained from the patient for \nthe publication of this article.\nDisclosure\nThe authors report no conflict of interest.\nReferences\n1. Imai A, Ichigo S, Takagi H, et al. Pelvic tumors with normal-appearing \nshapes of ovaries and uterus presenting as an emergency (review). On-\ncol Lett 2012; 4: 10-14.\n2. Dunneram Y, Greenwood DC, Cade JE. Diet, menopause and the risk \nof ovarian, endometrial and breast cancer. Proc Nutr Soc 2019; 78:  \n438-448. \n3. Wu Y, Sun W, Liu H, Zhang D. Age at menopause and risk of develop-\ning endometrial cancer: a  meta-analysis. Biomed Res Int 2019; 2019: \n8584130. \n\nMenopause Review/Przegląd Menopauzalny 20(3) 2021\n157\n4. Kotsopoulos J. Menopausal hormones: definitive evidence for breast \ncancer. Lancet 2019; 394: 1116-1118. \n5. Rodriguez AC, Blanchard Z, Maurer KA, Gertz J. Estrogen signaling in \nendometrial cancer: a key oncogenic pathway with several open ques-\ntions. Horm Cancer 2019; 10: 51-63. \n6. Amant F , Moerman P , Neven P , Timmerman D, van Limbergen E, Vergote \nI. endometrial cancer. Lancet 2005; 366: 491-505. \n7. Mulita F , Iliopoulos F , Kehagias I. A rare case of gastric-type mucinous \nendocervical adenocarcinoma in a 59-year-old woman. Prz Menopauz \n2020; 19: 147-150. \n8. Otify M, Fuller J, Ross J, Shaikh H, Johns J. 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