Acute abdomen with hemoperitoneum in a postmenopausal woman.

Gynecological emergencies may be encountered in postmenopausal ladies like that of ruptured ectopic pregnancy in the reproductive age group. We report a case of ruptured granulosa cell tumor in a 70-year-old woman who presented with acute abdomen and hemoperitoneum.

INTRODUCTION

Acute abdomen with hemoperitoneum in a lady of the reproductive age group is a common gynecological emergency. But when a postmenopausal lady presents with the same complaints, the diagnosis becomes a bit difficult. Here, we report a case of ruptured granulosa cell tumor of the ovary in a postmenopausal lady who presented with acute abdomen and hemoperitoneum.

CASE REPORT

A 70-year-old, P8L8 postmenopausal lady attended emergency with acute abdomen. She also gave history of bleeding per vaginum of three weeks duration 10 days back and a lump abdomen since one year. The lady attained menopause 15 years back and the last child birth was 30 years back. On examination, the lady was found pale with pulse rate of 120/min and blood pressure of 80/50 mm of Hg. Per abdominal examination revealed severe tenderness throughout the whole abdomen with a firm lump of size 10×6 cm approximately in the hypogastrium. Decision for emergency laparotomy along with resuscitation was taken. Emergency ultrasonography showed a right abdomino-pelvic mass lesion (11.3×12.3×7.1 cm) suggestive of sarcomatous change in fibroid or adnexal mass lesion. On laparotomy, we found hemoperitoneum with a ruptured right ovarian cyst. Left adnexa were found to be normal. Right-sided ovariotomy was done maintaining proper hemostasis. After staging, total abdominal hysterectomy with left-sided salpingo-oophorectomy was done. The specimen was then sent for histopathology. The patient stood the procedure well with required resuscitation and blood transfusion. The histopathology report showed granulosa cell tumor of the right ovary with evidence of torsion and cystoglandular hyperplasia of the endometrium. The patient was discharged after recovery with advice of regular follow-up.

DISCUSSION

Granulosa cell tumors of the ovary are rare neoplasms, accounting for approximately 1.5-3% of all ovarian malignancies.[1] They are classified under the category of sex-cord stromal tumors; juvenile (5%) or adult type.[2] In 6-10% of cases, tumor rupture causing acute abdominal pain can be the presenting symptom.[34] Adult granulosa cell tumors represent 1–2% of all ovarian tumors. Because this tumor produces estrogen, these women have abnormal menstruation. They may suffer amenorrhea, or irregular and heavy vaginal bleeding.[5] In 5–25% of cases, there is evidence of endometrial hyperplasia and well-differentiated endometrial carcinoma.[5] These symptoms and findings often lead to hysterectomies. After menopause, elevated estrogen suppresses follicle-stimulating hormone, and these women often do not complain of vasomotor symptoms. Granulosa cell tumors occur at any age, are prone to rupture, and vary in size, although on average, these tumors measure 12 cm. They may be bilateral in 5% of cases. Most women survive these tumors, with the survival rate ranging from 88–93%.[5] These tumors rarely metastasize. However, tumor size, surgical stage and cellular atypia,[6] and rupture affect the prognosis.[5]

Lee et al., also report a similar case of ruptured huge granulosa cell tumor of the ovary in a 53-year-old woman where total abdominal hysterectomy with bilateral salpingo-oophorectomy was performed.[7] Another case of ruptured ovarian granulosa cell tumor presenting as acute abdomen was reported by D. Habek et al.[8]

CONCLUSION

Recognizing that gynecological emergencies can arise even in postmenopausal women, clinicians should be more prompt in managing such complications.