PMC7399774_01
(a) Pelvic magnetic resonance imaging at diagnosis of ovarian torsion (T2-weighted axial image). The left ovary is indicated by the yellow allows. (b) Magnification (x40) of hematoxylin and eosin staining of the resected ovary. Scale is shown in the figure. Hemorrhagic corpus luteum is observed. (c) The left ovary at the one-month follow-up evaluation after emergent right salpingo-oophorectomy. The ovary is enlarged, measuring 4.4 x 2.4 cm. (d) The left ovary before the start of estrogen/gestagen therapy. The ovary is enlarged measuring 7.5 x 5.5 cm. (e) The left ovary five months after the start of estrogen/gestagen therapy. The ovary is reduced to normal size (3.9 x 2.0 cm). (f) The left ovary during estrogen/gestagen therapy. The ovary remained at a normal size (3.5 x 2.1 cm).
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Ovarian torsion was highly suspected (Figure 1(a)). Hemorrhagic corpus luteum was pathologically confirmed (Figure 1(b)). At the one-month follow-up, the left ovary was enlarged again (4.4 x 2.4 cm, Figure 1(c)). After a few cycles of EGT, the enlarged ovary reduced from 7.5 x 5.5 cm (Figure 1(d)) to normal size (five months after initiation of EGT, 3.9 x 2.0 cm, Figure 1(e)). Regular withdrawal bleeding was observed and the ovary size was essentially stable (Figure 1(f), 3.5 x 2.1 cm).
The results of hormone stimulation test. (a) The result of gonadotropin-releasing hormone (GnRH) stimulation test on cycle date (CD) 4. (b) The result of corticotropin-releasing hormone stimulation test on CD5. No abnormal findings were observed. ACTH: aderenocorticotropic hormone. (c, d) The results of thyroid-stimulating hormone test on CD6. No abnormal findings were observed. TSH: thyroid-stimulating hormone. (e) The result of growth hormone releasing peptide-2 stimulation test on CD9. No abnormal findings were observed.
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Gonadotropin-releasing hormone (GnRH) stimulation test on CD4 revealed an elevated FSH level of 89.4 mIU/mL with poor response to GnRH stimulation (maximum, 107.9 mIU/mL) and a slightly elevated LH level of 43.4 mIU/mL (Figure 2(a)). No abnormal findings were observed in corticotropin-releasing hormone stimulation test (Figure 2(b)), thyroid-stimulating hormone test (Figures 2(c) and 2(d)), and growth-hormone-releasing peptide-2 stimulation test (Figure 2(e)).
(a) Pituitary magnetic resonance imaging (gadolinium-enhanced T1-weighted sagittal image). No tumor is observed in the pituitary gland. (b) Result of positron emission tomography. No ectopic tumor is observed. (c, d) The left ovary after estrogen/gestagen therapy was discontinued. (c) Cycle date 3: 3.0 cm. (d) Cycle date 9: 4.8 cm.
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Contrast-enhanced pituitary MRI (3T) and 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) were conducted, but no evidence of pituitary adenoma or ectopic tumor was identified (Figures 3(a) and 3(b)). Though the left ovary became slightly enlarged during the treatment-free period (CD3: 3.0 cm, Figure 3(c); CD9: 4.8 cm, Figure 3(d)), it reduced to normal size after the treatment was resumed.