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Original Article

Clinicopathological analysis of ovarian tumors in perimenopausal
women: A study in a rural teaching hospital of eastern India

Phukan JP
1
, Sinha A

2
, Sardar R

3
, Guha P

4

Abstract
Introduction: Ovarian tumors are important in perimenopausal women as they are more likely to be
malignant. Aim: The aim was to study the various histological pattern of ovarian tumors and their clin-
ical presentation in perimenopausal age group. Materials and Methods: The study was carried out in
the departments of Gynaecology and Obstetrics and Pathology in a teaching hospital for two years from
June 2007 to May 2009. All patients presented with ovarian tumors of perimenopausal age group (40-
50 years) were included. Detailed clinical information, radiological findings and histopathological
reports were recorded.  Results: A total 52 ovarian tumors were included in this study. Most common
histological types were surface epithelial tumors (92.3%), out of which 54.2% were benign, 41.7% were
malignant and 4.2% were borderline. Serous cystadenoma was the most common benign tumor and
serous cystadenocarcinoma was the commonest malignant tumor. Abdominal discomfort was the com-
monest presenting symptom both in benign and malignant tumors (85.7% and 45.4% respectively). Most
of the malignant tumors were presented in stage III (50%), followed by stage II (27.3%). Conclusion:
In this: study, we found a relatively higher proportion of ovarian malignancies. So, any ovarian tumor
in perimenopausal age group is more likely to be malignant and that require a thorough evaluation and
management. Further research should be advocated in this field.

Key words: Ovarian tumor, perimenopausal age group, histological type

Introduction
Ovarian cancer is the second most common gynae-
cological malignancy after cervical cancer in

India
1
. Asian countries have rate of 2-6 new cases

per 1,00,000 women per year
2
. Approximately

25% of all gynaecologic malignant tumors are of
ovarian origin, but ovarian cancer is the most com-

mon fatal gynaecologic malignancy
3
. Ovarian car-

cinoma accounts for the greatest number of deaths
from malignancies of the female genital tract and
is the fifth leading cause of cancer fatalities in

women
4
. Although ovarian cancers affect all age

groups, primarily it is seen in postmenopausal

women
3,5

. Perimenopausal women are also at high-

er risk of developing ovarian malignancies as post-
menopausal women. The term perimenopause
should include the period immediately before the
menopause (when the endocrinological, biological
and clinical features of approaching menopause

commence) and the first year after menopause
6
.

Variability is the hallmark of the menopausal tran-
sition and no operational definition was given of

those features by the WHO
6
. However a better

practical definition is the phase preceding the onset
of menopause, generally occurring around 40-50
years of age during which the regular cycle of a

woman transitions to a pattern of irregular cycles
7
.

In India, the mean age of menopause is 45 years
8
.

1. Jyoti Prakash Phukan, Department of Pathology, Bankura Sammilani Medical College, Bankura,
West Bengal, India.

2. Anuradha Sinha, Department of Pathology, Bankura Sammilani Medical College, Bankura, West
Bengal, India.

3. Rakhi Sardar, Department of Gynaecology & Obstetrics, Chittaranjan Seva Sadan, Kolkata, West
Bengal, India.

4. Paulami Guha, Department of Gynaecology and Obstetrics, Riverside Regional Medical Center,
Virginia, USA.

Corresponds to: Dr Jyoti Prakash Phukan, Department of Pathology, Bankura Sammilani Medical
College, P.O. Kenduadihi, Bankura- 722102, West Bengal, India
Email: drjyotiphukan@yahoo.co.in

Bangladesh Journal of Medical Science Vol. 12 No. 03 July’13

263



During this time, in addition to the various peri-
menopausal symptoms including menstrual disor-
ders as a result of anovulation, women also
become at increased risk of developing various
ovarian pathologies.  
Various studies revealed that malignant ovarian

tumor is common after 40 years
9-12

. Surface epithe-

lial tumors account for majority of malignancies
3,13

.
Ovarian cancers are usually fatal when diagnosed
because of delay in diagnosis. Symptoms are usu-
ally absent in early stages and nonspecific in
advanced cases. Common presenting symptoms are
abdominal lump or distension of abdomen, pain in
abdomen, pressure effects and menstrual distur-

bances
8,10,14

. In this background, this study was
undertaken to determine clinical presentation and
histological pattern of ovarian tumor in peri-
menopausal age group in a rural teaching hospital
of eastern India.

Materials and methods
The study is a prospective study of two years dura-
tion undertaken in a teaching hospital of eastern
India, in the departments of Gynaecology and
Obstetrics and department of Pathology from June
2007 to May 2009. Before starting the study,
clearance from ethical committee was obtained. A
total 52 ovarian tumors of perimenopausal age
group, diagnosed histopathologically were includ-
ed. All oophorectomy specimens as well as hys-
terectomy with bilateral or unilateral salpin-
goophorectomy specimens in perimenopausal age
group were included in this study. Ovarian tumors
in which histological typing could not be done due
to torsion were excluded from this study.

Detailed clinical history was reviewed with regard
to age, clinical features, mode of presentation and
radiological findings. Information regarding signs
and symptoms, fine needle aspiration (FNAC)
findings of available cases, complete blood count,
ultrasonography (USG)/ Computed tomography
(CT) findings and biochemical investigation find-
ings including serum tumor markers like CA125,
fetoprotein and human chorionic gonadrotrophin
(HCG) levels were recorded in available cases.

Histopathological typing of ovarian tumors were
done according to World Health Organization clas-

sification
15
. We took 40-50 years age group as per-

imenopausal age group. Womens, who were diag-
nosed with ovarian tumors after their menopause
even if she falls in this age group, were excluded
from the study.

Results
A total number of 52 cases were studied. Among
them 28 (53.8%) were benign, 2 (3.8%) were bor-
derline and 22 (42.3%) were malignant tumors.
Surface epithelial tumors were the commonest
ovarian tumor (92.3%), out of which 54.2% were
benign, 41.7% were malignant and 4.2% were
borderline [Table 1].

Among surface epithelial tumors serous tumors
were the commonest (57.7%), followed by muci-
nous tumors (23.1%). The most common benign
tumor was serous cystadenoma (53.6% of all
benign tumors), which was also the commonest of
all ovarian tumors (28.8%).  Majority of malignant
tumors were of surface epithelial origin, serous
cystadenocarcinoma being the commonest (63.6%
of all malignant tumors) followed by mucinous
cystadenocarcinoma [Table 1]. Endometrioid
tumors comprises 7.7% and Brenner tumor (Figure
1) comprises only 3.8% of all ovarian tumors.
Only 2 cases of sex-cord stromal tumors were
found, 

Figure 1: Photomicrograph showing Brenner
tumor with solid nests of epithelial cells (Arrows)
embedded within fibrous tissue (H&E, 10x). Inset
shows epithelial nest in high power (H&E, 40x)

one was benign fibroma and the other was malig-
nant granulosa cell tumor (Figure 2).

Clinicopathological analysis of ovarian tumors in perimenopausal women

264



Figure 2: Photomicrograph showing malignant
granulosa cell tumor with trabecular and microfol-
licular (with Call-Exner bodies) growth pattern
(H&E, 20x).

Other varieties includes only 1 case of germ cell
tumor (mature cystic teratoma) and 1 Krukenberg
tumor. 

Abdominal discomfort was the commonest present-
ing symptom both in benign and malignant tumors
(85.7% and 45.4% respectively) [Table 2].
Abdominal swelling was present in 12 (42.8%) and
9 (40.9%) of benign and malignant cases respec-
tively. Menstrual abnormalities like dysmenor-
rhoea, menometrorrhagia and metrorrhagia were
also found both in benign and malignant tumors.

Metrorrhagia was the commonest menstrual abnor-
mality which was present in 35.7% and 27.3% of
benign and malignant categories. Cachexia was
present only in few malignant cases (13.6%).

Cystic tumors were most commonly benign
23(82.1%) while most hard lumps were malignant
14(63.6%) [Table 3]. Most benign tumors had
smooth surface (92.8%) while most malignant
tumors had irregular surface (81.8%). Most benign
tumors were mobile (85.7%) while most malignant
tumors had restricted mobility (77.3%).

Most of the malignant tumors were presented in
stage III (50%), followed by stage II (27.3%) dis-
ease. Only 3 cases (13.6%) presented in stage I
and 2 cases (9.1%) presented in stage IV disease. 

Discussion
The incidence, clinical appearances and the behav-
iour of different types of ovarian tumors are

extremely variable
14
. Ovarian tumors also displays

histological heterogeneity
16,17

.

In our study, benign tumors accounted for 28
(53.8%), malignant ovarian tumors 22 (43.2%)
and 2 (3.8%) of borderline. This result is similar

to the findings of other studies
12,14,18

. Similar studies
by Mondal et al found 63.1% benign, 29.6%

malignant and 7.3% borderline tumors
9
. Again

Phukan JP, Sinha A, Sardar R, Guha P

265

Table 1: Showing distribution of ovarian tumors according to histological types (n=52) 
Histogenesis Histological Types Total Number Percentage 
Surface epithelial tumors Serous tumors 30 57.7 
(n=48)   92.3% Benign 15 28.8 

 9.1 1 enilredroB 
 9.62 41 tnangilaM 
 1.32 21 sromut suonicuM 

 6.9 5 ngineB 
 9.1 1 enilredroB 
 5.11 6 tnangilaM 

     7.7 4 sromut dioirtemodnE 
 7.7 4 ngineB 

     8.3 2 sromut llec lanoitisnarT 
                                     Brenner 2 3.8 
Sex cord-stromal tumors Fibroma 1 1.9 
 (n=2)  3.8% Granulosa cell tumor 

 9.1 1 )tnangilam( 
Germ cell tumors Teratoma (Benign) 1 1.9 
(n=1) 1.9% 

 9.1 1 romut grebnekurK srehtO
 (n=1) 1.9% 



Gupta et al reported 72.9% benign, 22.9% malig-

nant and 4.1% borderline ovarian tumors
19

. The
slight increased proportion of malignant tumors in
our study is because our study population com-
prised of perimenopausal age group (40-50 years).
Previous studies also showed that malignant
tumors are common in 41 to 50 years age group

which was our study population
9
. Ovarian cancer

incidence rises as the age of the patient increases.
Ovarian cancer rises sharply between ages 45 and
54 years and remains elevated for the remainder of
a women’s life, paralleling gonadotropin levels

over this period
20
.

Histologically, surface ovarian tumors are the
commonest. In our study also surface epithelial
tumors were the commonest ovarian tumors
(92.3%) which is higher than previous stud-

ies
5,9,10,11,21,22

. This is because these tumors are more
common in older age group. Among the surface
epithelial tumors, serous cystadenoma is the com-
monest of all tumors  (28.8%) and also the com-
monest in benign category (53.6%). In the study
by Saeed et al and Ahmad et al found 38.09% and
31.42% of serous cystadenoma which is close to

our study
23,24

. In other studies, benign germ cell
tumors constitutes a major proportion of benign
group, which is common in younger age group.
This younger age group was excluded from our
study. Majority of malignant tumors were of sur-
face epithelial origin. serous cystadenocarcinoma
being the commonest (63.6% ) of all malignant
tumors. This finding is similar to previous stud-

ies
9,14

. Endometrioid carcinoma ranges from 10-

25% of all primary ovarian cancers
25
. However in

India, its proportion is found to be low ranging

from 4.2% to 5%
9,26

. But we have not found any
malignant endometrioid tumors. It may be due to
small sample size of our study.

Sex-cord stromal tumors were the second largest
group of tumors in this study comprising 3.8% of
tumors which is similar with previous study from

eastern India
9,26

. Germ cell tumors in our study
comprises only 1.9% of all tumors. This finding is

contrary to the previous studies
9-11,25

. This is
because germ cell tumors are mostly seen in chil-

dren and young adults
27
. This age group is exclud-

ed from our study. 
The majority of women with epithelial ovarian

cancer have vague and non-specific symptoms
28-30

.

In early stage, irregular menses (especially in pre-
menopausal women), urinary frequency, constipa-
tion, lower abdominal distension, pressure or pain

such as dyspareunia are usually seen
28-30

. In
advanced stage, patients have symptoms related to
the presence of ascites, omental metastasis or
bowel metastasis. The symptoms include abdomi-
nal distension, bloating, constipation, nausea,
anorexia and early satiety. Again menstrual abnor-
malities like menorrhagia, metrorrhagia are also
seen. In our study, abdominal discomfort was the
commonest presenting symptom both in benign and
malignant tumors (85.7% and 45.4%) respective-
ly. Abdominal swelling was also present in signif-
icant number of cases. In few studies, abdominal
pain is the commonest presenting complaint, while
in some other studies distension of the abdomen

was commonest
10,14,21,31,32

. Menstrual abnormalities
constitute the second commonest symptoms in our
study. They are present in 46.3% benign cases and
59.1% malignant cases respectively. Metrorrhagia
was the commonest menstrual abnormality seen in

Clinicopathological analysis of ovarian tumors in perimenopausal women

266

Table 2:  Table showing clinical presentations of ovarian tumors 
Symptoms Benign tumors Malignant  

  (%)  (n=28)(n=22)  tumors (%)  
Abdominal swelling 12(42.8%) 9(40.9%) 
Abdominal discomfort/pain 24(85.7%) 10(45.4%) 
Alimentary symptoms 5(17.8%) 6(27.3%) 
Cachexia --- 3(13.6%) 
Menstrual abnormalities  
Dysmennorhoea 2(7.1%) 5(22.7%) 
Menometrorrhagia 1(3.5%) 2(9.1%) 
Metrorrhagia 10(35.7%) 6(27.3%) 
Urinary symptoms 4(14.2%) 6(27.3%) 
Nonspecific symptoms 4(14.2%) 8(36.4%) 

Table 3: Showing clinical findings of different ovarian tumors 
Clinical findings Benign tumors Malignant tumors 
 n=28 (%) n=22(%)        
Consistency of lump 
Cystic 23(82.1%) 2(9.1%) 
Hard  - 14(63.6%) 
Variable 5(17.8%) 6(27.3%) 
Surface of lump 
Smooth 26(92.8%) 4(18.2%) 
Irregular 2(7.1%) 18(81.8%) 
Tenderness of lump 
Present 2(7.1%) 12(54.5%) 
Absent 26(92.8%) 10(45.5%) 
Mobility of lump 
Mobile 24(85.7%) 5(22.7%) 
Restricted 4(14.3%) 17(77.3%) 



35.7% and 27.3% of benign and malignant cases
respectively. Other menstrual abnormalities like
dysmenorrhoea and menometrorrhagia were also
seen. This finding is in contrast with other studies.
It may due be to our study is restricted to peri-
menopausal women in whom menstrual abnormal-
ities are quite common. 
In our study, majority of benign tumors were cys-
tic (82.1%), while a minor proportion of malignant
tumors were cystic (9.1%) on palpation. In a pre-
vious study by Amatya S et al found that 93.7% of
cystic tumors were benign while only 2.5% of
malignant tumors were cystic which is consistent

with our study
14

. We found that most benign tumors
were mobile (85.7%) while most malignant tumors
had restricted mobility (77.3%). Local spread of
malignant tumor was cause of restricted mobility
as the diagnosis was in late stage.
Ovarian cancers are considered as “silent killer” as
they do not produce symptoms until in advanced

stage
20

. So there is delay in diagnosis. Most of the
malignant tumors in our study were presented in
stage III (50%), followed by stage II (27.3%) dis-
ease. This findings are consistent with previous

studies
14,26

.

Conclusion
In this study, we found that surface epithelial
tumors were the commonest ovarian tumor in per-
imenopausal age group with a higher incidence of
malignancy. This is an alarming finding. However
our sample size is very small to make any definite
opinion. Amongst malignant ovarian tumors
delayed diagnosis is common and patients usually
present in late stage of the disease. So awareness
among public and doctors for early detection of
ovarian cancer in this vulnerable perimenopausal
age group and further research in this field with
larger samples are advocated.

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