The 3-dimensionel Ovarian Volume Assessment to Evaluate Whether Menopausal Related Symptoms and Hormone Levels Correlate with the Ovarian Volume

Menopause, the complete cessation of menstrual periods, related with many symptoms that reduce quality of life (QOL) of post-menopausal women. The World Health Organization defines QOL “as an individual’s perception of their position in life in the context of culture and values system in which they live, in reference to their goals, standards, and concerns in life” (1). The range and severity of menopausal symptoms vary widely due to lifestyle, cultural and genetical (2).

The most menopausal symptoms consist not only about female genital tracts but also vasomotor, physical, somatic, cardiovascular and skeletal symptoms. (2) Eighty-five percent of postmenopausal women have experienced menopause-related symptoms in terms of the vasomotor symptoms, arthralgia, headache, rapid weight gain, fatigue, sexual disfunction and urinary incontinence (3). These symptoms decrease QOL during post-menopausal period.

As it is known ovarian volume increases as from the pubertal beginning. During the premenopausal period the volume gradually decreases. In postmenopausal time atrophy is seen in ovaries but personal variations can be monitored (4). There are many studies in the literature that compared the ovarian volume with specifically fertility potentials, body mass index (BMI), hormonal status and bone mineral density (BMD) (5, 6).

To our knowledge although there are a number of studies on ovarian volume measurements in different periods of life, there is not any data about the relevance of ovarian volume and postmenopausal symptoms occurrence and severity. The purpose of our study was to evaluate the relationship between three- dimensional (3D) volume analyze and menopause-specific QOL (MSQOL) questionnaire and hormonal levels (7).

After the approval of Ankara Numune Training and Research Hospital Ethics Committee of clinical trials (decision number E-15-517, date: 24.06.2015) was obtained, transvaginal 3D ultrasonography substructure support was provided by Gazi University local Projects of Scientific Investigation Committee. A power analysis was conducted to determine the required sample size, which was calculated to be 60 patients. This prospective study included 62 postmenopausal women that applied for annual routine gynecological controls to Gazi University Hospital outpatient clinics between November 2016 and November 2017. Written informed consent was obtained from all 62 women who participated in the study. Inclusion criteria were confirmed menopausal status and absence of previous hysterectomy, ovarian surgery, hormonal use currently or during the past 6 months and a personal history of gynecological malignancy. Given the broad age distribution of the patients, menopausal status was assessed based on the clinical criterion of amenorrhea lasting at least one year. If the patients that had ovarian and/or tubal masses during pelvic examination and chronical pelvic pain were excluded from the study.

Demographical characteristics of patients such as age, BMI, gravida, age of menopause and time that the patients spend in menopause were recorded. During routine pelvic examination, 3D ultrasonographic images were applied for ovarian volume analysis. With 3D transvaginal ultrasonography probe, bilateral ovarian images were taken, and volume of ovaries were calculated by using Virtual Organ Computer-aided Analysis (VOCAL) volume analysis (GE Voluson E6 Ultrasound Systems). In order to enhance measurement reliability, all assessments were conducted by same physician.The VOCAL technique, a semi-automated 3D ultrasound method that enables accurate and reproducible volume measurements of irregularly shaped structures. Patients were questioned regarding the presence of stress urinary incontinence symptoms, and during the physical examination, the presence of incontinence was assessed by increasing intra-abdominal pressure and recorded accordingly. The blood serum levels of follicle stimulating hormone (FSH), estradiol (E2), free and total testosterone, dehydroepiandrosterone, androstenedione levels were assessed. In addition, mammography results and BMD measurements with dual-energy X-ray absorptiometry (DEXA) were also recorded.                

In addition to these investigations, the postmenopausal symptoms that affect psychosocial, physical, and sexual functions of women were estimated upon to the serum hormone values and ovarian volumes. These estimations were done by using standard MSQOL questionnaire that was prepared by Sunnybrook Health Science Center (7).

Patients answered 29 different questions about vasomotor, physical, and sexual symptoms and were asked for grading their complaints with numbers 0 to 6.

Statistical Analysis

IBM Statistical package for the social sciences , version 22.0 (SPSS Inc., Chicago, IL, USA) was used for the statistical analysis. Mean levels of all patient’s demographic data, 3D vocal volume analysis, serum hormone levels, MSQOL scoring results were calculated. The mean value differences between the groups with and without symptoms were tested using the Student’s test or Mann Whitney U test whether the distribution of the data was normal or not, respectively. The correlation analysis was done with Pearson correlation (2-tailed) test. Differences were accepted as significant if the p values were less than 0.05.

Total number of 62 postmenopausal patients were included to the study. The demographic data of patients, serum levels of hormones, DEXA results and calculations of ovarian volume by 3D vaginal ultrasound were given in Table 1. The mean ovarian volume was calculated as 1.91 cm³. A negative correlation was found in the decrease of ovarian volume and the increase of menopausal period (p=0.026). In addition, a significantly positive correlation was seen between menopausal age and ovarian volume. The earlier menopause age significantly correlated with lower ovarian volume (p=0.014).

There was a non-significant negative correlation between FSH levels and positive correlation between E2 levels and ovarian volume were found (p=0.46 and p=0.26, respectively)

Patients’ with and without postmenopausal symptoms were compared regarding ovarian volumes. No statistical difference was found between symptoms and 3D ovarian volume measurements (Table 2).

Table 3 shows the data of grading of vasomotor, psychosocial, physical and sexual symptoms according to MSQOL questionnaire in detail. Ovarian volume calculation was not significantly correlated with each of these symptoms and rating of the answers of the MSQOL questions.

This study evaluated the ovarian volume after the menopause with demographic, anthropometric and hormonal parameters and also menopausal symptoms and QOL of patients. According to our results, ovarian volume changes the hormonal values. However menopausal symptoms seem much more multifactorial; these symptoms were not associated with ovarian volume.

There is an ongoing debate on the impact of ovarian function on common menopausal symptoms after the menopause. This discrepancy may also lead to another uncertainty for the decision of prophylactic oophorectomy at the time of hysterectomy regarding to cause any iatrogenic benefit or harm to our patients.

During menopausal symptoms ovarian androgen secretion gradually decreases and postmenopausal ovaries maintain to be an important resource for androgens (8). In our study we aimed to analyze the correlation between the ovarian stromal volume and androgen values and also menopausal symptoms. There was no statistically meaningful correlation between the androgen levels and ovarian stromal volume decrease. This result can be interpreted in two different point. The ovaries are not an important resource for androgens during menopause or the ovarian androgen synthesis during menopause is minimal or negligible.

Previous studies evaluated 3D and 2D ultrasonographic ovarian volumes in women who were in reproductive ages. Nardo et al. (13) reported 3D ovarian stromal volume did not correlate with biochemical indices of PCOS. Flaws et al. (14) found that hormone replacement therapy using did not change ovarian volume. However, till the negative correlation of FSH levels and positive correlation of E2 levels make think that menopausal period is also dynamic period of life.

Although many factors have impact on bone mineral density (BMD), in a study a positive correlation between ovarian volume and BMD at the femoral neck both in T scores and Z scores was reported (5). Our results contrast with Armeni et al.’s (5) findings as there was not a significant difference in BMD T score of both femoral neck and lumbar spine according to ovarian volume values.

It is already come to be known that the prevelance of menopausal symptoms are related with many different factors like lifestyle, education of women, socioeconomic statute (15). There are different questionnaires that can evaluate the menopausal symptoms and QOL during this period. MSQOL is the most popular questionnaire for QOL evaluation during menopause period. As we already mentioned that menopausal symptoms are multifactorial and are affected by lifestyles; Korean and Chinese studies assessed the applicancy of this questionnaire in their countries. They found this questionnaire as a valid and reliable scale for assessment of menopausal symptoms and QOL (16, 17). In our country, the studies that evaluated menapousal symptoms also used MENQOL questionnaire. According to the results of these studies this questionnaire seems as a valid assessment for our population. (18, 19). In our study the questionnaire results were compared with ovarian volume, a clear correlation cannot be found. The symptoms did not increase when the volume decreased.

Study Limitations

The main limitation of our study is the variability in patients’ age ranges and duration of menopause. If the study is repeated with a larger sample size, patients can be stratified according to menopausal duration and age, allowing for group-based comparisons of symptoms and ovarian volumes. Such comparisons may enable a more objective and accurate evaluation of the relationship between ovarian volume, hormonal status, and clinical symptoms.

In our study, there was a correlation between hormone levels and ovarian volume; but this change did not reflect to symptoms. These results remarked that menopausal symptoms are multifactorial and affected by many other factors than hormonal status.

In conclusion ovarian volume was not correlated with menopausal symptoms and serum hormonal levels. This finding may be important and kept in mind for the decision of prophylactic oophorectomy at the time of hysterectomy after the menopause.