:-;•n;t:-.1-LEVE.'\THAL: JlllJA'l'h:l~AL I'OLYCYSTIC 0\'AR!E.

S Jill

concerned a squamous stratified epithelioma extending from a meta-

plastic fundal mucosa. It was combined with a large submucous myoma.
(c) The third was an adenocarcinoma combined with a submucous myoma
whieh had undergone changes into a polymorphous spindle-cell sarcoma.

REFERE.'\CF.S
Cam.p: Ztschr. f. Geburtsh. u, Gynak. 10: 3i56, 1884. Cottt, M. G.: Lyon Chir.
28: 520, 1931. de Gery, Chastenet, and Perrot, Maur·ic.e: Ann. rl 'Anat. Path. 9:
317, 1932. Ehrendorfer: Arch. f. Gyniik. 42: 255, 1892. Frankl: An•h.
Gynak. 95:: 269, 1910. Gutmann, M.: Monatschr. f. Geburtsh. u. Gyniik. 89:
309, 1931. Jansen, H.: Monatsehr. f. Geburtsh. u. Gyniik. 39: 207, 1914.
Moeller, Ellis S.: Surg. Gynec. Obst. 46: 187, 1928. Munroe Ken', .1. Ji. ·
Brit. M. J. 1: 6!l, 1910. Newel, Q. U.: AM. ~f. 0BS'r. & GYNEC. 17: ll!l,
1929. Piquand, G.: La Trib. Med. p. 213, 1905. Piquand, a.:
Ann. de Gynec. 10:
393, 485, 565, 1905. Roberts, Hubert: Lancet 1: 454, 1917. Su.tton, Bland: J.
Obst. & Gynec. Brit. Emp. 10: 1, 1906. Undstroemer, Martin: Acta. obst. et gynee.
Scandinav. 8: 112, 1929. Winter, G.: Ztschr. f. Geburtsh. u. Gynak. 57: 8, Hl06.

AMENORRHEA ASSOCIATED WITH BILATERAL

POLYCYSTIC OVARIES*
IRVING F. STEIN, M.D., AND MICHAEL L. LEVE-NTHAL, M.D ..
CHICAGO, ILL.
! Fr&tn Michael Reese Hospital arna Northwe.~tern University Medioa'l Sehool)

ACCORDING to leading authoritative works on gynecology, the

!-\ bilateral polycystic ovary is most commonly found in association
with utet'ine bleeding (Fig. 1). This association has been recognized
by the medical profession and is not infrequent in occurrence. Endo-
metrial hyperplasia, multiple follicle cysts with granulosa cell lining,
and a notable absence of corpora lntea in the ovar;r are the significant
pathologic findings in such cases. The bleeding in these patients is
readily explained by the fact that the increase in number of follicles
lined by granulosa cells produces an excess of secretion of estrogenic
hormone.
According to the same authoritative works, little or no mention is
made of bilateral polycystic ovaries aceompanied by amenorrhea, and
inasmuch as we have encountered a series of cases exemplifying the
latter conditions, we desire to present the results of our study of them.
Cyst formation in the follicular apparatus of the ovary is very com-
mon and is regarded to some extent as a physiologic process. When
these structures are visible to the naked eye, they are regarded as
cysts; when not, they are called follicles. When this process becomes
excessive, persistent or progressive, the ovary becomes enlarged, tense,
tender and painful, and produces what has been termed "cystic degen-
•Read at a meeting of the Central Association of Obst<;tridans and Gynecologists.
Novemb-er 1 to 3, 1934, New Orleans. La.
182 AMERICAN JOURNAL OF OBSTE1'RICS AND GYNECOLOGY

eration of the ovary," and is usually bilateral. The exact cause of this
formation is still in doubt; formerly, it was regarded as the result of
inflammatory change due to either local infection or that from some
distant focus. More recent observations and experiments point to an
endocrine causal relationship of the polycystic changes in the ovaries.
Furthermore, there are usually no adhesions or other gross or micro-
scopic evidences of inflammation in the ovaries found in these cases.
In the series of patients which we observed with bilateral polycystic
ovaries and amenorrhea, the ovaries were found to be from two to
four times the normal size and while they often maintained their
original shape, they were sometimes distinctly globular. In one case,
they were flat and soft, the so-called "oyster ovaries.'' 'l'he ovarian
cortex was found to be hypertrophied in all of the cases and the
tunica thickened, tough, and fibrotic .
The cysts were follicle cysts, near the surface, and almost entirely
confined to th e cortex, and they contained clear fluid. There were

Fig. 1.

from twenty to one hundred cysts in each ovary, varying in size from
1 mm. to about 1.5 em., but rarely larg·er. The color of the ovary was
oyster gray with bluish areas where the cysts were superficial and
appeared on the surface as sago-like bodies. On section, the variation
in size of the cysts and the clear fluid contents were revealed. Corpora
lutea were sometimes absent and when found, they were very small
and deeply placed.
The uteri in these patients were either normal in size or smaller and
firmer than normal. The remaining changes observed were those in-
volving the secondary sex characteristics. The breasts presented no
characteristic changes except in cases of long-standing amenorrhea
when they were small, firm. and pale.
In some patients, there was observed a distinct tendency toward
masculinizing changes. A typical rhomboid hairy escutcheon, hair
on the face, arms, and legs, and coarse skin was noted. No voice
changes have been observed by us. The external genitals in most
 STEIN -LEVEN'fHAL: BILATERAL POLYC'YSTH' OVARIES ] ii:1

patients were normal, but in ~orne, the labia minora and clitoris were
markedly hypertrophied. I1ibido is apparently not affect ed by the
changes noted in the ovaries.

CASE REPORTS

CASE J..- M. G., aged twenty-two, manied ont• and OJW·half years, gravida o, waH
first seen Oet. 3, 19~8. Her chief complaints were st<•rilit.y antl amenorrhea.
Menses began at age of thirteen, irregular, two to seven lllonths, five·t1ay durn·
tion, moderate, no pain. She was treatetl with estrogenie preparations, intramu~·
cularly; she then menstruated irregularly Pvery six or eight wet>ks; ~mall •lo~es pf
thyroid extract and calcium were given.
November, 1929: Menstruated about every seven weeks. Examination revealed
moderate obesity and slight struma. Bimanual examination: Uterus was 2° retro·
verted, normal size; right ovary palpable and eystie. January, 1930: Transabdomin:tl
pneumoperitoneum (:Pig. 2), revealed bilateral rystic ovaries, l':teh ovary appearing
as large as the uterine fundus. Opt>ration: l\fny 2, Hlc:O, laparotomy. Uterus was
small and both ovaries were polyrystic and enlarged, the right more so than tlw

F'ig. 2.

left. The left also contained a small fib1·oma. Wedge-resection of both ovaries. Un
eventful recovery; discharged from the hospital on the twelfth postoperative day.
Forty·eight hours after operation, slight uterine bleeding oecurred, and normal
menstrual periods occurred monthly thereafter. Patient became pregnant in October,
1930, and again in February, 1933; both pregnancies were carried to full term and
delivered normally. Menstruation since confinement is entirely normal, every tw<:nty·
eight days. August, 1934: Follow-up examination showe·i the uti'rus and hoth
ovarif's to he normal.
Pathologic- Rep-ort.-Gross: Sections from both ovaries ilhowed numerous c.v ~tit:
cavities varying from 1 mm. to 1 em . in size. Ovarian tuni<: was thickened and
fibrous. Microscopic: Thick tunic, many cysts varying in silc, lined by theca cells:
one normally developing graafian follicle ; co rpus albi<"an:;: old t•orpus lut~ nm;
tortuous and dilated blood vessels.

CASE 2.-B. K., aged twenty-nine, married five years, gravida o, was admitted
to the hospital Aug. 10, 1931. Her chief complaints were sterility and amenorrhea.
Menses began at the age of fifteen, were irregular for several months; no menses
for eight years prior to first examination. MPnstruated twice last year (under
our observation) after treatment with estrogenic hormone, intramuscularly. Ph.vH·
li:l4 AMERICAN JOURNAL 01<' Ol:ll:;'l''"'l'HW8 AND GYNI!:COLOGY

ical examination: Rigid type; tight coarse skin, hairy face, arms, and legs;
masculine escutcheon. Transabdominal pneumoperitoneum; bilateral cystic ovaries
almost as large as uterine fundus (Fig. 3). Operation: Wedge-resection of two-
thirds to three-fourths of each ovary. Uneventful recovery. Discharged from hos-
pital on thirteenth postoperative day.
Patient has menstruated regularly every twenty-eight days since operation. Fol·
low-up examination in May, 1933: uterus and both ovaries normal; secondary sex
characters evidence little improvement; no pregnancy to date.*
Pathologic Report.-Gross: Thie.k tunic, numerous cystic cavities up to 1 em. in
diameter near surface of ovary (Fig. 4). Microscopic: Tunic thick and fibrous;
numerous cysts varying in size, lined by hypertrophied theca layer. Granulosa cells
were scarce. Small (old) corpora albicantia. No corpora lutea.
CASE 3.-L. C., aged twenty-one, married two years, gravida o, was first seen
April 24, 1929. Her chief complaints were amenorrhea and sterility. Menses
began at the age of thirteen, were always irregular, one- to nine-month inter-
vals, usually six months_. lasting for five or six days, scant; no pain. Treatment was

Fig. 4.-Photomicrograph ( 6 diameters) of s ection of wedgP r emoved from ovary

(Ca se ~).

given over a period of four years with estrogenic hormone preparations, intra ·
muscularly, and thyroid extract by mouth. In December, 1929, patient had x-ray
stimulation of ovaries with no results. In October, 1931, she became pregnant, and
was delivered of a normal child at term, August, 1932. Following this, she had
four normal periods at regular intervals followed by amenorrhea of one year and
nine months. During this time, she was treated with estrogenic hormone preparations
without benefit. Examination r evealed a short, well-proportioned young woman;
breasts normal, masculine escutcheon, long labia minora and hypertrophied clitoris.
Bimanual examination showed normal sized uterus, both ovaries enlarged, globular
and tender.
July 6, 1933: Transabdominal pneumoperitoneum and intrauterine lipiodol in -
stillation showed both ovaries enlarged and elongated; tubes patent. Uterine contour
was normal (Fig. 5). Oct. 14, 1933: Operation: Bilateral wedge-resection of
about three-fourths of both ovaries, each of which was 5 by 7 em. in diameter; the
capsule was very thick and leathery. Uneventful postoperative course; discharged
from hospital on twelfth day. Patient menstruated forty-eight hours after opera-
*This patient is now (Jan. 30, 1935) three months pregnAnt.
 S'l'EIN-LEVBN'l'HAL: BlLA'fERA L POLYCYS'ril' OVARIEl:' J K!'J

tion anu has had regular monthly periods :for the past. year. Check-up examination
in September, 1934, showed the uterus and both ovaries normal to palpation .
Patholog·ic Rep01·t.-Gross: Thick tunic; numerous cysts up to 1 em. in diameter.
Microscopic: Moderately thick tunic; numerous eysts, some lined with granulosa
cells, others with theca cells; some corpora a.lbieantia; no corpora lutf'a; tortuous,
Jargt> and thi ckened blood vessels.
CAst: 4..-H. V•i., aged twenty-three, married tln·ee years, gravida o, was first
examined J an. 3, 1933. Her chief eomplaints were sterility and amenorrhea,
Menses began at the age of fifteen, were irregular, one to ~ix months, usually three
to four months; three- to fom-day duration; pr ofuse with clots and cramps. Last
menstruation occurred 8ix months previous to admission. l\' o contraception for two
years. Treated with estrogenic hormone intramuscularly and orally. Examination :
Patient was large, obese with feminine escutcheo n and largE flabby breasts. UteruR
normal; palpable left ovary was enlarged and eyHtie. Pt>h. 15, 193:l: Transuterine
pneumoperitoneum and lipiodol instillation showrd the ut.-rus to be normal in size;
both ovaries were enlarged and rysti c ; fallopian tulws were patent (Fig. ti ). Mar.
11 . l!l33 : Operation: Bilateral wrdge-reseetion of ova riPs whi(·h werp ~o Jargr that

F'ig- , (i.

more than three-fourths of each was removed, leaving the hilus approximately th•·
size of a normal ovary.
The patient made an uneventful recovery and was discharged on the tenth post-
operative day. She menstruated on the sixth day and regularly every twenty-eight
days thereafter for the past year and one-half. Bimanual examination in March,
1934, revealed a normal genital status.
Pathologic Repm·t,...._....{1ross: Each section showed several cysts up to 1.5 em. in
diameter. Microscopic: The ovary appeared normal; tuniea moderately thickened
and below were multiple small cysts; some lined with granulosa cells, others with
theca cells. Normal cystic follicles; small corpora albicantia; cluster of granulosa
cells evidently the edge of a normal follicle. No corpora lutea. In one portion w a~
a small papillary cystadenoma. Tortuous and thickened blood vessels.
CASE 5.~0. B., aged twenty·five, married on e and one-half years, gravida o, was
first seen in the clinic Jan. 9, 1933. Her chief complaints were irregular menses
and sterility. Menses began at the age of fift een, t.wo- to three-month intervals,
painful, duration three days. Last menstruation Dec. 29, l93iL Examination: M.alP
escutcheon, hairy thighs, breasts normal. Bimanual: Cystic swelling of right ovary
palpable, but not left. Uterus was small. Transuterine pneumoperitoneum and
lipiodol instillation: Both ovaries cystic; right larger than lE'ft; tubes patent to ga~
186 AMERH'AN JOURNAL OF OBSTETRICS AND GYNECOLOGY

and filled with lipiodol (Fig. 7). Operation: We,lge-reseetion of one-half to two-
thirds of both ovaries which were polycystie; the uterus was fountl to l>e small, firm,
and slightly bicornuate.
Uneventful postoperative t·ourse; patient was discharged on the tenth day. Men-
struation occurred on the fourth postoperative day, and regularly each month there-
after. Follow-up examination in 'leptemher, 1!134; uterus and ovaries found normal
on palpation.
P(/Jthologio Repo·rt.-Gross: Thick tmvic; numerous cysts varying in size up to
l.i) em. Hemonhagic stroma. Microscopie: Moderately thickened tunic; recent
eorpus luteum with hemorrhagic corpus luteum qst; many cysts lined by theca cells.
Lurge corpus albicans; edematous vascular stroma with hemorrhage.

CAS!<: 6.- K A., aged thirty-three, married fifteen years, gravida ii, was admitted
to the hospital Oct. 23, 1933. Her ehief complaints were irregular menses for nine
years, abnormal hairy growth for three years, and pain in groin for three years.
Menses began at the age of twelve, regular until ten years ago, since then, five- to
nine-month intervals, becoming longer. Menses were seant, lasting three or four days
with no pain. Hairy growth on faf·t>, back, arms, and legs for past three y<>ars.

Fig. 7. Fig.~.

becoming more noticeable. Pain in both lowt>r quadrants for three years, with lower
abdominal pain accompanying the menstrual moliminia even in the absence of bleed-
ing. Gained 15 pounds in past year; weight, 175. Examination: short, obese, male
escutcheon, hair on body and face; pendulous breasts. Uterus normal in size; both
ovaries enlarged, cystic, tender. Transuterine pneumoperitoneum and lipiodol in-
stillation: Both ovaries were enlarged, uterus was normal, and fallopian tubes were
patent (Fig. 8). Operation: Bilateral wedge-resection of about one·half of each
ovary, which contained multiple cortical l'ysts.
Uneventful recovery, discharged on thirteenth postoperative day. Uterine bleeding
occurred on fifth postoperative day and menstruation recurred monthly thereafter
(eleven months). Follow-up examination in June, 1934: No evidence of reformation
of cysts, genital status normal.
Pathologio Report_-Gross: Thick tunic; numerous cystic cavities varying in size
up to 1.5 em. Microscopic: Tunic thickened in some sections and normal in others.
Normal follicle with maturating ovum nt>ar surface. Large theca cyst with corpus
albicans; recent corpus luteum.
CASE 7.-M. B., aged twenty, single, was admitted to the hospital Aug. 29, 1933.
Her chief complaints were amenorrhea and pain in both lower quadrants for one
 STEIN-LEVENTHAT,: BJI,ATEHAL POLYf'Y,:TII ' OVA RIBS JR7

year. Menses began at fourteen years of age, always irregular, six weeks to !'our
months, usually two m«:'nths, seven-day duration, moderate, occasional clots, no
dysm enorrhea. Physical examination revealed a tall, thin girl, with muddy nHH
plexion; facial acne; scant breast deYelopm<'nt. Rertal P-xamination show ~ d the
ntl•rus to he e rect, and of normal size. The lt•ft oYary wa> •·ystie a nd from 7 to ~
tm. in length. The right ovary was cysti•· and ;) em. long. Transabdominal pn••un1o
peritoneum on Aug. 30, 1933. Bilateral pol~· rys tie ovariPs, I'!H:lJ a~ large as th l' 111Jr ·
mal uterin e fundus (Fig. 9). Operation: "'edg·p-re ~N·tion of thl-' •?ystie portit.>ll of
erw h ovary. Patient made an un eve ntful reeovt,ry and was tlis<·h arg<•d fr om tiu' lu" -
pital on the ninth postoperative day. Menstruation lws bt'l' n rt•gular since O)Jl' ratinn ,
and pain has been reli!'ved. Patien t was manird a ft>w mo::tthH aft t<r operatio11 nnd
ha~ remainE'd in good health. She has JnO\'Cd to a distant •·ity and J'eport.·d i"
O~toher, 1!);)4, t.hat she was in good IH'n lth aJHl t.k1t nwnstruation had n·<·uned
monthly.
Patholopi~· Rilport.- Gross : Sed ions of oraries showed n umt•rous l'. yst~; :- nHl
hemorrhngie a nd edematous 9troma. Microscopil' : :\1.ode ra t e ly thi•·keJH' d tunk; hug<·
corpu s lnteum t>yst; numerous cysts lin<'d hy th••:·: t !'Plls: folli<'l<' 1·ysts with gr;wnloH: I
!'Pll lining. Corpora albicantia; <liltttt>tl blood Y!'Hst'ls and ''<•ry l'fl.s<·nlnr st 1'/.Jill a.

DIAGNOSIS AND TREA T1fEN'f

The diagnosis of polycystic ovaries h: mad e only after careful and

repeated examinations. The history of irregular menses with or with-
out pain gives little elne to the ovarian condition and a bimanual or
rectal examination may not always r eveal th e presence of polycystic
ovaries. Due to the fact that the ovaries often show transient enlarge-
ments incident to physiologic changes, one must not anive at hasty
judgments. Furthermore, in cases of flat "oyster oYaries, '' it is
:>ometimes difficult to palpate the pathologie enlat·gement. Conflict-
ing opinions are not infrequent concerning the peesence of th ese
swellings.
The diagnosis is greatly enhanced in cases of ovarian swellings by
the use of pneumoroentgenog raphy, as one of us has previously de-
scribed. We have been able to demonstrate the bilateral ovarian en-
largements by this method when palpatory findings were doubtful or
188 AMERICAN JOURNAL OF OBS'l'E'fRICS AND GYNECOLOGY

disputed. The shadow of the normal ovary usually appears on the

film to be about one-fourth of the size of that of the uterine corpus.
When the ovary is polycystic, it appears from three-fourths to us large
as the uterine shadow. This method of diagnosis has been of especial
value when there was a difference of opinion concerning the presence
of. . ovarian pathology. 'l'he film evidence is convincing as may be seen
in the accompanying illustrations. After using pneumoroentgeno-
graphic diagnosis for more than ten years, we feel that we are quali-
fied to endorse it as a most valuable aid in gynecology, and especially
so in recognizing relatively small ovarian swellings which may escape
detection on bimanual examination.
The treatment of amenorrhea and sterility in the group of patients
under consideration was at first conservative, using endocrine prepa-
rations; eventually the treatment became surgical. In some of the
earlier cases, injections of various endocrine preparations were made
in an effort to adjust the menstrual cycle. Estrogenic hormone prep-
arations which were reputed to be more or less potent were adminis-
tered intramuscularly. Uterine bleeding occurred as a result of this
treatment in some instances, but it is impossible to say whether this
was true menstruation or anovular bleeding. At any rate, no lasting
restoration of function followed these treatments and no pregnancies
occurred. The use of anterior pituitary-like substances was avoided
in order that a cystic change in the ovaries might not be thereby pro-
voked, for, as Zondek has shown, hyperhormonal amenorrhea with
overstimulation of the graafian follicles can be produced by the in-
jection of prolan.
In the patients referred to in this series, we have resected from
one-half to three-fourths of each ovary by wedge-resection, thereby
removing the cortex containing the cysts, and have sutured the hilus
with the finest catgut. The immediate results have been entirely satis-
factory. All of the patients recovered uneventfully, and were dis-
charged from the hospital from the ninth to the thirteenth postopera-
tive days. Uterine bleeding occurred on the third to the fifth post-
operative day and menstruation occurred monthly thereafter in every
case. Our first patient, operated upon four years ago, has given birth
to two children since operation.
DISOUSSlON

The ovarian change in bilateral cystic ovaries is most probably a

result of some hormonal stimulation and very likely relates to the an-
terior lobe of the pituitary gland. Geist reported fifty cases in which
"antuitrin-S" was injected in large doses a few days prior to opera-
tion for :fibroids. At operation, the ovaries showed definite changes.
While the follicles did not grow in size, they were greatly increased
in number. Geist described the additional changes in the ovary which
 STEIN·LEVENTHAL: BILATEHAL POLYCYS'l'll' OVARIE~ ]1'\!1

varied in intensity in direct relationship to the amount of hormone

injected. He quotes the work of Mandelstamm and Tschackowsky
who likewise produced polycystic ovaries in 'Nomen by the use of an-
terior pituitary-Hke substances.
Oddly enough, the surgical treatment directed to the ovary in our
series adjusted the endocrine balance to the extent of restoring nor
mal menstruation and the reproductive function. Theoretically, one
would expect that if the cystic portion of the ovary were remov<~d
without also removing the abnormal stimulus which produced thr
ovarian ehange, the same factors would still be operative, resulting
in reformation of the polycystic change. Thus far, this has not been
our experience although we have observed our patients over a perio(l
of from one to four years since operation.
Whenever one attempts to correlate the fnnction or dysfunction
with the structure of any of the endoerine glands, one is apt to en-
counter grave difficulties, due to the recognized instability of the
normal anatomy of all glands of internal Recretion. The association
of amenorrhea-with polycystic ovaries in our series is no exception
to this statement. The pathologist is unable to conclude from a study
of the sections taken from the ovaries in our patients that amenorrhea
was a symptom. He can demonstrate no anatomic structure or char-
acteristic change in the ovary which enables him to describe the clini-
cal picture. The only consistent pathologic finding is the presence of
follicle cysts lined by theca cells (Table I). The fact remains, how-
ever, that when we remove the cystic portion of the ovaries which to
all appearances are the same as those observed in patients with uterint•
bleeding, normal function is restored to the sex apparatus.
It is unlikely that polycystic ovaries are congenital for the condi-
tion develops as a rule after the patient has menstruated more or less
regularly for a period of years. The amenorrhea is usually secondary.
It is also unlikely, for reasons stated above, that the multiple cyst
formation is explained on the basis of inflammatory change. 'fhat
hormones play a role in the polycystic change in the ovaries is ex-
tremely plausible in the light of our present-day conception of sex
physiology. Whether it results from an excegsi ve production of
anterior pituitary sex hormone or not is debatablP.
H is reasonable to assume that a mechani('al factor operates actually b1
produce the most significant symptoms, namely: amenorrhea and steril-
ity. Tho overproduction of cystic follicles which crowd the ovarian
cortex but which do not rupture on the surface of the ovary, to-
gether with the presence of a thickened tunic, prevents the immature
follicles from ripening and reaching the surface. It is possible that
some of these follicles develop, and being impeded in their pathway to
the surface of the ovary, may rupture into the eysts. We have ob-
 ~
c

P>
~
t%j
~
j;
z
TABLE l. BILATERAL POLYCYSTIC OVARIES WITH AMENORRHEA. HISTOPATHOLOGIC J<'INDINGS '-;
0
-~~---

I
c::~
I I BLOOD I NORMAL ! FOLLICLE CYSTS ! CORPORA CORPORA
I
'rUNIC A I STRO~IA J VESSELS FOLLICL~;s ALBIC ANTI.\ TlTMOR
THECA GRANULOSA! LTTTEA
zP>
--·---- ------- -----
I - - - ---- -- --- -----·---- ~i t:"'
-1-l'rhiek ~--------- !Tortuous 1
J<'ew Many IRecent Many, old
Distended ~
2 Many ~ew: old, ,small I 0
3
l!?~c~ I~ lvfan~y Fe\Y i;!;j
j_
I IllCK ~-Lortuous jl'·ew, small
I Ul
Thick I I 8
4 Normal to moder-1 Tortuous
10I ne . .
In section Many :Manv. small !Early papillary ~
ately thick i Distended . cystadenoma ::0
5 !Moderately thick Edematous Hyperplasia Man~· Few [Recent with e.L 1 Lar~e, recent 0Ul
Vascular I cyst
6 ]Normal to moder- FC'W Many Few One, recent Many >
atelv thick
z0
7 [Mode;~tely thick [Vascular [Dilated I Many I-c.l. cyst [Many 0
-----
><
z
~
0
s
0
><
 STEIN-LEVENTHAL: BILATERAL POL YC'Yf.i'l'l<' OVARIES 1!)]

served, in one of our sections, a normal maturing follicle just below

and adjacent to a thin-walled theca cyst, so situated that if the fol-
licle ruptured at all, its contained ovum would be discharged into the
cyst cavity. This may account for the finding of small corpora lutea
and albicantia even in the absence of menstruation. Ordinaril:v no
corpora lutea would be formt>d unless the g-raafian follicles reaehed
the surface of the ovary and rupturt>d. In further substantiation of
the mechanical theory, we obst>rved that by removin!!· the cystic eortex
which formed the barrier, physiologi<' function was restored. A p
parently the incisional scar in the ovary is of no ~:ig·nifiea.ncf'.

SUMMARY A"'D CO:\'('LFSIONf.:

1. A series of seven cases is herewith J'eporte\1 in which anwnorrht'a

was associated with the presem•t> of bilateral polyc,vsti<: nvaries.
2. Bilateral polycystic ovaries are most lik<'ly the r·<•sult of hormona I
influences and not the result of inflammatory ehangt>.
3. The diagnosis of ovarian pathology is gwatly facilitated by the
use of pneumoroentgenography.
4. The treatment of the amenorrhea with estrogenie hormone in the
patients referred to proved unsatisfactory.
5. Surgical treatment, consisting of wedge-resection of the eystie
cortex of the ovaries, 'vas successful in completely restoring physio-
logic function. Menstruation in every instance became normal an<1
remianed so during the period of obsf'rYation. Pre·gnaney followerl in
two patients.
6. It is our belief that a meehanieal crowding of the cortex by eysts
intf'rferes with the progress of the normal graafian follicles to the
surface of the ovary. This mechanical faetor may aecount for the
l'ymptoms of amenorrhea and sterility.
7. Hecurrenee of the polycystic chang'f' in tht' ovary was not found
in tlw follow-np examinations in any of the patients in this st>rie:;;,

REFEREXCES

Zondek, B.: A.rch. f. Gyniik. 144: 131, 19:10. Mt!!ndelsta.m-m and T.~olWJik<YWsk!i:
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•we are gTeatly indebted to Dr. Otto Saphir for· \'aiuable assistanee in the stu•lY anti
Interpretation of the ovarian tissue changes.