What is the appropriate management approach for a patient with oophritis?

Management of Oophoritis

For autoimmune oophoritis, conservative management with symptom relief is the primary approach, as there is no proven safe and effective immunosuppressive therapy established by randomized controlled trials. 1

Initial Diagnostic Considerations

When evaluating suspected oophoritis, particularly autoimmune oophoritis, clinicians should assess for:

• Association with autoimmune polyendocrine syndromes (Type I or Type II), including Hashimoto's thyroiditis and Addison's disease 2, 3
• Presence of adrenal cortical or steroid cell antibodies, and/or antibodies to adrenal and ovarian steroidogenic enzymes 3
• Clinical presentation typically includes secondary amenorrhea, infertility, and elevated FSH levels with low estradiol 4, 3
• Ovarian imaging may reveal cystic enlargement due to gonadotropin stimulation of follicles 4

Primary Management Strategy

Symptom Management (First-Line)

• Hormone replacement therapy for symptom relief of estrogen deficiency is the mainstay of treatment 3
• Avoid unnecessary surgical intervention: Recognition of cystic ovarian changes as part of autoimmune oophoritis can prevent oophorectomy in patients whose ovarian tissue is already compromised 4

Immunosuppressive Therapy Considerations

Corticosteroid therapy should be limited to use in placebo-controlled trials only, as the risks may outweigh benefits 1:

• While one case demonstrated potential benefit with alternate-day glucocorticoid treatment (return of menses and ovulatory progesterone levels over 16 weeks in histologically proven autoimmune oophoritis) 1
• Significant complications have been documented, including iatrogenic Cushing syndrome and osteonecrosis, in a patient treated with 9 months of corticosteroids without restoration of menses 1
• No prospective randomized placebo-controlled studies have proven safety and efficacy of immunosuppressive therapy for this condition 1

Critical Pitfalls to Avoid

• Do not perform oophorectomy for cystic ovarian enlargement without considering autoimmune oophoritis, as the cystic changes result from elevated gonadotropins stimulating already compromised ovarian tissue 4
• Do not initiate empirical corticosteroid therapy outside of clinical trials, given the potential for serious complications without proven benefit 1
• Histologic confirmation shows folliculotropic lymphoplasmacytic infiltrate concentrated in the theca interna layer of developing follicles, sparing primordial follicles 2

Special Considerations

Infectious Oophoritis

For xanthogranulomatous oophoritis associated with bacterial infection (e.g., E. coli):

• Appropriate antimicrobial therapy targeting the identified organism is indicated 5
• This represents a distinct entity from autoimmune oophoritis and requires different management 5

Fertility Considerations

• Granulosa cells are typically spared in autoimmune oophoritis, with normal to high inhibin A and B levels 3
• Further investigation is needed to assess treatment options for fertility restoration, as current evidence is insufficient to recommend specific interventions 3