Implementation of a Standardized Tool to Evaluate Heavy Menstrual Bleeding in Adolescents

females presenting with ovarian myxomas. There are no reported cases in the pre-pubertal population. We present an ovarian myxoma in a prepubertal girl and the associated radiographic features. Case: A previously healthy 6 year old girl presented to the emergency department with one day of abdominal pain, nausea and vomiting. Computed tomography demonstrated a 9 cm heterogenous pelvic mass, likely of ovarian origin. There was a thin capsule with enhancing soft tissue bands, coalescing into more nodular central areas. Interspersed regions of low attenuation, Hounsfield units indicated fluid density which could reflect hemorrhage, necrosis or proteinaceous fluid. Therewas no evidence of fat or calcifications. There was no lymphadenopathy, ascites, or peritoneal soft tissue deposits. The abdomen and pelvis were otherwise free of disease. The ovaries could not be clearly distinguished bilaterally. Preoperative tumor markers were within normal limits; HCG 18 mIU/ml, AFP 3 ng/ml, Ca-125 10 U/ml, Testosterone 4 ng/dL, Estradiol 20pg/ml. Exploratory laparotomy was performed by pediatric surgery and pediatric gynecology as co-surgeons. The right ovary was uniformly enlarged, with an area of thin capsule and underlying solid mass. Disease tissue was isolated to the right ovary, with normal left ovary, abdomen and pelvis. Oophrectomy was performed. Frozen section demonstrated a “mucin producing tumor” and the appendix was subsequently removed along with the omentum. Final pathology was consistent with ovarian benign stromal neoplasmwith abundant myxoid changes and cystic degeneration which most closed represents ovarian myxoma. The appendix and omentumwere unremarkable. The patient recovered without incident and is currently doing well. Comments: Ovarian myxoma is a rare, benign sex-cord stromal tumor. It has never been reported in a prepubertal child, but should be included in the differential of a complex adnexal mass without laboratory or other radiologic features concerning formalignancy. As demonstrated by our case, ovarian masses with solid and cystic components, without classic teratomatous features, can be difficult to differentiate from mucinous cystadnocarcinoma ovarian myxoma should be considered pre-operatively.