Postoperative hormonal modulation in a patient with granulosa cell tumor and myasthenia gravis: a gyneco-oncologic...

Perioperative management of granulosa cell tumors (GCTs) becomes significantly more complex in patients with neuromuscular conditions such as myasthenia gravis (MG). Herein, we describe a case of surgically managed stage I GCT in a woman with MG and hypothyroidism. This case is unique because the patient developed postoperative cardiac instability attributed to abrupt estrogen withdrawal after oophorectomy, which resolved rapidly with estrogen replacement.

A 38-year-old woman (gravida 0, para 0), married for 8 years, and who is a known case of MG and hypothyroidism presented to our center with a 2-week history of dull lower abdominal pain, intensifying during menstruation. The MRI raised a suspicion of malignancy after which the patient was taken for comprehensive staging surgery in which abdominal hysterectomy and bilateral salpingo-oophorectomy were performed. On post-op day 3, she developed palpitations, chest discomfort, progressive fatigue, and drowsiness. The patient was successfully managed with oral estradiol and discharged on post-op day 9.

From a gynecologic oncologic perspective, comprehensive surgical staging remains the standard of care for apparent early-stage AGCT. In our case, the patient's co-morbid MG added significant complexity to the perioperative planning. The cardiac arrhythmia developed as a result of sudden withdrawal of estrogen due to oophorectomy was successfully managed with oral estradiol, and the patient was successfully discharged.

Prompt recognition of post-oophorectomy hormonal withdrawal and judicious use of estrogen therapy may be essential in mitigating postoperative complications in hormone-sensitive tumors like AGCTs.