Benign Diseases of the Female Reproductive Tract II

Book Review Novak’s Gynecology Chapter 13.

Benign Diseases of the Female Reproductive Tract II

by SMC OBGY R1 Choi, Suk Joo

II. Pelvic Mass

C. Reproductive Age Group

1. Differential Diagnosis
- Age is important determinant of the likelihood of malignancy

2. Uterine Mass

1) Uterine Leiomyomas

a. At least 20% of all women of reproductive age and may be discovered incidentally during routine annual examination
b. Asymptomatic fibroids may be present in 40-50% of women older than 40 years of age
c. Fewer than one-half of uterine leiomyomas produced symptoms.
d. Each leiomyomas arises from a single neoplastic cell within the smooth muscle of the myometrium
e. Fibroids have the potential to enlarge during pregnancy as well as to regress after menopause
f. Fibroids are discrete nodular tumors that vary in size
g. Degenerative changes are reported in approximately 2/3 of all specimens

i) During pregnancy of in women taking progestational agents
ii) With necrosis
iii) As a “smooth muscle tumor of uncertain malignant potential”

h. Studies suggest that malignant degeneration of a preexisting leiomyoma is extremely uncommon, occurring in less than 0.5%

i. Symptoms

i) menorrhagia
ii) chronic pelvic pain (dysmenorrhea, dyspareunia, pelvic pressure)
iii) acute pain from torsion of a pedunculated leiomyomas or infarction
iv) urinary sx. ? frequency, partial ureteral obstruction, complete urethral obstruction
j. Leiomyomas are an infrequent primary cause of infertility and have been reported as a sole cause in less than 3% of infertile patients
k. Symptoms infrequently associated

i) Rectosigmoid compression
ii) Prolapse of a pedunculated submucous tumor through the cervix
iii) Venous stasis of the lower extremities and possible thrombophlebitis
iv) Polycythemia
v) Ascites

3. Ovarian Masses

a. About 2/3 of ovarian tumors are encounted during the reproductive years
b. Most ovarian tumor(80-85%) are benign, 2/3 of this tumors occur between 20-44yr
c. The chance that a primary ovarian tumor is malignant in a patient younger than 45 years of age is less than 1 in 15
d. The most common symptoms : abdominal distension, abdominal pain or discomfort,lower abdominal pressure sensation, urinary and GI Sx
e. If the tumor is hormonally active, symptoms of hormonal imbalance (vaginal bleeding related to estrogen production)
f. Acute pain occur with adnexal torsion, cyst rupture, or bleeding into a cyst.
g. DDx between benign and malignancy

i) Mass that unilateral, cystic, mobile, smooth are most likely to be benign
ii) Mass that bilateral, solid, fixed, irregular and associated with ascites, cul-de-sac nodule, and a rapid growth are more likely to be malignant.

1) Nonneoplastic Ovarian Mass
: - Benign and usually do not cause sx. or require surgical management.
- Combination monophasic OC Tx reduce the risk of functional ovarian cysts .
- Triphasic OC therapy increased the risk.
- Smokers have a twofold increased risk.

a. Follicular Cysts

: The most common functional cyst, which is rarely larger than 8cm

b. Corpus Luteum Cysts

: Less common than follicular cysts, and called cyst when its diameter is greater than 3cm
Halban syndrome which simulated ectopic pregnancy ? persistent corpus luteum cyst
If ruptured, leading to a hemoperitoneum and require a surgical management

c. Theca Lutein Cysts

: The least common
Bilateral and occur during preg. (including molar preg.)
1/4 of molar preg and 10% of choriocarcinoma may be associated
Association with multiple gestations, DM, Rh sensitization,
clomiphen citrate and human menopausal gonadotropin /
human chorionic gonadotropin ovulation induction,
the use of GnRH analogs

2) Other Benign Masses

a. Endometriosis
b. Polycystic Ovaries

: Originally considered the sine qua non of PCOS
22% of general population
Evaluate hyperandrogenism and chronic anovulation as well as
polycystic ovaries

3) Neoplastic Masses

- More than 80% of benign cystic teratomas(dermoid cysts) occur during the
reproductive age
- More than 3/4 of malignant transformation occur older than 40 years of age
- The risk of torsion with dermoid cysts is 15% and it occur more frequently
than with ovarian tumors in general (d/t high fat content, “float”)
- An ovarian cystectomy is almost always possible
- Preserving a small amount of ovarian cortex in a young pt. with a benign
lesion is preferable to the loss of the entire ovary
- The risk of epithelial tumors increases with age

a. Cystic Teratoma
: Most common (66%) benign tumors in women < 40yr

b. Serous Tumors

: Generally benign, 5-10% have borderline malignant potential,
20-25% are malignant.

c. Benign Mucinous Tumors

: Typically have a lobulated, smooth surface
5-10% of mucinous ovarian tumors are malignant
-> DDx with metastatic GI tumors
d. Others : fibroma, Brenner tumor, mixed forms of tumor

4) Other Adnexal Masses

a. Ectopic pregnancies
b. Paraovarian cyst

4. Diagnosis

1) Complete pelvic exam (rectovaginal exam, Pap test)
-> Estimation in centimeters

2) Other studies

a. Endometrial sampling with an endometrial biopsy or D&C
b. Urinary tract studies (cystometric measurements)
c. Cystoscopy
d. USG or IVP

3) Labaratory studies

a. Pregnancy test, Pap test, CBC, ESR, Stool test, Tumor marker (e.g. CA 125)
b. A number of benign conditions (Ut. myoma, PID, pregnancy, ES) can elevate
CA125, and thus lead to unnecessary surgical intervention
4) Imaging studies
a. USG : transvaginal of transabdominal
b. CT
c. Abdominal flat plate X-ray : calcification
d. Hysteroscopy
e. HSG
f. MRI : most useful in the Dx. of uterine anomalies

5. Management

1) Management of Leiomyomas

a. Nonsurgical

- Judicious pt. observation and F/U are indicated primarily intervention is
reserved for specific indications and Sx.
- Use of GnRH agonist 40-60% decrease in uterine volume
- Hypoestrogenism results from treatment and associated with reversible bone
loss and Sx.
- Ix. of GnRH agonist

i) Preservation of fertility in women with large myoma before attempting
conception, or preoprerative treatment before myomectomy
ii) Treatment of anemia to allow recovery of normal hemoglobin levels
before surgical management, minimizing the need for transfusion or
allowing autologous blood donation.
iii) Treatment of women approaching menopause in an effort to avoid surgery
iv) Preoperative treatment of large myomas to make vaginal hysterectomy,
hysteroscopic resection or ablation or laparoscopic destruction more
v) Treatment of women with medical contraindication to surgery
vi) Treatment of women with personal or medical indications for delaying

b. Surgical
- Indication
i) Abnormal uterine bleeding with resultant anemia, unresponsive to
hormonal management
ii) Chronic pain with severe dysmenorrhea, dyspareunia, or lower
abdominal pressure or pain
iii) Acute pain as in torsion of a pedunculated myoma or prolapsing
submucosal fibroid
iv) Urinary symptoms or sign such as hydronephrosis after complete
v) Rapid enlargement of the uterus during the premenopausal years, or
any increase in uterine size in a postmenopausal woman, because of
inability to exclude a uterine sarcoma
vi) Infertility with leiomyomas as the only abnormal finding
vii) Enlarged uterine size with compression sx. or discomfort.

- Hysterectomy
- Abdominal myomectomy
- Vaginal myomectomy
- Hysteroscopic resection

2) Management of Ovarian Masses

a. OC are effective in leading to resolution of functional ovarian cysts
b. OC are effective in reducing the risk of subsequent ovarian cysts.
c. Symptomatic cysts should be evaluated promptly, although mildly
symptomatic masses suspected to be functional can be managed with
analgesics rather than surgery.
d. Surgical intervention in significant pain or the suspicion of malignancy
e. Malignancy : on USG large cysts, multiloculations, septa, papillae,
increased blood flow
f. In suspicion of a malignant cyst : at any age, explorative laparotomy
should be done promptly
g. Laparoscopic surgery should be reserved for diagnostic or therapeutic
purposes for pt at very low risk for malignancy

D. Postmenopausal Age Group

Ovarian Size

- Before menopause, 3.5 X 2 X 1.5 cm
- In early menopause 2 X 1.5 X 0.5 cm
- In late menopause 1.5 X 0.75 X 0.5 cm

1. Differential Diagnosis

1) Ovarian Masses

a. Postmenopausal palpable ovary (PMPO) syndrome
b. The incidence of ovarian cancer increases with age and is predominantly
a disease of postmenopausal women : the average patient age is 61 years
c. Asymptomatic, small (<5cm in diameter), unilocular, thin-walled cyst
: the risk of malignancy is extremely low and follow the conservative
therapy without surgery
d. Indication of surgery
i) Adverse pedigree with a strong family history of ovarian, breast,
endometrial, colon cancer
ii) Mass appears to be enlarging
e. The risk of malignancy for pelvic mass : 50%

2) Uterine and Other Masses
a. Paraovarian cysts and unusual tumors such as benign retroperitoneal
cytst of mullerian type

III. Vulvar Condition

A. Neonatal : various developmental and congenital abnormalities

1. Ambiguous Genitalia
1) Chromosomal abnormalities, enzyme deficiencies, prenatal
masculinization of a female fetus resulting from maternal
androgen-secreting ovarian tumors
2) The situation of ambiguous genitalia represents a social
and potential medical emergency that is best handled by a
team of specialists
2. Gentle probing of the introitus and anus to determine the patency
of the hymen or possible imperforated anus
3. "Strawberry" hemangiomas
1) Congenital vulvar tumor
2) Superficial vascular lesions and large cavernous hemangiomas
3) Treatment is controversial : spontaneous regress, cryotherapy, argon
laser tx., sclerosis

B. Childhood

1. Vulvovaginitis

2. Lichen sclerosus, seborrheic, atopic vulvitis

1) Lichen sclerosus -
: "cigarette paper" appearance in a keyhole distribution
(the vulva and anus)
reassuarance that condition will regress as the child progresses
through and menarche
progesterone oil, betamethasone valerate, temovate cream
3. Labial agglutination
4. Vulvovaginal complaints of any sort in a young child should prompt the
consideration of possible sexual abuse

C. Adolescence

1. Adolescence with gonadal dysgenesis or androgen insensitivity
2. Vaginal agenesis, imperforated hymen, transverse and longitudinal
vaginal septa, vaginal and uterine duplications, hymenal bands.
3. Tight hymenal ring

D. Reproductive Women

1. Vulvar Sx are most often related to a primary vaginitis and a secondary
2. Pigmented vulvar lesion
3. Vulvar Bx. : essential in distinguishing benign from premalignant or
malignant vulvar lesions especially because many lesions may
have a somewhat similar appearance
4. Other vulvar conditions

1) Pseudofolliculitis
2) Fox-Fordyce disease
3) Hidradenitis suppurativa
4) Acanthosis nigricans

5. Intraepithelial neoplasia

1) Extramammary Paget's disease
2) Vulvar intraepithelial neoplasia is associated with HPV infection

6. Vulvar tumors, cysts and masses

1) Condyloma acuminata
2) Molluscum contagiosum
3) Syphilis and condyloma lata
4) Lesions of mammary-like anogenital glands(fibroadenoma, lactating
glands) is not supported by observations in human embryos
5) Bartholin duct cysts are a common vulvar lesion
6) Bartholin abscess
7) Skene duct

7. Vulvar Ulcers

1) Herpes simplex virus, syphilis, lymphogranuloma venereum, and granuloma
2) Crohn's disease
3) Bechet's disease, genital and oral ulcerations with ocular inflammation
4) Lichen planus
5) Plasma cell mucositis

E. Postmenopausal Women

1. Vulvar dystrophies

1) Leukoplakia, lichen sclerosus et atrophicus, atrophic hyperplastic
vulvitis, kraurosis vulvae
2) The malignant potential of the vulvar dystrophies is less than 5%

2. Squamous hyperplasia

1) Pruritus
2) Thickened and hyperkeratotic
3) Excoriation
4) Discrete or symmetrical and multiple
5) Tx. : flourinated corticosteroid for 6 weeks

3. Lichen Sclerosis

1) Most common white lesion of the vulva
2) Occur at any age, although it is most common among postmenopausal women
3) Pruritus, dyspareunia, burning
4) Decreased subcutaneous fat such that the vulvar is atrophic, with small
or absent labia minora , thin labia majora, and sometimes phimosis
5) Tx : 2% testosterone cream in a petrolatum base applied twice daily for
3 weeks and then once daily for 3 weeks
0.05% clobetasol
superficial vulvectomy

4. Mixed Dystrophy

1) Consists of varying proportions of hypoplastic and hyperplastic tissue
2) Account for about 20% of vulvar dystrophies
3) Burning, pruritus and dyspareunia
4) Tx : Fluorinated corticosteroid ointment three times daily for 6-8weeks
followed by 2% testosterone ointment 3 times daily for 6-8 weeks

5. Urethral Lesions

1) Urethral caruncles and prolapse of the urethral mucosa
2) various vulvar skin lesion, including seborrheic keratoses and "cherry"
hemangiomas (senile hemangiomas), occur more commonly on aging skin

IV. Vaginal Conditions

- Vaginal discharge is one of the most common vaginal symptoms
- Vaginal candidiasis to chlmydia cervicitis to bacterial vaginosis to cervical
carcinoma can cause vaginal discharge
- Other noninfectious cause of vaginal discharge

1) Retained foreign body
2) Ulceration - lichen planus
3) Malignancy - cervical, vaginal
4) Postmenopausal atrophic vaginitis, postradiation vulvovaginitis

A. Pediatric

1. Sexual abuse should be considered in prepubertal children with vaginal
2. Culture for gonorrhea and chlamydia
3. Tx : focus on hygienic and cleansing measures
short-term(<4weeks) course of topical estrogens and broad-spectrum

B. Adolescence and Older

1. Toxic Shock Syndrome

1) Associated with vaginal tampon use and vaginal staphylococcus aureus- produced exotoxins
2) Fever, hypotension, a diffuse erythroderma with desquamationof the palms and soles, plus involvement of at least three major organ systems
2. Fibroepithelial polyps consist of polypoid folds of connective tissues, capillaries and stroma covered by vaginal epithelium
3. Cysts of embryonic origin can arise from mesonephric, paramesonephric, and urogenital sinus epithelium
: Gartner's duct cysts are of mesonephric origin
4. Vaginal adenosis, the presence of epithelial-lined glands within the vagina
: close observation and Bx to R/O vaginal clear cell adenocarcinoma