OVARY

A. Functional cysts
1. Follicular cyst  Most frequent cystic structures in normal ovaries MANAGEMENT:
 Mayle solitary or multiple but Freq multiple  Conservative observation
 Minimum dm: 2.5 to 3cm to as large as 15cm  Majority of cysts disappear spont by either
 Not neoplastic reabsorption of fluid or silent rupture within 4-8
 Dependent on gonadotropins for growth wks of initial dx
 Clinically may present w/ S/Sx of ovarian enlargement
 Most are asymptomatic, and are discovered incidentally
 May rupture during examination b/c of thin walls – tenesmus, transient pelvic
tenderness, deep dyspareunia, or no pain
 Most comm found in young menstruating women
 Translucent, thin-walled, filled with a watery, clear to straw-colored fluid
 Histologically: closely packed layer of round, plump granulosa cells, with the
spindle-shaped cells of the theca interna deeper in the stroma
 Better termed: Follicular hematoma (blood from the vascular theca zone fills
the cavity of the cyst)
 Malignant ovarian masses cx:
1. Internal papillations (echogenic structures protruding into the masses)
2. Loculations
3. Solid lesions or cystic lesions w/ solid components
4. Thick septations
5. Smaller cysts adjacent to or part of the wall of the larger larger cyst-
daughter cyst

2. Corpus luteum cyst  Less common than FC but clinically more important MANAGEMENT:
 Termed as corpus luteum cyst: minimum of 3cm in dm  Cystectomy – operative treatment of choice
 Assoc w/ normal endocrine function or prolonged secretion of progesterone w/preservation of the remaining portion of the
 Most CLC are small ave dm 4cm ovary
 Grossly: smooth surface, purplish to red brown
 Asymptomatic to causing massive intraperitoneal bleeding associated w/
rupture
 Dull, unilateral, lower abdominal and pelvic pain
 Halban’s classic triad:

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 1. Delay in normal period
2. Unilateral pelvic pain
3. Small, tender, adnexal mass

3. Theca lutein cyst
 Least common of the three types pf physiologic ovarian cyst MANAGEMENT:
 Bilateral and produce massive enlargement of ovaries  Conservative: cysts gradually regress
 From prolonged or excessive stimulation of the ovaries – endogenous
gonadotropins or increased sensitivity to gonadotropins
 Hyperreactio luteinalis – ovarian enlargement sec to the devt of multiple
luteinized follicular cysts
 Honeycombed appearance
 Grossly: Lobulated
 Histo:lining consists of theca lutein cells (paralutein cells)

4. Luteomas of pregnancy  Rare MANAGEMENT:

 Benign  Regress spontaneously following compl of
 Hyperplastic reaxn of ovarian theca cells pregnancy
 Asymptomatic
 Solid, fleshy, hemorrhagic nodules disc incidentally

B. Benign neoplasms
1. Mucinous cystadenoma  Epithelial cells filled w/ mucin MANAGEMENT:
 Resemble cells of the endocervix or may mimic intestinal cells

2. Serous cystadenoma  Occur during the reproductive years

3. Transitional cell tumors  Rare, small, smooth, solid fibro epithelial ovarian tumors MANAGEMENT:
(Brenner tumor)  Generally asymptomatic  Operative
 Result from: metaplasia of coelomic epithelium into uroepithelium  Simple excision
 CT scan: Extensive amorphous calcification within the solid components of
the ovarian mass
 Grossly: Smooth, firm, gray-white, solid tumors
 Slow growing
 Histo: 2 components:
1. Solid mass or nests of epithelial cells

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 2. Surrounding fibrous stroma
 Pale epithelial cells: Coffee bean

4. Benign cystic teratoma  Cystic structures MANAGEMENT:

(Dermoid cyst/Mature teratoma)
 Histo: elements from all 3 germ cell layers  Cystectomy with preservation of as much as
 Teratoma: ‘’monstrous growth’’ normal ovarian tissue as possible
 Dermoid: common term
 Most common ovarian neoplasm
 Dermoids - most common in prepubertal females and common in teenagers
 On palpation: have both cystic and solid comp – doughy consistency
 Cysts:
1. Unilocular
2. Walls: smooth, shiny, opaque white color
3. When opened: thick sebaceous fluid pours from cyst, tangled
masses of hair and firm areas of cartilage and teeth
4. Sebaceous material – thick fluid at body temp but solidifies when in
room air
 Histo:
1. Mature cells from 3 germ layers
2. Skin and skin appendages
3. Sebaceous glands
4. Sweat glands
5. Hair follicles
6. Muscle fibers
7. Cartilage
8. Bone
9. Teeth – premolar and molar
 Fluid is sebaceous
 Solid elements contained in nipple (mamilla) – prominence or tubercle of
Rokitansky
 Asymptomatic discovered coincidentally
 Sx: Pain and sensation of pelvic pressure
 Complications:
1. Torsion – most freq
2. Rupture

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 3. Infection
4. Hemorrhage
5. Malignant degeneration
 3 Assoc dis:
1. Thyrotoxicosis
2. Carcinoid syndrome
3. Autoimmune hemolytic anemia
 Struma ovarii – a teratoma in which the thyroid tissue has overgrown

5. Endometriomas  One of the most common causes of enlargement of the ovary MANAGEMENT:
 Size: Small to superficial-blue black implants1-5mm dm to large  Choice between medical and operative
multiloculated, hemorrhagic cyst 5 to 10mm in dm management depends on several factors:
 Areas of ovarian endometriosis that become cystic - endometriomas Patient’s age, future reproductive plans,
 Larger cyst – bilateral severity of symptoms
 Rarely large chocolate cysts: may reach up to 15-20cm
 Surface of ovary w/ endometriosis – irregular, puckered, and scarred
 Most are asymptomatic
 Most common symptoms – pelvic pain, dyspareunia, and infertility
 UTZ: thick walled cyst w/ relatively homogenous echo pattern that is
echolucent

6. Fibroma  Most common benign, solid neoplasm of the ovary MANAGEMENT:

 Malignant potential is low  Exploratory operation
 Size: Small nodule to huge pelvic tumors – weighing 50 lbs  Simple excision of tumor
 Extremely slow-growing tumors
 Diameter is important clinically – ascites is directly proportional to the size of
the tumor
 Misdiagnosed to leiomyomas
 Aveg age: 48 - Common in post- menopausal women
 Pelvic symptoms: Pressure and abdominal enlargement
 Smaller tumors are asymptomatic – do not elaborate hormones, no change
in pattern of menstrual flow
 Maybe pedunculated – easily palpable during one exam yet difficult on

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7. Sex cord stromal tumors
8. Adenofibroma
cystadenofibroma
9. Ovarian remnant syndrome
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subsequent
 Meig’s syndrome: Ovarian fibroma, ascites, hydrothorax
 Grossly: Heavy, solid, well encapsulated and grayish white
 Cut surface: homogeneous white or yellow solid tissue w/ a trabeculated or
whorled appearance similar to myommas
 Histo: Connective tissue, stromal cells, collagen
 Derived from the sex cords of the ovary and the specialized stroma of the
developing gland
 Some are hormonally active tumors
and  Are closely related MANAGEMENT:
 Consists of fibrous and epithelial components  TAHBSO (Post-menopausal women)
 Epithelial comp: Serous  Simple excision in younger women
 Histo: May be mucinous and endometroid or clear cell
 Differ form benign epithelial cystadenomas – preponderance oof conn tissue
 Cystadenofibromas – microscopic or occasional macroscopic areas that are
cystic
 Adenofibromas: small fibrous tumors that arise from the surface of the ovary
 Occur in post-menopausal women – 1-15cm in dm
 Grossly: Gray or white tumors difficult to distinguish from fibromas
 Smaller tumors – asymptomatic
 Large tumors – may cause pressure symptoms or rarely adnexal torsion
 Chronic pelvic pain sec to a small area of functioning ovarian tissue following MANAGEMENT:
intended total removal of both ovaries  Surgical removal of the ovarian remnant
 Pain is cyclic and exacerbated by after coitus
 Half presents with pain and half with pelvic mass
 Histo: Ovarian follicles and stroma
 VULVA

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 1. Urethral caruncle  Primarily affects postmenopausal women and premenarchal females MANAGEMENT
 Result from decreased estrogen  Initial: oral or topical estrogen and avoidance of
 Small, fleshy mass at the posterior portion of urethral meatus irritation
 Tissue is smooth, friable, bright red – initially appears as an eversion of the  If does not regress: cryosurgery, laser therapy,
urethra fulguration, or operative excision
 Maybe pedunculated and grow to be 1-2 cm
 Growth is sec to chronic irritation or infection
 Histo: Transitional and stratified squamous epithelium w/ a loose conn tissue
 Freq subdivided by histo appearance:
1. Papillomatous
2. Granulomatous
3. Angiomatous
 Many are asymptomatic
 Others: Dysuria, Frequency, Urgency
 Dx: Biopsy under local anesthesia

2. Cyst  Most common large cyst of vulva – obstructed Bartholin duct (BD opens in
vulva vestibule at 5 and 7 o’clock position)
 Occur in third decade
 Non-inflammed cyst contain sterile, clear, mucinous fluid
 Don’t require treatment unless large enough to cause
discomfort
 Infammed cyst: Oral antib. Or I and D
 Epidermal cyst
 Most common small vulvar cysts
 Firm, smooth surfaced, white, yellow, slightly pink,or skin
colored papules 0.5cm to 2cm
 Located in hair-bearing areas
 Firm to shotyy in consistency
 Nontender and slow growing

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 3. Nevus  Comm referred to as mole – localized nest or cluster of melanocytes MANAGEMENT:
 One of the most common benign neoplasms in females  Ideally: excision and examined histologically
 Dm (3 to 10 mm)  Flat junctional nevus and dysplastic nevus –
 Grossly: greatest potential for malignant transformation

 Benign nevi Dysplastic nevi

Flat, Elevated, pedunculated 6-20 mm size
Generally
Color is even Speckling of color
Additional red, white, or blue
hues
Borders are sharp Diffuse margination
Shape is symmetrical Asymmetry
5 types of vulvar
asymptomatic
hemangiomas
1. Strawberry  Bright redto dak
Histo:
red
 Elevated 1. Junctional (symmetric macule)
2. Compound
 Rarely increases in size after age 2
3. Intradermal nevi (both papules)
2. Cavernous  Purple
 Melanoma – 2nd most common malignancy arising in the vulva
 Vary in size
 Larger lesions: extends into the
subcutaneous tissue
4. Hemangioma  Rare malformations of blood vessels MANAGEMENT:
3. Senile or cherry  Common small lesions
 Freq discovered during childhood  In adults, initial tx: may require subtotal resection
 Arise on labia majora
 Single, 1-2cm in dm, flat, soft, color from  If questionable diff dx: Excisional biopsy
 Usually in postmenopausal women
brown to red or purple  If associated with bleeding cryosurgery,
 Less than 3cm in dm, multiple
 Asymptomatic; occasionally ulcerated sclerotherapy, or with use of lasers
 Red-brown to dark blue
and ble
4. Angiokeratomas  Approx 2x the size of cherry
angiomas
 Occur b/w ages 30-50
 Rapid growth
 Tendency to bleed during strenuous
exercises
5. Pyogenic  Overgrowth of inflamed granulation
granulomas tissue
 Grow under the hormonal influence
of pregnancy
 Approx 1 cm in dm
 Pedunculated and ‘’pinched’’ at the
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 Tx: wide and deep excision
 5. Fibroma  Most common benign solid tumors of the vulva MANAGEMENT:
 More freq than lipomas  Operative removal of if symptomatic or continue
 Comm found in labia majora to grow
 Grow slowly and vary from few centimeters too one gigantic vulvar fibroma
(>250 lbs)
 B/w 1-10 cm in dm
 Smaller fibromas: discovered as subcutaneous nodules, firm
 Larger ones: Cystic
 Smooth surface and distinct contour
 Low grade potential for malignancy

6. Lipoma  2nd most freq tyoe of benign vulvar mesenchymal tumor MANAGEMENT:
 Common hamartoma of fat, lipomas of the vulva  Excision to establish dx, smaller tumors, followed
 Most comm located periclitorally or within the labia majora conservatively
 Softer and larger than fibromas

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  Slow growing, extremely low malignant potential
 Unless extremely large don’t produce symptoms

7. Hidradenoma  Or Mammary-like gland adenoma MANAGEMENT:

 Located in anogenital area of women  Excisional biopsy
 Small, smooth-surfaced, medium soft to firm nodules
 Found in labia majora/minora
 Appear cystic and asymptomatic
 Some report itching, bleeding, and mild pain
 Maybe cystic or solid
 Well-defined capsules and arise deep in the dermis

8. Syringoma  Benign skin adnexal neoplasm – eccrine origin MANAGEMENT:

 Common in the face and eyelids but unusual in vulva  Topical steroids
 Small, asymptomatic papules (<5mm in dm)  Topical tretinoin
 Loc in labia majora  Oral isotretinoin
 Maybe hormonally related
 Pregnancy may aggravate assoc pruritus
 Fox-Fordyce disease (most comm diff dx) – condition of multiple retention
cysts of apocrine glands accompanied by inflammation of the skin, pruritic
while syringoma isn’t

9. Endometriosis  Uncommon MANAGEMENT:

 Firm, small nodule or nodules may be cystic or solid and vary from few mm  Wide excision
to several cm in dm  Laser vaporization dep on the size of the mass
 Lesions are blue, red, purple, depending on size and closeness to surface of
skin
 Usually found at the site of old, healed obstetric laceration, episiotomy site,
area of operative removal of Bartholin duct cyst or along canal of Nuck
 Sx: Pain and introital dyspareunia

10. Granular cell myoblastoma  Rare, slow growing tumor, solid vulvar tumor
 Originates from neural sheath (Schwann) – Schwannoma
 Located in labia majora, occasionally in clitoris
 Are subcutaneous nodules – 1 to 5 cm in dm

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  Benign but infiltrates the surrounding local tissue

11. Von Recklinghausen’’s  Vulva is sometimes involved MANAGEMENT:

disease  Generalized neurofibromatosisor café-au-lait spots  Excision
 Lesions are fleshy, brownish red, polypoid tumors

12. Hematomas  Usually sec to blunt trauma – straddle injury from a fall, automobile accident MANAGEMENT:
physical assault  Conservative, unless greater than 10 cm in dm or
rapidly expanding
 Compression ice pack
 If it continues to expand, operative therapy is
indicated

1. Urethral diverticulum
2. Inclusion cyst
3. Dysodontogenic cyst
VAGINA
 Permanent, epithelialized, saclike projection that arises from the posterior urethra MANAGEMENT:
 Maybe congenital and acquired - Most are acquired and present in women b/w 30  Excisional surgery if not acutely infected
and 60 y/o
 Present as a mass of anterior vaginal wall
 Sx: Nonspecific, identical to the symptoms of lower UTI
 Common symptoms: Urinary urgency, frequency and dysuria
 3 Ds: Dysuria, Dyspareunia, Dribbling of urine
 Dx: Voiding cystourethrography and cystourethroscopy
 Most common cystic structures of the vagina MANAGEMENT:
 Loc in the post or lat walls of the lower third of the vagina  If it causes dyspareunia or pain, tx is
 Vary from 1mm to 3mm in dm excisional biopsy
 More common in parous women
 Majority are asymptomatic
 Thin-walled, soft, cysts of embryonic origin MANAGEMENT:
1. Mesonephros (Gardner duct cyst)  Operative excision for chronic symptoms

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1. Endocervical and Cervical
polyps
2. Nabothian cyst
3. Cervical myoma
2. Paramesonephricum (Mullerian cyst)
3. Urogenital sinus (Vestibular cyst)
 Single, maybe multiple
 Large cyst maybe mistaken for cystocele, ant. Enterocele
 Most are asymptomatic, sausage shaped tumors
CERVIX
 Most common benign neoplastic growths of the cervix MANAGEMENT:
 Most common in multiparous women in 40s or 50s  Maybe managed in the office by grasping
 Single polyp but multiple polyps may occur the base of the polyp w/ a clamp
 Majority are smooth, soft, reddish purple to cherry red and fragile  Polyp is usually friable, if bleeding ensues,
 Readily bleed when touched base may be treated w/ chemical cautery,
electrocautery or cryocautery
 Polyps may arise from either endocervical canal (endocervical canal) or ectocervix
(cervical polyp
 Origin: Sec to inflammation or abnormal focal responsiveness to hormonal
stimulation
 Classic symptom: Intermenstrual bleeding esp ff coitus or pelvic examination
 Six histologic subtypes:
1. Adenomatous – 80%
2. Cystic
3. Fibrous
4. Vascular
5. Inflammatory
6. Fibromyomatous
 Retention cysts of endocervical columnar cells
 So common that they are considered normal feature of adult cervix
 Grossly: Translucent or opaque whitish or yellow in color
 3mm to 3 cm in dm
 Asymptomatic, no tx is necessary
 Smooth, firm masses -similar to myomas of the fundus
 Solitary growth in contrast to uterine myomas
 Most are small and asymptomatic
 Sx: Dysuria, urgency, urethral or ureteral obstruction, dyspareuniaor obstruction of
the cervix
 Dx: Inspection and palpation
 Grossly and Histo: identical and indistinguishable from myoma of the corpus of the

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 uterus
UTERUS
1. Endometrial polyp
2. Leiomyomas  Also called myomas
 Most common benign neoplasms of the uterus
 Benign tumors of muscle cell origin
 Fibroids or fibromyomas
 Contain varying amounts of fibrous tissue – sec to degeneration of some of the
muscle cells
 1/3 of myomas – symptomatic causing abnormal and excessive uterine bleeding,
pelvic pain, pelvic pressure, bowel and bladder dysfunction, infertility, recurrent
miscarriage, abdominal protrusion

 Risk factors:
1. Increasing age
2. Early menarche
3. Low parity
4. Tamoxifen use
5. Obesity
6. High fat diet (in some studies)
 Smoking – decreased incidence of myomata
 Growth of myomas – dependent on gonadal steroids, Inc number of steroids
receptors
 Limited malignant transformation - <1%
 Rarely causes mass effect on adjacent organs
 May be single but most often are multiple
 Vary in size – microscopic to multinodular uterine tumors – may weigh >5o lbs
 Initially – begin as intramural myomas
 Small myomas – round, firm, solid tumors
 Classified into subgroups by their anatomic and position to the layers of uterus

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  3 most common types:
1. Intramural
2. Subserous – knobby contour on pelvic exam – may become a parasitic myoma
3. Submucous – troublesome clinically; assoc w/ abnormal vaginal bleeding or
distortion of uterine cavity – result to infertility or miscarriage
 Broad ligament myoma – growth of a myoma in lateral direction from uterus –
clinical significance: difficult to diff from solid ovarian tumor on pelvic exam
 Grossly: Lighter color than normal myometrium
 Cut surface: Glistening, pearl-white appearance w/ smooth muscle arranged in
trabecular whorled config
 Histo: Proliferation of mature smooth cells
 Cellular leiomyomata - <5% of myomas exhibit hypercellularity
 Extent of myoma’s degeneration:
1. Hyaline – mildest form
2. Myxomatous
3. Calcific
4. Cystic

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 5. Fatty
6. Red degeneration and necrosis - acute form, causes severe pain and
localized peritoneal irritation
 Most common symptoms: Pressure from enlarging pelvic mass, pain
(dysmenorrhea), AUB
 Severity of symptoms r/t number, location, size of myomas
 Acquired dysmenorrhea – one of the most freq compaints
 Mild pelvic discomfort -
3. Adenomyosis
FALLOPIAN TUBES
1. Leiomyoma
2. Adenomatoid tumor
3. Paratubal cyst
4. Hydrosalpinx

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