Topic 4.

Benign neoplasms of the sexual organs of a woman

I. Scientific and methodological substantiation of the topic

The hormone-dependent pathology is one of the most common problems of modern

gynecology. The urgency of this problem is caused by a significant number of patients, a
prolonged course often with relapses and a medico-social task of maintaining reproductive
function in patients.
In recent years, new methods for the prevention, diagnosis and treatment of female
genital tumors have been successfully developed and are being introduced. Knowledge of benign
neoplasms, methods of early diagnosis and methods of their treatment is necessary for the doctor
of any specialty in his practical activity. Leiomyoma of the uterus is a benign hormone-
dependent tumor, which consists of muscle elements. In recent years, cases of leiomyoma of the
uterus have become frequent in women of reproductive age (30-35 years). The increase in the
incidence of leiomyoma of the uterus is associated with the influence of environmental factors,
labor associated with dangerous factors of production, neuropsychic overstrain.
Among tumors of female genital organs, ovarian tumors rank second after cervical
cancer. The variety of the structure and origin of ovarian tumors is explained by the participation
in their structure of cells different in histological structure, origin and embryogenesis with
different hormonal and secretory functions. This makes it difficult to classify tumors of the
ovaries, their correct diagnosis and treatment. Tumors of the ovaries are mainly prone to
malignancy, clinically this process at early stages is very difficult to diagnose, so studying this
very problem is very important and relevant for doctors of all specialties.

II. Teaching and educational purposes.

To get acquainted with the classification, clinic, methods of diagnosis of the most
common benign tumors of the uterus and ovaries, methods of their differential diagnosis,
treatment, prevention of possible complications and rehabilitation, with a clinic, methods of
diagnosis and treatment of cervical disease.

To know:
1. etiology and pathogenesis of uterine leiomyoma;
2. classification of the leiomyomas of the uterus and their frequency;
3. basic principles of diagnosis, treatment and prevention of uterine leiomyoma;
4. benign pathological conditions of the cervix uteri, their diagnosis and treatment;
5. precancerous conditions of the cervix, their diagnosis and treatment;
6. classification of benign ovarian tumors, their difference from tumor formations of
ovaries and malignant tumors
7. the role of preventive examinations in timely diagnosis and the peculiarities of dispensary
observation of patients with ovarian tumors;
8. possible complications and their prevention, including surgical methods of treatment,
their required volume in each specific case.

Be able to:
1. examine the patient with the leiomyomas of the uterus;
2. on the basis of the anamnesis, the clinic, the conducted differential diagnosis, to make the
diagnosis;
3. prescribe pathogenetic treatment;
4. collection of anamnesis characteristic of ovarian tumors and its analysis;
5. diagnose an ovarian tumor (cyst) with an objective examination of the patient;
6. compile an individual plan for additional examination of a patient with precancerous
cervical conditions for differential diagnosis and evaluate the data of instrumental and
clinical laboratory examination;
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 7. develop an individual treatment plan for a particular patient;
8. to justify the necessary volume of surgery for different variants of ovarian tumors,
depending on the nature of the tumor and the age of the patient;
9. to substantiate the possibility of developing complications in ovarian tumors and their
prevention;
10. describe the macro preparation obtained during the operation;
11. describe the course of the operation of removing the cystoma (indicating the anatomical
and surgical "leg" of the cystoma)

III. Initial and basic knowledge

Anatomy:
 the size of the non-pregnant uterus and its placement in the small pelvis;
 ligamentous apparatus of the uterus;
 blood supply to the uterus and appendages.

Histology:
 tissue structure of the uterine wall;
 histological structure of the endometrium
 morphological and histological structure of the ovaries.

Normal physiology:
 female sex hormones, places of their production, influence on the endometrium,
depending on the phase of the menstrual cycle.

Pathologicalphysiology:
 definition of the concept of "tumor", signs of tumor growth
 the difference between a malignant tumor and a benign one.

IV. Content of the training material

BENIGN TUMORS OF THE VULVA

To benign tumors of the vulva are: fibroma, fibromyoma, lipoma, hemangioma.

Fibroma is a benign tumor that develops from the connective tissue of the labia majora,
less often from the fascia of the small pelvis and the parameter. Occurs rarely, it is localized in
the posterior third of the labia majora. Diagosis of vulvar fibroids does not present difficulties. It
is a tumor-like formation on the stem, movable, painless. Treatment - surgical.
Fibromioma is a benign tumor that develops from muscle and connective tissue
elements. Most often, the source of its development are round uterine ligaments. Diagnosis and
treatment of fibroids are as the same as Fibroma.
Lipoma, or fibrolipoma - is a benign tumor that develops from fat and connective tissue.
She is localized not only in the thick of the labia majora, but also on the pubis. Diagnosis is easy.
The nodes of tumors are located on a wide base or stem, can reach large sizes and are accessible
for examination. If blood circulation is disturbed, edema, hemorrhage, necrosis develops in them,
secondary infection, which can lead to abscessing of the tumor, joins. Treatment is surgical,
prognosis is favorable.
Hemangioma starts from vascular rudiments, separated in the process of embryogenesis,
according to the type of congenital malformation of the vessels of the skin and mucous
membranes of the external genital organs. It is most often localized in the region of the labia

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majora in the form of a cyanotic or crimson node. The tumor grows rapidly, can reach large
sizes. Treatment is surgical.
The vulva cyst is very rare. Often there is a cyst of the Bartholin gland, which refers to
retention cysts formed as a result of blockage (inflammatory processes) of the excretory duct and
accumulation in the cavity of the gland secretion. Cyst size is usually small. With suppuration of
the cyst, an abscess of the large (Bartholin) gland of the vestibule is formed, which is
accompanied by sharp pain, hyperemia of the gland and surrounding tissues, high body
temperature, increased ESR and leukocytosis. The cyst of the large gland of the vaginal vestibule
is sometimes bilateral and, as a rule, is a consequence of gonorrheal infection.
It is not difficult to establish a diagnosis of cyst of the large gland of the vestibule. It is
easy to distinguish from inguinal hernia, which descends through the inguinal canal into a large
sexual’s lip.
Treatment is surgical. The operation is to remove the cyst from its bed. The cysts are
sutured with catgut sutures. On the skin of the wound, silk sutures are applied. Puncture of the
cyst gives only a temporary effect, because the secret in the cavity of the gland accumulates
repeatedly.
In the vulva area, cysts of a different origin are sometimes observed: atheroma, dermoid
cyst, hydradenoma.
Hydradenoma is a retentional benign tumor (cyst) that develops from the sweat glands.
Single or multiple nodules are located under the skin or in the thick of the labia majora. The
hydradenoma usually has small dimensions, inside contains the secret of the sweat glands. She is
rare and, as a rule, does not turn into malignant formations.
Treatment is surgical, prognosis is favorable.

LEIOMYOMA OF THE UTERUS.

One of the important medico-social problems of modern society is the health of the
nation, due to which the problem of reproductive health of women becomes more important
every year. Among the frequent reasons for the decline or loss of fertility of women, a special
role is assigned to benign hormone-dependent tumors of the genitals and, in the first place, to
uterine tumors. According to the International Statistical Classification of Diseases and Related
Health Problems (1995), benign uterine stromal tumors (fibromas, fibromyitis, fibroids) are
combined by the term "myomas".
Leiomyoma is a benign hormone-conditioned and hormone-dependent tumor, consisting
of muscle and stromal elements. About one in five women are referred to the uterine leiomyoma.
The disease occurs in women aged 30-35 years. With the growth of uterine leiomyoma, the
hypothalamic-pituitary-ovarian-adrenal cortex system is involved in the pathological process,
accompanied by changes in the gonadotropic function of the pituitary gland. As a result,
neurohumoral mechanisms regulating the menstrual cycle are violated, which is manifested by
an imbalance in the production of estrogen's hormones.

The group at increased risk of uterine fibroids include:

 Women who have not given birth, with impaired fat metabolism;
 Family history (presence of a tumor in a member of the immediate family);
 Often in women with inflammatory diseases of the appendages;
 Diseases of the liver, thyroid gland, breast.

A special place that the uterine leiomyoma occupies in the structure of tumors of the
female sexual sphere determines that its formation, growth and development is controlled by
steroid hormones of the ovaries and, to some extent, by the adrenal glands. To date, the hormone
dependence of the Leiomyoma of the uterus has been proven, and, first of all, the role of absolute
or relative hyperestrogenism in the mechanism of its development. In recent years, data have
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been accumulated that progesterone along with estrogen can also stimulate the growth of uterine
leiomyoma. According to a number of studies, polypeptide factors play an important role in the
mechanism of the development of uterine leiomyoma. So the insulin-like growth factor I i II can
act as mediators of the action of estrogens in the tissue of the uterine leiomyoma. It is established
that tumor growth depends on: its nutrition, type and age of the patient. The processes of
development and growth of uterine leiomyoma as benign myometrium hyperplasia, as well as
the development of hyperplastic processes in the endometrium, can be caused not only by the
violation of cyclicity in the activity of the hypothalamic- pituitary system, but also by local
disturbances of the state of immunity. In patients with uterine myoma, a quantitative and
qualitative reconstruction of the hormone-receptor apparatus was established. Pathological
changes of metabolic function of the liver, leads to hyperestrogenism, and can also be the cause
of uterine fibroids.

Classification:
Depending on the direction of growth, consider: a typical and atypical arrangement of
nodes.
A. Typical location:
 subperitoneal (subserousal) - development in the direction of the abdominal cavity;
 intermuscular (interstitial)
 submucosal (submucosal node).
 In 12.5% of cases, a combination of two types of nodes is encountered: intramural with
subserousal (more often) and intermuscular (interstitial)
 with submucosal (less often). Multiple nodes of uterine myoma, located intramural and
subserousal.

B. Atypical location:
 Retrocervical,
 Retroperitoneal,
 Antecervical,
 Subperitoneal,
 Paracervical,
 Intraligamental

The growth of a node can be:

 centropetal (inward),
 expansive (stratification of tissue),
 eccentric (outside),
 intraligamentary (in the leaves of the broad ligament).

According to the international classification (МCВ 10):

D 25 Uterus leiomyoma
D 25.0 Submucous uterine leiomyoma.
D 25.1 Intramural uterine leiomyoma.
D 25.2 Subserosal uterine leiomyoma.
D 25.9 Unspecified uterine leiomyoma.

The World Health Organization has proposed a classification of uterine leiomyomas

according to the degree of their differentiation:
 Unspecified uterine leiomyoma(8890/0)

Histological options
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  Мitotically active variant
 Cellular option (8892/0)
 Hemorrhagic cell variant
 Epithelioid variant (8891/0)
 Myxoid option (8896/0)
 Atypical option (8893/0)
 Lipoleomyomatous option (8890/0)

Growth Options
 Diffuse leiomyomatosis (8890/1)
 Exfoliating leiomyoma
 Intravenous leiomyomatosis (8890/1)
 Metastatic leiomyoma (8898/1)

By the frequency of nodes: in the body of the uterus, in the isthmus, less often in the
vaginal part of the cervix. Interconnected tumor localization - 4.5%.
Uterine fibroids vary in size: from a ball to a tumor that fills the entire abdominal cavity. Uterine
fibroids can take the form of a single node (for example, "stem" uterine fibroids - a single
subdivision), or in the form of multiple nodes. In the latter case, they speak of multiple fibroids.
There are leiomyoma, which grows rapidly and slowly. Clinic of the disease depends on the
growth rate and tumor size, on the topographical location of leiomatous nodes, the age of the
patient; duration of the disease; localization of myomatous nodes.
The main symptoms: bleeding, signs of compression of neighboring organs and impaired
their function, pain, infertility, anemia and the phenomenon of circulatory insufficiency.
A typical symptom is pain. It can be permanent, sharp (if the growth of the subperitoneal
node, the pressure of the myomatous nodes on the nerve plexus of the small pelvis), cramping-
with submucosal localization of the node. A similar pain - if a fibromatous node has born. The
pain is persistent and pronounced in the arrangement of the nodes between the leaves of the
broad ligament. Pain can also be as a result of node necrosis, with the development of a septic
state in the future.

Complications of leiomyoma of the uterus

 necrosis of the leiomatous node;
 gangrene of Submucousal leiomatous node;
 torsion of the leg of the leiomatous node;
 rupture of the capsule and rupture of the vessels of the node;
 maligning the node;
 a violation of the function of adjacent organs (bladder or rectum)

Diagnosis of uterine’s leiomyoma

Diagnosis, as a rule, is simple and is carried out on the basis of bimanual research.
Palpable dense tumor, sometimes with multiple nodes, with a smooth outer surface, are more
often mobile. Sometimes the mobility of the tumor is limited because of its magnitude. Most
often, myoma develops in women who have a history of low birth, irregular sex life,
gynecological and obstetric anamnesis (pathological labor with the use of surgical methods,
menstrual irregularities, pelvic surgery, inflammatory diseases of abortions, infertility,
extragenital pathology) . If the usual methods of investigation are insufficient, ultrasound
diagnostics, hysteroscopy is used. Of the additional methods, the most common are hysteroscopy
(hysterosalpingography is not currently used) and hysteroresectoscopy or separate diagnostic
curettage of the cervical canal and the walls of the uterine cavity. The most informative method
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for diagnosing submucous uterine myoma is hysteroscopy. The advantage of this method is the
possibility of simultaneous endometrial biopsy, which is important for the diagnosis of
hyperplastic processes. Laparoscopy is used when there is a need for differential diagnosis of
tumors, for which there are contraindications for conservative therapy. Most often, differential
diagnosis should be carried out with pregnancy, ovarian tumors, uterine body cancer, colon
tumors.

Diagnostics:
1. anamnesis collection;
2. bimanual examination;
3. operation of separate medical-diagnostic curettage of the cervical canal and the walls of
the uterus;
4. sounding of the uterus;
5. hysteroscopy;
6. hysteroresectoscopy.

Submucosal uterine’s myoma, as well as deformation of the uterine cavity with the
centripetal growth of the interstitial node, are revealed during hysteroscopy;
Ultrasound.informativeness of ultrasound with a myoma reaches 92.8-95.7%.
X-ray research (review). Accurately assess the size and location of any node allows
magnetic resonance (MRI) and computed tomography (CT). To perform differential diagnosis of
leiomyoma and other tumors of the pelvic organs, abdominal cavity and retroperitoneal space in
difficult cases allows laparoscopy.
The method of computed tomography (CT) differs high sensitivity (88.9%). Benign
tumors of the uterus on the tomograms have clear contours, a homogeneous structure due to the
density of the tissues. With the help of CT it is easy to determine the site of the node, its
secondary changes in the form of calcifications and necrosis.
The method of magnetic resonance imaging (MRI) makes it possible to make a
qualitative assessment of the tissue structure, to determine the degree of spread of the tumor
process.
Treatment.
In the Complex treatment of leiomyoma include conservative and operative methods.
Indications for conservative treatment: small tumor sizes (up to 12 weeks in a woman of
childbearing age, up to 14-15 weeks in menopausal period), which are not accompanied by
bleeding, violation of the function of adjacent organs, pain; with contraindications to the surgical
method of treatment.
The basis for the conservative therapy of myoma is hormones. In this case preference is
given to analogues of gonadotropin-releasing hormone (Dipherelin). They are used only after the
exclusion of oncopathology: separate diagnostic curettage is performed, tissue samples are
sended to histology. Dipherelin at a dosage of 3.75 mg (1 intramuscular injection) in the first 5
days of the menstrual cycle every 3 to 6 weeks. Also used gestagens (Duphaston, Femoston),
from the 16th to the 25th day of the menstrual cycle for 6 months (course dose 300 mg). For
women of pre-menopausal age, the drug is administered continuously for 3 months at 5-10 mg /
day. Patients with reproductive age are prescribed Pregnin according to a cyclic schedule: from
the 16th to the 26th day of the cycle, 0.04 g three times a day for 3 months. A high progestational
effect has a 17-OPC, which is prescribed for women who has a menstrual cycle on the 14th,
17th, 21st days at a dose of 125-250 mg for 6 months. For patients of reproductive age give
combined estrogen-progesterone medications, which suppress the synthesis and secretion of
gonadotropic hormones, are used for small-sized myoma (6-7 weeks of gestation). The drugs are
used from the 5th to the 25th day of the cycle for 1 g, every day for 3 months or more.
Indications for surgical treatment: tumor size more than 12-13 weeks, rapid tumor
growth; suspicion of malignancy; violation of the function of adjacent organs; hemorrhagic
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syndrome, a combination with internal endometriosis; combination with ovarian tumors;
complications.
Methods of surgical treatment:
1. conservative (conservative myomectomy, twisting out the submucosal nodes)
2. radical (Supravaginal amputation of the uterus with appendages and without, extirpation
of the uterus with appendages and without).
3. EMC (embolization of uterine vessels).

Embolization of uterine vessels is a promising method for treating symptomatic uterine

fibroids - as an independent method, and as a preoperative preparation for the next
myomectomy, which allows to reduce the amount of intraoperative blood loss, but requires
additional x-ray endovascular equipment.

Advantages of vascular embolization:

‒ less blood loss;
‒ low frequency of infectious complications;
‒ low level of mortality;
‒ reduction of the periods of recovery;
‒ preservation of woman's fertility.

Possible complications of embolization:

‒ thromboembolic complications;
‒ inflammatory processes;
‒ necrosis of the subserous node;
‒ amenorrhea.

The technology of YIFU - ablation is a unique non-invasive (remote) method of local

destruction of neoplasms (nodular fibromyoma of , local endometriosis)
This is a unique method of ultrasonic ablation of neoplasms, which is carried out on apparatus JI
(Manufacturer: ChongingHaifu (HIFU) Technology Co., Ltd.), Which allows to preserve the
reproductive function of a woman.
During treatment, due to short ultrasonic pulses, heating of the neoplasm tissue takes
place with subsequent thermal coagulation necrosis. The treatment process is carried out under
the ultrasound - control in real time. The time of medical manipulation depends on the size and
number of nodes, on average it lasts from 3 to 6:00, in one stage.

Indications:
1. symptomatic fibroid of the uterus body in women of reproductive age who want to keep
the uterus and plan a pregnancy.
2. symptomatic fibroids of the uterine body in premenopausal or menopausal women who
do not want to be operated on, or if surgical intervention is not possible.

Benefits:
‒ Non-invasive surgical method,
‒ An organ-preserving intervention,
‒ High efficiency for uterine myoma of various sizes and locations,
‒ Influence on the maximum number of nodes with multiple lesions,
‒ Absence of traumatization, blood loss,
‒ A good cosmetic effect,
‒ Short terms of hospitalization and rehabilitation,
‒ Absence of influence on the endometrium in comparison with uterine artery
embolization,
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 ‒ Absence / minimization of side effects.

Complications:
‒ burn of the skin in the intonation zone of I-II st.,
‒ edema of soft tissues,
‒ temperature increase to sub febrile within 2-4 days.

Contraindications:
‒ Obesity 3-4 tbsp. by abdominal type,
‒ Coarse cicatricial changes in the skin of the lower abdomen,
‒ Inflammatory diseases of the pelvic organs
‒ Intrauterine contraceptives,
‒ Fibromatous node on the leg.

BENIGN TUMORS OF THE OVARIES

Benign tumors of the ovaries are 75-80% of all ovarian tumors. Benign ovarian tumors
include such concepts as cysts and ovarian cysts. Ovarian cysts are tumor-like formations
characterized by fluid accumulation, among normal ovarian tissue, surrounded by a clear
capsule. These include: the follicular cyst of the ovary, the cyst of the yellow body, the
parovarial cyst. Cystoma is an ovarian tumor, which has all the characteristics of tumor growth
(benign).

Classification. There are many classifications of ovarian tumors - by clinic, clinical-

morphological and histological principles, but none of them fully satisfy clinicians.

1. Retentinal non-proliferating ovarian tumors (follicular cyst)

2. The real (proliferating) ovarian tumors (Blastoma)
a) Tumors of epithelial tissue:

1. Mature forms of the cysts (simple serousal, proliferating papillary, superficial papillary,
pseudomycinosis ).
2. Immature forms of the cysts:
ovarian cancer;
primary, Adenocarcinoma;
secondary ovarian cancer on the basis of malignant degeneration of the ovarian cyst;
metastatic forms of the cysts (tumor of Crookenberg).
b) Tumors of connective tissue (stromatogenic)
1. Mature forms (fibroma and ovarian fibromyoma).
2. Immature forms (ovarian sarcoma, ovarian endothelioma).
c) Mixed ovarian tumors (teratoid):
c) Mixed ovarian tumors (teratoid):
1. Psevdocyst form of teratoma - dermoid.
2. Dense (solid) forms of teratom (teratoblastoma, embryoma).
3. Teratoma with one-sided differentiationthe ovarian, chorionepithelioma of the ovary,
hypernephroma.

According to the International Histological Classification, compiled by WHO experts,

ovarian tumors are divided into eight groups. Given its complexity, (1977) classification.

I. Epithelial tumors.
A. Serous tumors.
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1. Benign: a) cystadenoma and papillary cystadenoma; b) superficial papilloma;в)
adenofibroma and cystadenofibroma; c) superficial papilloma.
2. Вorderline (potentially low degree of malignancy): a) cystadenoma and papillary
cystadenoma; b)adenofibroma and cystadenofibroma.
3. Malignant: a) adenocarcinoma, papillary adenocarcinoma and papillary cystadenocarcinoma;
b) superficial papillary carcinoma; c) malignant adenofibroma and cystadenofibroma
B. Mucinous tumors
1. Benign: a) cystadenoma; b) adenofibroma and cystadenofibroma.
2. Intermediate (potentially low degree of malignancy): a) cystadenomas; b) adenofibroma and
cystadenofibroma.
3. Malignant: a) adenocarcinoma and cystadenocarcinoma; b) malignant adenofibroma and
cystadenofibroma.
C. Endometrioid tumors
1. Benign: a) adenoma and cystadenoma; b) adenofibroma and cystadenofibroma.
2. Borderline: (potentially low degree of malignancy): a) adenoma and cystadenoma; b)
adenofibroma and cystadenofibroma.
3.Malignant: a) carcinoma (adenocarcinoma, adenoacanthoma, malignant adenofibroma and
cystadenofibroma); b) endometrial stromal sarcoma;c) mesodermal (Muller) mixed tumors,.
D. Clear cell (mesonofroid) tumors
1. Benign: adenofibroma.
2. Borderline (potentially low degree of malignancy).
3. Malignant: carcinoma and adenocarcinoma.
E. Brenner's tumors.
1. Benign.
2. Borderline (intermediate malignancy).
3. Malignant.
F. Mixed epithelial tumors
1. Benign.
2. Borderline (intermediate malignancy).
3. Malignant.
G. Undifferentiated carcinoma.
H. Unclassified epithelial tumors
ІІ.Tumors of stroma of the genital cord
A. Granulostromal-cell tumors.
1. Granulosocell tumors.
2. Tekom fiber group: a) lipoma; b) fibroma; c) unclassified.
B. Androblastoma: a tumor from the cells of Sertoli and Leydig.
1. Higthly differentiated: a) tubular androblastoma, tumor from Sertoli cells, b) tubular
androblastoma with accumulation of lipids,c) tumor from Sertoli cells with accumulation of
lipids (Lesen's lipid follicle) c) tumor from Sertoli and Leydig cells; d) a tumor from Leydig
cells, e) tumor from the hilus cells.
2. tumors of intermediate (transitional) differentiation
3. Low-differentiated (sarcomatous) tumors.
4. Tumors with heterologous elements
C. Gynandroblastoma
D. Unclassified tumors stroma of the genital tract.
III. Lipid-cell (lipid-cell) tumors.
IV. Germinogenic tumors.
A. Disgerminoma
B. Tumor of the endodermal sinus
C. Embryonic carcinoma.
D. Polyembrioma.
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E. Chorionepithelioma
F. Teratoms
1. Immature
2. Mature: a) solid; b) cystic (dermoid cyst, dermoid cyst with malignancy)
3. Monodermal (highly specific): a) ovarian struma; b) carcinoid; c) ovarian struma and
carcinoid;
G. Mixed heminogenic tumors
V. Gonadoblastoma;
A. Pure (mixed with other forms).
B. Mixed with Disgerminoma and other forms of germ cell tumors
VI. Tumors of soft tissues, nonspecific for the ovaries.
VII. Unclassified tumors.
VIII. Secondary (metastatic) tumors.
IX. Tumor-like processes.
A. Luteine tumors of pregnancy
B. Ovarian stromal hyperplasia and hypertecosis
C. Massive ovarian edema.
D. Single follicular cyst and yellow body cyst.
E. Multiple follicular cysts (polycystic ovary).
F. Multiple luteinized follicular cysts and (or) yellow body cyst .
G. Endometriosis
H. Superficial epithelial cysts of inclusion (germinal cyst- inclusions).
I. Simple cysts.
J. Inflammatory processes.
K. Paraovarial cysts.
Most of these tumors are rare. The complexity of developing a classification due to the fact those
in the formation ovarian take the endoderm, ectoderm,
mesoderm

Clinical picture. Complaints are nonspecific. Symptomatology depends on the

magnitude, location of the tumor and the presence of complications. The most frequent
complaint is pain that occurs in the lower abdomen, in the lower back, sometimes in the iliac
areas. Most often, it has a aching character. Acute pain occurs when the knee is twisted, the
hemorrhage and rupture of the tumor capsule. As a rule, pain is not associated with menstruation
and occurs due to inflammation or irritation of serous cover, spasms of smooth muscles of
hollow organs or as a result of circulatory disorders.
The nature of pain depends on the individual characteristics of the nervous system. The
innervation of the reproductive system is characterized by a significant development of the
receptor apparatus. A tumor in the ovary can irritate the receptors of the genital organs and
peritoneum of the small pelvis, as well as nerve endings and plexuses of the vascular system of
the uterus and appendages. Pain also arises from the dilatation of the tumor capsule, which leads
to irritation of the receptor apparatus and disruption of the blood supply to the tumor wall, which
can cause pain sensations regardless of other causes and factors. Often, patients complain of
disorders of neighboring organs, in particular, on dysuric phenomena, and at large tumor sizes -
on a feeling of heaviness and an increase in the abdomen.
Benign tumors of the ovaries regardless of the structure in the clinical course, have much
in common. In the early stages of the disease, as a rule, asymptomatic or symptomatic is so
insignificant that a patient for a long time suffers or does not pay due attention to it.
Hemograma in benign ovarian tumors are nonspecific, although there is often an
acceleration of ESR to 25-30 mm / h. Leukocytosis usually occurs only in the presence of
complications, the leukocyte formula is not changed.

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Most often there are epithelial tumors (serous or mucinous cysts), dermoid ovarian cysts or
mature teratomas, ovarian fibroids.

Epithelial tumors.
By the nature of growth, cysts and cysts are devide. Cysts are benign nonblastomatous
retention formations that grow due to accumulation of secretion (retentio - delay).
Cystoma is benign blastomatous formation, growing at the expense of their own tissue.
Both cysts and blastomas have an anatomical and surgical legs. The anatomical leg consists of
three formations: lig.suspenrium ovarii, the ovary's own ligament (ligovariiproprium) and the
part of the broad ligament (mesovarium). The surgical leg is intersects during surgery and
includes an anatomical leg and a fallopian tube,or intestinal part,or omentum,
Serous tumors are divided into smooth-walled and papillary tumors, and papillary
tumors, in turn, are inverted (papillae located inside the capsule) and evertent (papillae located
on the outer surface of the capsule). Sometimes there can be a combination of both options.
Mucinous cysts are multi-chambered, characterized by rapid growth. The tumor content
is a mucus-like fluid.
Ovarian fibroids are bean-shaped, dense, easily necrotic, often accompanied by ascites,
sometimes in combination with anemia and hydrothorax. This triad (ascites, hydrothorax,
anemia) is called Meyer's syndrome.
Dermoid ovarian cysts, or mature teratomas, usually have a long leg, located in front of
the uterus, strongly mobile. Most often they occur in young women and even before puberty,
while others tumors mainly occur at the age of 40 and more years.
The hormone-producing tumors are divided into 2 groups, which differ from each other
in clinical course. Feminizing ovarian tumors (granuloseocular, tekakletochnye) produce more
estrogens. Girls have signs of premature puberty, and in women of adulthood - a disorder of the
menstrual cycle and chaotic bleeding. In post-menopause, there is a kind of rejuvenation of the
body (juicy mucous membrane of the vagina, the appearance of bloody discharge, a high
karyopicnotic index, hyperplasia of the mucous membrane of the body of the uterus).
Masculinizing tumors (androblastoma, lipoid-cell tumors) produce a large amount of male sex
hormone testosterone, which leads to the cessation of menstruation, hirsutism (increased hair
flow), infertility, and in the later stages of the disease - baldness, change in the tone of the voice.
The follicular cyst is a tumor-like formation that occurs as a result of fluid accumulation
in the cystic-anatomized follicle. Microscopically, these are thin-walled single-chambered
formations, of a tauto-elastic consistency. They can occur at any age, even in childhood, but are
often formed after a period of puberty. In the anamnesis of such patients inflammation is often
found. The main symptom of the disease is pain in the lower abdomen, less often - a violation of
the menstrual cycle. When vaginal examination from the side or in front of the uterus, a
sedentary cyst with a size of up to 10 cm is determined, often with the phenomena of the
inflammatory process of the appendages.After the diagnosis is established, you can observe the
patient for 2-3 menstrual cycles. If during this time the formation does not resolve, then it is
necessary to perform the operation, which consists in removing the cyst and forming the ovary
from the remains of the ovarian tissue. In the climacteric and postmenopausal periods, the
uterine appendages are removed from the affected side.
The yellow body cyst is relatively rare (in 2-5% of cases). In its structure it resembles a
yellow body, but reaches a large size (usually up to 2 cm). Its walls are thick, the inner surface is
folded, yellow. The content is a clear clear liquid, sometimes with an admixture of blood. These
formations are found in patients aged 16 to 55 years. The main symptom is the pain in the lower
abdomen associated with the presence of an accompanying inflammatory process of the uterine
appendages. There are no specific clinical signs. The main complication is a hemorrhage into the
cyst cavity. Most often, the cyst of the yellow body is palpable on the side of the uterus, and has
a non-uniform consistency. Such cysts mainly arise during pregnancy, after its interruption they
quickly resolve. Gradually, the layer of luteal cells is replaced by a connective tissue, and the
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formation can become a cyst without epithelium. If you suspect a yellow body cyst, you should
observe the patient for 2-3 menstrual cycles, because during this time the cyst may reverse
development. Otherwise, surgery is indicated - laparotomy with removal of the cyst and the
formation of the ovary from unchanged tissue.
Paraovarial cysts are a retentive formation, located between the leaves of the broad
ligament of the uterus . Most often occurs in 20-40 years of age. The ovary appendage
(epiophoron, paraophoron) reaches its maximum development during puberty and atrophies with
age. Macroscopically, the parovarial cyst has the appearance of a round or oval shape, a tauto-
elastic consistency. In most cases it is single-chambered with clear liquid contents. Dimensions
can range from small to gigantic, occupying the entire abdominal cavity, most often with a
diameter of 8-10 cm. Its wall is thin, transparent, with a network of vessels consisting of vessels
of the mesentery of the uterine tube and the wall of the cyst. On the upper pole of the cyst, a
spaced, elongated, deformed fallopian tube is visible. The ovary is located near the posterior-
lower pole of the cyst, and in other cases it may also be a plaster on its lower surface.
The paravarian cyst when grows toward the abdominal cavity, one of the sheets of the
wide uterine ligament protrudes and a leg is formed, consisting of the leaves of the uterine tube.
Often, it includes the uterine tube, and sometimes its own ovary ligament. Histologically, the
cyst wall is formed by a fibrous fibrous tissue. Its internal surface is covered with cylindrical,
cubic or single-row flat epithelium. In these cases, papillary tissue are found on the inner surface.
The clinical picture is characterized by pain in the lower abdomen and in the lower back.
With an increase in the size of the cyst, signs of compression of neighboring organs may appear
and the size of the abdomen may increase. Sometimes there are violations of the menstrual cycle
and infertility, which is more typical for the association of a parovarial cyst with concomitant
pathology: uterine myoma, cyst or ovarian cystoma.
Of the complications observed with the parovarial cyst, the torsion of the leg is of
practical importance, the clinical manifestations of which depend on the formations that make up
the stem.
Diagnosis of parovarial cysts is often severe. Diagnosis is assisted by ultrasound, in
which a tumor-like formation with liquid contents is identified next to the ovary.
Treatment operative, cystectomy, hemostasis, peritonization due to of the broad ligament.
Complications of benign ovarian tumors. The most serious complication of benign
ovarian tumors is their malignant transformation. The most dangerous in this regard are papillary
cysts, less often mucinous and very rarely dermoid ovarian cysts. At the initial stages of
malignancy, there is no characteristic clinic, and therefore, when an ovarian cyst is found, the
question of surgical treatment should be raised.
Suppuration of the wall or the contents of the tumor occurs very rarely. Infection
penetrates lymphogenically or hematogenously, most often from the intestine, and, possibly,
from other foci of infection. When an abscess occurs, perifocal adhesions are formed. The
abscess can break into the intestine or the bladder, followed by the formation of appropriate
fistulas. Suppuration is accompanied by symptoms of purulent infection (fever, leukocytosis,
peritoneal symptoms).
Torsion of the legs of the tumor. Partial torsion of the leg of the tumor is accompanied
by all the above-mentioned manifestations, which are slightly expressed and can disappear even
without prompt treatment. Another cases require urgent surgical intervention - removal of the
tumor. Delayed surgical intervention leads to tumor necrosis, attachment of a secondary
infection, adhesion to neighboring organs, limited peritonitis, which further complicates the
operation till to diffuse peritonitis.
Hemorrhages occur more often in the wall, less often in the tumor cavity. They are
usually accompanied by increased pain. Before surgical treatment and histological examination
are almost not diagnosed. The rupture of the capsule of the cystoma occurs rarely, only with
direct mechanical trauma, and also due to rough examination. It is characterized by acute pain,
bleeding, shock. Bimanual examination is determined by the absence of a tumor, which before
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that was clearly palpable. The rupture can lead to the implantation of tumor elements on the
peritoneum (especially the ovarian mucinous cyst). The main methods of diagnosis of ovarian
tumors: clinical methods (anamnesis, complaints, rectovaginal study), ultrasound, CT, MRI,
oncomarker detection (CA 125, HE -4), gastrointestinal tract (fibrocolono, fibrogastroscopy),
cytological method of exudate study in the cavity, etc.
Treatment is surgical. The volume depends on: the type of tumor (pathomorphology), the
age of the woman, the prevalence of the process or present tumor (endometrioidal ovarian
tumor).

VII. Methodical support

Location of the lesson:

• examination room of the gynecological department
• department of gynecology No. 1,
• small operating room of gynecological department,
Equipment: tables, drawings on the topic, a set of video films and instruments for gynecological
examination, operating material.

VIII. Control questions

1. Give the definition of uterine leiomyoma.
2. In which departments of the uterus leiomatous nodes develop.
3. Clinical manifestations of uterine leiomyoma, how does the clinic depend on the location of
the nodes?
4. Complications of uterine leiomyoma.
5. List the methods of diagnosis of uterine leiomyoma.
6. What are the methods for diagnosing the submucosal form of uterine leiomyoma?
7. Give methods for treating uterine leiomyoma.
8. Indications for conservative treatment.
9. Methods of conservative treatment of uterine leiomyoma.
10. Indications for surgical treatment of uterine leiomyoma.
11. Types of conservative operations, indications for this type of operation.
12. Types of semi-radical operations, indications for this type of operation.
13. Radical operations with leiomyoma of the uterus, indications.
14. Treatment of complications of uterine leiomyoma.
15. Give a classification of benign ovarian tumors.
16. What ovarian tumors of epithelial origin do you know? Their clinical significance
17. What methods of research should be used to diagnose an ovarian tumor?
18. With what diseases are differential diagnoses with suspicion of an ovarian tumor?
19. What kind of treatment should be prescribed when a patient has an ovarian tumor?
20. Determine the scope of surgery for ovarian tumors, depending on the nature of the tumor and
the age of the patient.
21. What is the "leg" of the cyst (anatomical and surgical)?
22. Tell us about the group of tumors of the stroma of sexual strand (clinic, diagnosis, treatment)
23. What do you know about germ cell tumors of the ovaries?
24. Name the most common complications for ovarian tumors.
25. Tell us about the prevention of complications in ovarian tumors.

Literature:
Basic:
1. Intrauterine pathology: the reference book of the doctor "Gynecologist": by
management / V.A. Benyuk, V.N. Goncharenko, Yu. V. Kuvita [and others]; Ed.
V.A.Benyuk. - Kiev: Library "Health of Ukraine", 2013. - 203 p. : And l., Tab.
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 2. Algorithms in obstetrics and gynecology: a reference book of a doctor / ed. V.A.
Benyuka; National Medical University. A .A .Bogomolets, Clinical Hospital
"Theophany". - M.: Health of Ukraine, 2009. - 425 p. : And l., Tab.
3. Ambulatory-polyclinic care in gynecology: a directory of a doctor / ed. V.A. Benyuka, V.
Ya. Goloty, IA Usevich; National Medical University.A .A .Bogomolets. - M.: Health of
Ukraine, 2007. - 504 p. : Tab.
4. Unified clinical protocol of primary, secondary (specialized) and tertiary (highly
specialized) medical care Abnormal uterine bleeding, approved by the Order of the
Ministry of Health of Ukraine 04/13/2016 № 353
Additional:
1. Aushery and gynecology. Volume 1. Author: VM Zaporozhan, N. G. Tsegelsky, NM
Rozhkovskaya. Publisher: Odesskiymeduniversitet. Odessa.
2. Gynecology: a textbook / А.В. Stepankivsky, N.A. Scherbina - the fourth ed., Ispra. - M:
VSV "Medicine", 2018. - 432 p. + 2 seconds. Colour. incl.
3. Gynecology: A Textbook for Honey. High schools IV. ac. Approved by MON / Ed. B.
Ventskyvsky, K. Stepankivsky, V.P. Lakatosha. - M., 2012. - 352 p.
4. Modern classification of uterine leiomyomas / B.A. Zabolotnov, A.N. Rybalka, V.Y.
Shatila, N.V. Kosolapova.- Woman's health No. 1 (97), 2015.- p. 70-73.

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