GYNECOLOGY: BENIGN GYNECOLOGIC LESIONS

PPT-2021, Comprehensive Gynecology 7th ed. FEU-NRMF Batch 2022

BENIGN VULVAR LESIONS the skin surface. These may be seen at the site of an episiotomy
URETHRAL CARUNCLE or obstetric laceration.
▪ Theories of histogenesis:
▪ Urethral caruncle and urethra prolapse are conditions that primarily
 embryonic remnants and occlusion of pilosebaceous ducts of
affect postmenopausal and premenarchal women. They are thought
to occur as a result of decreased estrogen. sweat glands.
▪ A urethral caruncle is a small, fleshy mass that occurs at the HISTOLOGY:
posterior portion of the urethral meatus of postmenopausal women. ▪ epithelial lining keratinized, stratified squamous epithelium with a
▪ Gross description: Small, fleshy outgrowth of the distal edge of the center of cellular debris that grossly resembles sebaceous material.
urethra secondary chronic irritation or infection ▪ Most epidermal cysts do not have sebaceous cells or sebaceous
The tissue of the caruncle is soft, smooth, friable, and bright red material
and initially appears as an eversion of the urethra. FEATURES:
Urethral caruncles are generally small, single, and sessile, but ▪ multiple cysts, majority less than 1 cm in diameter.
they may be pedunculated and grow to be 1 to 2 cm in diameter.
PRESENTATION:
▪ asymptomatic unless secondarily infected.

DIFFERENTIAL DIAGNOSIS: (LARGE EPIDERMAL CYSTS)

▪ fibromas
▪ lipomas
▪ hidradenomas

TREATMENT: NONE
▪ Mainly observation
CLINICAL PRESENTATION ▪ If infected - local heat application, incision and drainage
▪ Majority are asymptomatic ▪ Recurrently infected cysts or with pain - excised when acute
▪ Others experienced dysuria, frequency and urgency. inflammation has subsided
▪ Sometimes the caruncle produces point tenderness after contact
with undergarments or during intercourse BARTHOLIN’S DUCT CYST
▪ Often secondarily infected, producing ulceration and bleeding.
BARTHOLIN’S GLAND
▪ Ulcerative lesions usually produce spotting on contact more
Location:
commonly than hematuria.
▪ entrance of the vagina at 5 o’clock
INCIDENCE: and 7 o’clock distal to the hymenal
▪ more frequent during postmenopausal years ring.
▪ Duct approximately 2 cm long,
ORIGIN:
and open in a groove between the
▪ arise from an ectropion of the posterior urethral wall associated with
hymen and labia minora in the
retraction and atrophy of the postmenopausal vagina.
posterior lateral wall of the vagina
▪ growth secondary to chronic irritation or infection.
▪ Rounded, pea-sized glands deep in the perineum
DIFFERENTIAL DIAGNOSIS: ▪ Normally are not palpable
▪ Primary carcinoma of the urethra
▪ prolapse of the urethral mucosa
▪ Most common large cyst of the vulva
DIAGNOSIS: BIOPSY
is a cystic dilation of an obstructed
▪ The diagnosis of a urethral caruncle is established by biopsy under
Bartholin duct.
local anesthesia, as it can appear like a neoplasm.
▪ Cause: obstruction of the duct
▪ Histologic appearance: caruncle is composed of transitional and
secondary to nonspecific
stratified squamous epithelium with a loose connective tissue. Often
inflammation or trauma
the submucosal layer contains relatively large dilated veins
Noninflamed cysts contain sterile,
▪ Classified according to histologic appearance:
clear, mucinous fluid.
 Papillomatous
▪ Mostly are asymptomatic
 Granulomatous
 Angiomatous TREATMENT:
▪ occur most often during the third decade.
INITIAL THERAPY:
▪ They do not require treatment unless large enough to cause
▪ oral or topical estrogen
discomfort.
▪ avoidance or irritation
Inflamed cysts may be treated with oral antibiotics or incision and
If the caruncle does not regress or is symptomatic, it may be
drainage
destroyed by
▪ IF ASYMPTOMATIC: not necessary in women less than 40
Cryosurgery
▪ IF SYMPTOMATIC OR WITH INFECTED: “marsupialization”.
laser therapy ▪ IN WOMEN OLDER THAN 40: do an excision biopsy to exclude
fulguration adenocarcinoma of Bartholin’s gland
operative excision.
Following operative destruction, a Foley catheter is usually left in NEVUS
place for 48 to 72 hours to prevent urinary retention. ▪ Commonly referred to as a mole
Small, asymptomatic urethral caruncles do not need treatment ▪ undifferentiated cells arise from the
embryonic neural crest are present
INCLUSION CYSTS OF THE VULVA from birth.
▪ most are not related to trauma ▪ one of the most common benign
An “inclusion cyst” may arise when bits of epithelium are neoplasms in females
implanted in the skin during surgery or trauma sufficient to break ▪ localized nest or cluster of
melanocytes.

1
BENIGN GYNECOLOGIC LESION AISH
 GROSS APPEARANCE: SYMPTOMS:
▪ blue to dark brown to black, and some amelanotic The symptoms of a urethral diverticulum are nonspecific and are
▪ Diameter - a few millimeters to 2 cm. identical to the symptoms of a lower urinary tract infection.
▪ flat, elevated, or pedunculated ▪ Urinary urgency
▪ The diameter of most common nevi ranges from a 3 to 10 mm. ▪ Urinary frequency
▪ Grossly, a benign nevus may be flat, elevated, or pedunculated. The ▪ 3 Ds (dysuria, dyspareunia, and dribbling of urine)
borders are sharp, the color even, and the shape is symmetrical.
CLASSIC SIGN:
DIFFERENTIAL DIAGNOSIS: ▪ expression of purulent material from the urethra after compression
▪ Hemangiomas ▪ (ppt notes) discharge by manual expression is specific, its sensitivity
▪ Endometriosis is poor
▪ malignant melanoma DIAGNOSTIC TOOL:
▪ vulvar intraepithelial neoplasia, To diagnose this elusive condition, one should suspect urethral
▪ seborrheic keratosis. diverticulum in any woman with chronic or recurrent lower urinary tract
Three major groups: symptoms.
 Junctional (a symmetric macule) ▪ Cystourethrography
➔ and dysplastic nevus, with greatest potential for malignant ▪ Cystourethroscopy
transformation
 Compound TREATMENT:
 Intradermal nevi (both papules) ▪ Complete excision of fistulous connection
▪ Recurrence rate = 10% and 20%
Dysplastic nevi are commonly 6 to 20 mm with one or more ▪ Many failures are due to incomplete surgical resection
atypical features such as speckling of color, diffuse margination,
additional red, white, or blue hues, and asymmetry. COMPLICATION OF SURGERY: 1 TO 2%
Vulvar nevi are generally asymptomatic. ▪ urinary incontinence
→Most women do not closely inspect their vulvar skin; however, ▪ urethrovaginal fistula
during examination, the use of a mirror held by the patient may DIFFERENTIAL DIAGNOSIS:
facilitate teaching self-vulvar exam ▪ Gartner’s duct cysts
▪ irritants to vulvar skin may lead to malignant melanoma ▪ Ectopic ureter that empties into the urethra
▪ 50% arise from preexisting nevus ▪ Skene’s glands cysts
▪ ABCD: Asymmetry, Border irregularity, Color variegation, and
Diameter greater than 6 mm

RISK FACTORS:
▪ age - 50s.
▪ Family history of melanoma

FIBROMA
▪ Most common benign solid tumor of the vulva SKENE’S DUCT CYSTS
▪ Fibromas occur in all age groups ▪ Rare
LOCATION: PRESENTATION:
▪ commonly in the labia majora ▪ Discomfort
They actually arise from deeper connective ▪ found on routine examination
tissue. Thus they should be considered as ▪ Physical compression of the cyst should not produce fluid from the
dermatofibromas. urethral meatus (unlike compression of a urethral diverticula)
They grow slowly and vary from a few TREATMENT:
centimeters to one gigantic vulvar fibroma reported to weigh more ▪ excision with careful dissection to avoid urethral injury.
than 250 pounds. Most are between 1 and 10 cm in diameter.
The smaller fibromas are discovered as subcutaneous nodules.. INCLUSION CYSTS
Fibromas have a smooth surface and a distinct contour. ▪ epidermal inclusion cysts or sebaceous cysts
On cut surface the tissue is gray-white. ▪ Most common cystic structure of the vagina
Smaller fibromas are asymptomatic LOCATION:
larger ones may produce chronic pressure symptoms or acute ▪ posterior and lateral walls of the lower third of the vagina
pain when they degenerate. CAUSE:
COURSE: ▪ birth trauma or gynecologic surgery
▪ Slow growing but may attain gigantic proportion PRESENTATION:
▪ low-grade potential to become malignant ▪ Usually asymptomatic
TREATMENT: TREATMENT:
▪ operative removal ▪ excision
→Done if they cause dyspareunia or pain
BENIGN VAGINAL LESIONS
URETHRAL DIVERTICULUM EPITHELIAL CYSTS
▪ A permanent, epithelialized, sac-like LOCATION:
projection arising from the posterior urethra ▪ immediately beneath the epidermis
▪ Most are thought to be congenital or acquired ▪ Most commonly on the anterior half of the labia majora.
present in women between 30-60 years of CHARACTERISTICS:
age. ▪ multiple, freely movable, round, slow growing, and non-tender;
▪ Prevalence: ▪ Consistency: firm to shotty
 reproductive-age females ▪ Grossly: white or yellow; contents are caseous
 peak incidence fourth decade of life

2 BENIGN GYNECOLOGIC LESIONS AISH

 ▪ Local scarring of adjacent skin occurs when rupture of the contents CERVICAL MYOMA
of the cyst produces an inflammatory reaction in the subcutaneous ▪ Smooth, firm, solitary masses mostly
tissue arising from the isthmus
DYSONTOGENIC CYSTS ▪ Most are small and asymptomatic
▪ Thin-walled soft cyst of embryonic origin ▪ Expanding myomas produce
Types: symptoms secondary to mechanical
 Gartner’s duct cyst – from mesonephros pressure on adjacent organs
 Mullerian cyst - from perimesonephrium ▪ DIAGNOSIS: Inspection and Palpation
 Vestibular cyst – from urogenital sinus
MANAGEMENT:
▪ Mostly asymptomatic
▪ Operative excision indicated for chronic symptoms ▪ Asymptomatic and small – maybe
 Marsupialization – for infected cases observed
 Excision – for those uninfected ones ▪ Occurrence and persistence of symptoms are indications for
treatment

BENIGN LESIONS OF THE CERVIX

ENDOCERVICAL AND CERVICAL POLYP CERVICAL STENOSIS
▪ Often occurs in the internal os
▪ Maybe congenital or acquired
▪ The causes of acquired cervical stenosis are operative, radiation,
infection, neoplasia, or atrophic changes
▪ Symptoms differ depending on the menopausal status of the woman
▪ Common symptoms in premenopausal women include
dysmenorrhea, pelvic pain, abnormal bleeding, amenorrhea, and
infertility.
→The infertility is usually associated with endometriosis, which is
commonly found in reproductive-age women with cervical stenosis.
▪ Most common benign neoplastic growths of the cervix ▪ Postmenopausal women are usually asymptomatic for a long time.
▪ common in multiparous women in their 40s and 50s. Slowly they develop a hematometra (blood), hydrometra (clear
▪ Origin: inflammation or abnormal focal responsiveness to hormonal fluid), or pyometra (exudate).
stimulation DIAGNOSIS:
▪ Usually asymptomatic ▪ inability to introduce a cervical dilator into the uterine cavity
SYMPTOM : MANAGEMENT:
 Classic: Intermenstrual bleeding, and following contact ▪ Cervical dilatation under ultrasound guidance
 leucorrhea from the infected cervix ▪ Laminaria tent or T-tube as stent for a few days
The classic symptom of an endocervical polyp is intermenstrual
bleeding, especially following contact such as coitus or a pelvic
BENIGN LESIONS OF THE UTERUS
examination. Sometimes an associated leukorrhea emanates from
ENDOMETRIAL POLYPS
the infected cervix.
▪ Localized overgrowths of the
HISTOLOGIC SUBTYPES:
endometrial glands and
 Adenomatous (80%) Cystic
stroma projecting beyond the
 Fibrous Vascular
endometrial surface
 Inflammatory Fibromyomatous
They are soft, pliable, and
▪ Malignant degeneration is extremely rare may be single or multiple.
DIFFERENTIAL DIAGNOSIS: Most polyps arise from the
fundus of the uterus.
 Endometrial polyps - Prolapsed myoma
 Squamous papilloma - Sarcoma Polypoid hyperplasia is a benign condition in which numerous
 Cervical carcinoma - Microglandular hyperplasia small polyps are discovered throughout the endometrial cavity
 Retained products of conception ▪ Peak age incidence is at 40-49 years
▪ MANAGEMENT: Polypectomy ▪ Cause is unknown
▪ Because polyps are often associated with endometrial hyperplasia,
unopposed estrogen has been implicated as a possible etiology
NABOTHIAN CYSTS ▪ Mostly are asymptomatic, mostly are detected by sonography.
▪ Retentions mucus cysts of endocervical columnar cells usually at ▪ Common manifestation is abnormal uterine bleeding
the transformation zone No single abnormal bleeding pattern is diagnostic for polyps;
retention cysts of endocervical columnar cells occurring where a however, menorrhagia, premenstrual and postmenstrual staining,
tunnel or cleft has been covered by squamous metaplasia. and scanty postmenstrual spotting are the most common.
▪ These cysts are so common that they are considered a normal ▪ Has 3 histological components:
feature of the adult cervix.  Endometrial glands
▪ Gross appearance: translucent or opaque whitish or yellow  Endometrial stroma
▪ Vary from microscopic to macroscopic size, 3mm-3cm  Central vascular channels
These mucous retention cysts are produced by the spontaneous
healing process of the cervix ▪ Malignant transformation is estimated at 0.5%
▪ Asymptomatic DIFFERENTIAL DIAGNOSIS:
▪ No treatment is necessary ▪ Submucous leiomyoma
▪ Adenomyoma
▪ Retained products of conception
▪ Endometrial hyperplasia
▪ Endometrial carcinoma
▪ Uterine sarcoma

OPTIMAL MANAGEMENT: removal by Hysteroscopy with D and C

3 BENIGN GYNECOLOGIC LESIONS AISH

 HEMATOMETRA HISTOLOGIC APPEARANCE:
▪ Uterus is distended with blood secondary to gynatresia, which is ▪ With proliferation of mature smooth muscle cells.
partial or complete obstruction of any portion of the lower genital ▪ The non-striated muscle fibers are arranged in interlacing bundles
tract. with variable amount of fibrous connective tissue in-between.
COMMON CONGENITAL CAUSES COMMON ACQUIRED CAUSES Types degeneration:
▪ Imperforate hymen ▪ Senile atrophy of  Hyaline Myxomatous
▪ Transverse vaginal septum endocervical canal and  Calcific Cystic
endometrium  Fatty Necrosis
▪ Scarring of the isthmus by
 Red or Carneous
synechiae
▪ Cervical stenosis associated ▪ Malignant transformation is 0.3 to 0.7%, usually into a Sarcoma
to surgery, radiation therapy, CLINICAL MANIFESTATIONS:
cryotherapy or
electrocautery, endometrial ▪ Most common symptom:
ablation  Pressure from an enlarging mass
▪ Malignant disease of  Pain including dysmenorrhea
endocervical canal  Abnormal uterine bleeding
The severity of symptoms is usually related to the number, location,
DIAGNOSIS: and size of the myomas. However, over two thirds of women with
▪ History of amenorrhea and cyclic abdominal pain uterine myomas are asymptomatic.
Confirmed by: ▪ Rapid growth after menopause, consider Leiomyosarcoma
▪ Ultrasonography
▪ Probe the cervix with dilator and with release of dark brownish black DIAGNOSIS:
blood ▪ Physical examination – Internal
MANAGEMENT examination
 Palpation of an enlarged, firm,
▪ Depends on the operative relief of lower genital tract obstruction
irregular uterus
LEIOMYOMA ▪ Ultrasonography
▪ Benign tumors of muscle cell origin ▪ Hysteroscopy
▪ The most frequent pelvic tumor ▪ CT Scan or MRI
▪ the most common tumor in women DIFFERENTIAL DIAGNOSIS:
CLINICAL CHARACTERISTICS: ▪ Pregnancy
 Highest prevalence at the 5th decade of woman’s life ▪ Adenomyosis
 →Found in 30-50% of perimenopausal women ▪ Ovarian neoplasm
 Rare before menarche, diminish in size after menopause
MANAGEMENT:
 Enlarges during pregnancy and occasionally during OCP use
▪ Observation – for small and asymptomatic
▪ Symptomatic leiomyomas are the primary indication for The management of small, asymptomatic myomas is judicious
approximately 30% of all hysterectomies observation. When the tumor is first discovered, it is appropriate to
RISKS FACTORS: perform a pelvic examination at 6-month intervals to determine the
 Increasing age Early menarche rate of growth.
 Low parity Tamoxifen use If symptoms do not improve with conservative management,
 Obesity High fat diet operative therapy may be considered.
▪ Surgical:
TYPES OF MYOMA  Myomectomy
3 most common types:  Hysterectomy
 Intramural ▪ Medical: (Summary of medical management at the last page)
 Subserous  GnRH agonists
 Submucous  Danazol
Other types:  Medroxyprogesterone acetate
 Intraligamentary  RU 486
 Parasitic myomas
The three most common types of myomas are intramural,
subserous, and submucous, with special nomenclature for broad
ligament and parasitic myomas

ORIGIN:
▪ Each tumor develops from a single muscle cell a progenitor myocyte
▪ Cytogenetic analysis demonstrated that myomas have multiple
chromosomal abnormalities affecting regulation of growth-inducing
proteins and cytokines
Current theory: The growth may be influenced by estrogen and
progesterone levels.
▪ Uterine artery embolization
 Gelatin sponge (Gelfoam) silicon spheres
 Metal coils
 Polyvinyl alcohol (PVA) particles
 Gelatin microspheres

GROSS APPEARANCE: Factors affecting the type of surgical approach:

▪ Lighter in color than the normal myometrium ▪ Age of the patient
▪ Cut surface: Glistening, pearl-white with smooth muscle arranged ▪ Parity
in trabeculated or whorl configuration. ▪ Future reproductive plans

4 BENIGN GYNECOLOGIC LESIONS AISH

 Classic indications for Contraindications to
CLINICAL PRESENTATION:
Myomectomy: Myomectomy:
▪ Persistent abnormal bleeding ▪ Pregnancy ▪ Over 50% are asymptomatic
▪ Pain or pressure ▪ Advanced adnexal disease ▪ Symptomatic cases are between the ages of 35 and 50
▪ Enlargement of an ▪ Malignancy CLASSIC SYMPTOMS:
asymptomatic myoma to ▪ When enucleation of the ▪ Secondary dysmenorrhea
more than 8 cm in a woman myoma results in severe ▪ Menorrhagia
who has not completed reduction of endometrial
childbearing surface that the uterus would HISTOPATHOLOGY
not be functional ▪ The standard criterion used in diagnosis of
adenomyosis is the Presence of endometrial
Myomectomy maybe performed through: glands and stroma within the myometrium
▪ Laparoscopy more than one low power field (2.5 mm)
▪ Hysteroscopy from the basalis layer endometrium
▪ Laparotomy ▪ Derived from the aberrant glands of the basalis
▪ Vaginally layer of the endometrium
Indications for Hysterectomy: PATHOLOGIC PRESENTATION:
▪ All indications for myomectomy, ▪ Diffuse involvement of both anterior and posterior myometrium
plus: ▪ Focal area of involvement or adenomyoma
▪ Asymptomatic myomas when the uterus that has reached the size
of 14 to 16 weeks gestation DIAGNOSIS
▪ Rapid growth of myoma after menopause wherein we can consider ▪ Pelvic examination findings:
leiomyosarcoma  Uterus is diffusely enlarged, globular, usually 2-3 x normal size.
▪ Diagnosis is confirmed following histologic examination of
ADVANTAGES OF PREOPERATIVE GNRH AGONIST TREATMENT: hysterectomy specimen
Advantages Gained by Uterine- Advantages Gained by Induction ▪ Diagnostic tools:
Fibroid Shrinkage of Amenorrhea Ultrasound and MRI are both useful to help differentiate between
▪ May allow vaginal ▪ May correct adenomyosis and uterine myomas in a young woman desiring
hysterectomy hypermenorrhea-
future childbearing
▪ May decrease intra-operative menorrhagia-associated
blood loss anemia  Ultrasonography
▪ May allow Pfannenstiel ▪ May improve ability to donate →Sensitivity: 53-89% - Specificity: 50-89%
incision blood  MRI
▪ May facilitate endoscopic ▪ May decrease need for non- →Sensitivity: 88-93% - Specificity: 66-91%
myomectomy autologous blood transfusion
▪ May atrophy endometrium, MANAGEMENT:
facilitating hysteroscopic ▪ NO satisfactory medical management
resection of submucosal  GnRH agonist
myoma  Cyclic hormones
DISADVANTAGES OF PREOPERATIVE GNRH AGONIST
 Prostaglandin synthetase
▪ Delay to final tissue diagnosis
Patients with adenomyosis have been treated with GnRH agonists,
▪ Degeneration of some myomas, necessitating piecemeal
enucleation at myomectomy progestogens, and progesterone-containing IUDs, cyclic hormones,
▪ Hypoestrogenic side effects. or prostaglandin synthetase inhibitors for their abnormal bleeding and
→Trabecular bone loss pain
→Vasomotor symptoms: e.g. hot flushes ▪ Hysterectomy is the definitive treatment
▪ Cost Factors to consider:
▪ Need to self-administer or receive injections in many cases
 Age
▪ Vaginal hemorrhage in approximately 2% of patients
 Parity
 Reproductive plans
COMPLICATIONS OF UTERINE ARTERY EMBOLIZATION:
 Uterine size
▪ Post-embolization fever
 Presence of associated pelvic pathology
▪ Sepsis from infarction of the necrotic myometrium
Hysterectomy is the definitive treatment if this therapy is appropriate
▪ Ovarian failure
for the woman’s age, parity, and plans for future reproduction. Size of
▪ Abdominal pain
the uterus, degree of prolapse, and presence of associated pelvic
ASSOCIATED RARE DISEASE: pathology determine the choice of surgical approach
▪ Intravenous leiomyomatosis Women who become pregnant with adenomyosis are at
 Benign smooth muscles fibers invade and slowly grow into the increased risk of pregnancy complications such as premature
venous channels of the pelvis labor and delivery, low birthweight, and preterm premature
 Grossly appears like a “spaghetti” tumor rupture of membranes.
▪ Leiomyomatosis peritonealis dessiminata (LPD)
 Benign multiple small nodules over the surface of the pelvis BENIGN LESIONS OF THE OVIDUCTS
and abdominal peritoneum ADENOMATOID TUMORS
 Usually associated with recent pregnancy ▪ Most prevalent benign tumor of the oviduct is the angiomyoma or
 Management: Progestational therapy adenomatoid tumor
▪ Small, gray-white, circumscribed nodules 1-2 cm in diameter
ADENOMYOSIS ▪ These tumors are usually unilateral and present as small nodules
Adenomyosis has often been referred to as endometriosis interna just under the tubal serosa.
PATHOGENESIS : UNKNOWN ▪ Do not become malignant
▪ Theories:
 Disruption of the of the barrier between the endometrium and PARATUBAL CYSTS
myometrium Paratubal cysts are frequently incidental discoveries during
 Trauma to the endometrial-myometrial interface gynecologic operations for other abnormalities.
The disease is associated with increased parity, particularly uterine ▪ Vary is size from 0.5 cm to 20 cm in diameter
surgeries and traumas.

5 BENIGN GYNECOLOGIC LESIONS AISH

 ▪ Hydatid cysts of Morgagni – pedunculated and near the fimbrial THECA LUTEIN CYSTS
end of the oviduct Theca lutein cysts are by far the least common of the three types of
▪ Majority are accessory lumina of the fallopian tubes physiologic ovarian cysts
▪ Often difficult to differentiate from an ovarian mass ▪ Almost always bilateral, producing moderate to massive
▪ May grow rapidly during pregnancy enlargement of the ovaries
▪ Treatment: Simple excision
ETIOLOGY:
BENIGN LESIONS OF THE OVARY ▪ Prolonged or excessive stimulation of the ovaries by endogenous
FUNCTIONAL CYSTS or exogenous gonadotrophins or increased ovarian sensitivity to
▪ Also called Non-neoplastic cysts gonadotrophins
Types: COMPLICATIONS:
 Follicular cysts ▪ Torsion of pedicle
 Corpus luteum cysts ▪ Intraperitoneal bleeding
 Theca lutein cysts
FOLLICULAR CYSTS TREATMENT:
▪ Observation: most will regress gradually
▪ The most frequent cystic structures in normal ovaries of young
menstruating women
BENIGN NEOPLASMS OF THE OVARY
▪ Translucent, thin-walled filled with watery, clear to straw-colored
BENIGN CYSTIC TERATOMA
fluid
▪ Dermoid Cysts or Mature Teratoma
▪ A normal follicle may develop into a physiologic cyst
▪ Cystic ovarian structures that contain elements of the 3 germ
▪ Minimum diameter to be considered a cyst = 2.5 - 3.0 cm
layers (ectoderm, mesoderm & endoderm)
▪ Highly Dependent on gonadotrophins for growth
▪ Compose >90% of germ cell tumors of the ovary; 20-25% of all
▪ May arise from:
ovarian neoplasms
 Dominant mature follicle’s failure to rupture (Persistent follicle)
▪ Most common ovarian neoplasm in prepubertal females and also
 Immature follicle’s failure to undergo atresia
common in teenagers
▪ Occur bilaterally 10-15% of the time
▪ Believed to arise from a single germ cell after the 1st meiotic
division, from totipotential stem cell.
▪ Chromosomal make-up: 46,XX
▪ Associated with 3 medical condition:
 Thyrotoxicosis
Most follicular cysts are asymptomatic and are discovered during  Autoimmune hemolytic anemia
ultrasound imaging of the pelvis or a routine pelvic examination.  Carcinoid syndrome
▪ Symptoms are varied and nonspecific to the ovary ▪ Grossly:
 Surface: Smooth, shiny, opaque white color
MANAGEMENT OPTIONS:  Cut-section: Thick sebaceous fluid, with tangled masses of hair
▪ Initial Management: Observation and firm areas of cartilage and teeth
▪ Majority will disappear spontaneously in 4-8 weeks:
 reabsorption of the cyst fluid
 silent rupture
▪ Medical management
 OCP
▪ Surgery
 For persistent ovarian masses
 Cystectomy is commonly done ▪ Most common complication: Torsion of the pedicle (more
common in younger women)
CORPUS LUTEUM CYSTS
DIAGNOSIS:
Corpus luteum cysts are less common than follicular cysts, but ▪ Palpation
clinically they are more important.  The diagnosis of a dermoid cyst is often established when a
▪ Corpora lutea that is at least 3 cm in diameter semisolid mass is palpated anterior to the broad ligament
▪ Corpora lutea develop from graafian follicles ▪ Ultrasonography – 95% predictive value
▪ Vary from asymptomatic masses to causing catastrophic and  Most dermoids have a characteristic ultrasound picture. These
massive intraperitoneal bleeding characteristics include a dense echogenic area within a larger
Corpus luteum cysts may be associated with either normal endocrine cystic area, a cyst filled with bands of mixed echoes, and an
function or prolonged secretion of progesterone. echoic dense cyst
DIFFERENTIAL DIAGNOSIS:
MANAGEMENT:
▪ Ectopic pregnancy
▪ Surgical: Oophorocystectomy
▪ Adnexal torsion
Operative treatment of benign cystic teratomas is cystectomy with
▪ ruptured endometrioma
preservation of as much normal ovarian tissue as possible.
MANAGEMENT:  Laparotomy
▪ Surgical exploration: Cystectomy  Laparoscopy

ENDOMETRIOMAS
Endometriosis of the ovary is usually associated with endometriosis
in other areas of the pelvic cavity
▪ Secondary to endometriosis of the ovary
▪ Varies from small, superficial , blue-black implants 1-5 mm in
diameter to large, multiloculated, hemorrhagic cysts 5-10 in
diameter

6 BENIGN GYNECOLOGIC LESIONS AISH

 COMMON SYMPTOMS: ▪ Management: Surgery (TAH-BSO)
▪ Pelvic pain →bilateral salpingo-oophorectomy and total abdominal
▪ Dyspareunia hysterectomy are performed.
▪ Infertility

DIAGNOSIS:
▪ Pelvic exam findings: Ovaries are tender and immobile due to
adhesions to surrounding structures
▪ Ultrasonography: Thick-walled cyst with homogenous echopattern

MANAGEMENT: MEDICAL OR SURGICAL

Factors to consider:
 Patient’s age
 Future reproductive plans
 Severity of symptoms
▪ Medical therapy rarely successful if disease has produced ovarian
enlargement
▪ Common surgical procedure: Cystectomy
Often surgical therapy is complicated by formation of de novo and
recurrent adhesions.

FIBROMA
▪ Most common benign, solid neoplasm of the ovary
Their malignant potential is low, less than 1%.
▪ Arise from the undifferentiated fibrous stroma of the ovary
▪ Extremely slow growing
▪ Incidence of associated ascites: directly proportional to the size of
the tumor
▪ Average age of affected women: 48 years

SYMPTOMS:
▪ Pressure on adjacent structures
▪ Abdominal enlargement
The pelvic symptoms that develop with growth of fibromas include
pressure and abdominal enlargement, which may be secondary to
both the size of the tumor and ascites.
Meigs’ syndrome:
 association of ovarian fibroma
 ascites
 hydrothorax

GROSSLY:
 Heavy, solid, well-encapsulated and grayish white
 Cut surface: Homogenous white or yellowish white solid tissue
with trabeculated or whorled appearance

▪ Histologically: Connective tissue, stromal cells, and varying

amount of collagen, spindle-shaped, mature fibroblast

7 BENIGN GYNECOLOGIC LESIONS AISH