Lorna G.

Raymundo MD
Medical Center Manila
 Urethral Caruncle

◦ Small fleshy outgrowth of the

distal edge of the urethra

◦ Smooth, soft, friable and

bright red

◦ Most frequently seen in ◦ Initial therapy is oral or

postmenopausal women topical estrogen

◦ Arise from an ectropion of the ◦ If it does not regress or

posterior urethral wall symptomatic, may be
associated with retraction and destroyed by cryosurgery,
atrophy laser therapy, fulguration, or
operative excision
 Urethral prolapse

◦ Predominantly a disease of
premenarcheal females

◦ Annular rosette of friable,

edematous, prolapsed
mucosa

◦ Treated with hot sitz bath

and antibiotics to reduce
inflammation and infection
 Bartholin's duct cyst

◦ most common large cyst

◦ Cystic mass that usually

arises as a result of
obstruction of Bartholin's duct

◦ Treatment necessary only if

infected or large enough to
cause symptoms
 Epidermal inclusion
cyst

◦ most common small

vulvar cyst

◦ May develop after a

trauma

◦ Usually require no
treatment, unless infected
 Nevus (mole)

◦ Localized nest or clusters

of melanocytes

◦ Undiffereniated cells arise

from the embryonic neural
crest and are present from
birth

◦ Exhibit wide range in

depth of color, and some
may be amelanotic
◦ Three major histological ◦ All vulvar nevi should be
group: excised and examined
 junctional histologically
 compound
 intradermal nevi  Flat junctional nevus
and dysplastic nevus –
◦ 50 % of malignant greatest potential for
melanomas arise from a malignant
preexisting nevus transformation
◦ Characteristic clinical feature of early malignant
melanoma:

 A – asymmetry
 B – border irregularity
 C – color variegation
 D – diameter usually greater than 6 mm.
 Hemangioma

◦ Rare malformations of blood vessels

◦ Usually single, 1-2cm in diameter, flat, soft, and

range in color from brown to red or purple

◦ Predominantly thin-walled capillaries arranged

randomly and separated by thin connective tissue
septa
◦ Five different types:

 Strawberry hemagiomas – usually bright red to dark

red, elevated, and rarely increases in size after age 2
 Cavernous hemangiomas – usually purple in color
and vary in size with the largest extending deep into
the subcutaneous tissue

 Spontaneous resolution generally occurs before age 6

 Senile or cherry angiomas – arise on the labia majora,
usually in postmenopausal women
 Less than 3 mm in diameter, multiple

 Angiokeratomas – twice the size of cherry angiomas,

and seen in women between ages 30 to 50
 Noted for its rapid growth and tendency to bleed during
strenous exercise

 Pyogenic granulomas – overgrowth of inflammed

granulation tissue.
 They grow under the hormonal influence of pregnancy
 Fibroma

◦ Most common benign

solid tumor of the vulva

◦ Occur in all age group

◦ Commonly found in the

labia majora, but arise
from deeper connective
tissue

◦ Treatment is operative
removal if symptomatic
and continue to grow
 Lipoma

◦ Benign, slow growing,

circumscribed tumors of
fat cell arising from the
subcutaneous tissue

◦ Softer and larger than

fibromas

◦ Low malignant potential

◦ Treatment is excision
 Hidradenoma

◦ Small, rare, benign

◦ Originate from apocrine

sweat glands of the inner
surface of the labia
majora and nearby
peritoneum

◦ Exclusive to white women

between ages 30 and 70
 Syringoma

◦ Very rare

◦ Adenoma of the apocrine

sweat gland

◦ Generally asymptomatic
 Granular Cell
Myoblastoma

◦ Schwannoma –
originating from the
neural sheath (Schwann)
cells

◦ Subcutaneous nodules

◦ Benign but infiltrate the

surrounding local

◦ Treatment is wide
excision
 Urethral Diverticulum

◦ Permanent, epithelialized,
saclike projection that
arises from the posterior
urethra

◦ May be congenital or
acquired
◦ 3 D’s associated with
diverticula
◦ Most common symptoms
 Dysuria
are urinary urgency,  Dysparerunia
frequency and dysuria  Dribbling of the urine
 Inclusion Cysts

◦ Most common cystic

structure of the vagina

◦ Usually at the posterior or

lateral wall of the lower
third of the vagina

◦ Result from birth trauma

or gynecologic surgery
 Dysontogenetic Cysts

◦ Thin-walled, soft cysts of

embryonic origin
 Gartner’s duct cyst
(mesonephros)
 mullerian cyst
(perimesonephrium)
 Vestibular cyst
 (urogenital sinus)

◦ Most commonly found in

the lower one third of the
vagina
 Endocervical and
Cervical Polyps

◦ Most common benign

neoplastic growth of the
cervix

◦ Common in multiparous
women in their 40’s and
50’s

◦ Classic symptom –
intermittent bleeding,
postcoital or after an
examination
◦ Usually secondary to
inflammation or abnormal
focal response to
hormone
◦ If base is in the
endocervix – narrow, long
pedicle (reproductive
years)
◦ Treatment – polypectomy
◦ In women older than 40-
evaluate for endometrial
pathology
 5% of asymptomatic women
with endocervical polyps have
endometrial pathology

◦ If base is in the ectocervix

– short, broad base and
occur in postmenopausal
years
 Nabothian Cysts

◦ Retention cysts of
endocervical columnar
cells occurring where a
tunnel or cleft has been
covered by squamous
metaplasia

◦ So common, considered a
normal feature of the ◦ Produced by the
adult cervix spontaneous healing
process of the cervix
 Cervical Myomas

◦ Solitary, smooth, firm

masses

◦ About 3 to 8% of all
myomas

◦ May produce dysuria,

urgency, urethral or ◦ Treatments include:
ureteral obstruction,  Medical management with
dysparenia, and GnRH agonists
obstruction  Myomectomy
 Hyesterectomy
 Endometrial Polyps

◦ Localized overgrowths of
glands and stroma that
project beyond the
surface of the
endometrium

◦ Soft and pliable

◦ Most arise from the

fundus
◦ Peak incidence between ◦ 3 histologic components:
age 40 – 49
 Endometrial glands
◦ Often associated with  Endometrial stroma
endometrial hyperplasia  Central vascular channels

◦ Unopposed estrogen
◦ Treatment
◦ Malignant transformation  Removal by hysteroscopy
followed by D&C
– 0.5%
 Leiomyomas
◦ Fibroids or Fibromyoma ◦ More prone to grow and
become symptomatic in
◦ Fibrous tissue, smooth nullis
muscle cells
◦ Risk factors:
◦ Most frequent and most  Increasing age
common tumor in women  Early menarche
 Low parity
 Tamoxifen use
◦ Highest prevalence – 5th  High fat diet
decade of life  Family history

◦ One-third become  Decrease incidence associated

symptomatic with smoking
◦ Most common types:

 Intramural

 Subserous
parasitic myoma

 Submucous
 Only 5 to 10 %
 Associated with vaginal
bleeding
 Distortion of uterine cavity
◦ Each tumor develop from a ◦ Influenced by relative
single muscle cell levels of estrogen and
(progenitor myocyte) progsterone

◦ Have multiple chromosomal ◦ Rare before menarche,

abnormalities diminish in size after
menopause
◦ Neoplastic transformation
from normal myometrium to
myoma is the result of a
somatic mutation in the
singe progenitor cell
◦ Fate – relatively poor ◦ Symptoms:
vascular supply:
 Pressure from and enlarging
 Red, or carneous, pelvic mass
degeneration – severe pain
and peritoneal irritation (5 to  Dysmenorrhea
10%)

 Abnormal uterine bleeding

 Hyaline degeneration(65%) menorrhagia
intermenstrual spotting
 Myxomatous degeneration disruption of a normal
(15%) pattern

 Calcific degeneration (10%)

◦ Management:

 Pelvic exam at 6-month

interval to determine growth

 Myomectomy vs hysterectomy
◦ Indications for myomectomy: ◦ Indications for hysterectomy:
 Persistent abnormal bleeding  Same as for myomectomy
 Pain or pressure  Myomas size 14 to 16 weeks
 Enlargement of an asymptomatic gestation
myoma to more than 8 cm in a
woman who has not completed
childbearing

◦ Contraindications:
 Pregnancy
 Advanced adnexal disease
 Malignancy
 Conditions that would result in
severe reduction of endometrial
tissues
◦ Medical management: ◦ Uterine artery embolization

 GnRH agonists  Gelatin sponge (Gelfoam)

 MPA silicone spheres
 Danazol  Gelatin microspheres
 Antiprogesterone RU 486  Metal coils
 Polyvinyl alcohol (PVA) particles
of various diameters
Advantages of Preoperative GnRH Agonist Treatment
Advantages gained by Uterine-fibroid Shrinkage
may allow vaginal hysterectomy
may decrease intraoperative blood loss
may allow Pfannensteil incision
may facilitate endoscopic myomectomy

Advantages gained by Induction of Amenorrhea

may correct hypermenorrhea-menorrhagia associated anemia
may improve ability to donate blood
may decrease need for autologous blood trasfusion
may atrophy endometrium, facilitating hysteroscopic resection of
of submucousal tumors
Advantages of Preoperative GnRH Agonist Treatment
Delay to final tissue diagnosis
Degeneration of some leiomyomas, necessitating piecemeal
enucleation at myomectomy
Hypoestrogenic side effects (e.g., trabecular bone loss, vasomotor
flushes
Cost
Need to self-administer or receive injections in many cases
Vaginal hemorrhage in approximately 2% of patients
◦ 3 associated but rare disease:

 Intravenous leiomyomatosis – benign smooth muscle fibers

invade and slowly grow into the venous channels of the pelvis

 Leiomyomatosis peritonealis disseminata (LPD) – multiple small

nodules over the surface of the pelvis and abdominal
peritoneum

 Autosomal syndrome of uterine and cutaneous leiomyomata

and renal cell carcinoma
 Adenomyosis

◦ Presence of ectopic
endometrial glands and
stroma

◦ Derived from aberrant

glands of the basalis layer
of the endometrium

◦ Secondary dysmenorrhea,
menorrhagia, dyspareunia
◦ Management includes:

 GnRH agonists

 Cyclic hormones

 Prostaglandin synthetase
inhibitors

 Hysterectomy
 Adenomatoid Tumors

◦ Angiomyoma

◦ Most prevalent benign tumor

◦ Small, grayish white circumscribed

nodules

◦ Do not become malignant

 Paratubal cysts

◦ Frequent incidental
finding on operation

◦ Often multiple, 0.5 to 20

cm ◦ May grow rapidly during
pregnancy, and may
◦ 3rd to 4th decade of life cause torsion

◦ Hydatid cysts of Morgagni ◦ Treatment is excision

Functional Cysts

 Follicular cysts
◦ Most frequent cystic
structure in normal
ovaries

◦ Solitary or multiple

◦ Dependent on
gonadotropins for growth
◦ Translucent, thin-walled, ◦ Treatment is conservative
filled with a watery, clear
to straw-colored fluid ◦ Usually disappear by
reabsorption or silent
◦ May result from either the rupture in 4-8 weeks
dominant mature
follicle’s failing to rupture
(persistent follicle) or
immature follicle’s to
undergo normal process
of atresia
◦ Sonographic findings of ◦ Cysts should be removed
concern:
 in the perimenopausal and
 Presence of internal postmenopausal women if
septations mass is anything other than
 Thickness of septations simple
 Bilaterality
 Solid elements  Ca-125 is abnormal (>35)
 Internal echoes
 Papulations or daughter cysts  If cyst is persistent or large
(>10 cm)
 Ascites or free-fluid in the
cul-de-sac
Functional Cyst

 Corpus Luteum Cyst

◦ Develop from mature

graafian follicles

◦ Small, average diameter

of 4 cm. ◦ May cause intraperitoneal
bleeding
◦ Dull, unilateral, lower
abdominal and pelvic ◦ Most rupture occur
pain between days 20 and 26
of the cycle
Functional Cysts

 Theca Lutein Cysts

◦ Least common

◦ Almost always bilateral

◦ Seen in approximately
◦ Produce moderate to 50% of molar pregancy
massive enlargement of and 10% of
the ovaries choriocarcinoma

◦ Arise from prolonged or ◦ Hyperreactio luteinalis –

excessive stimulation to multiple leutinized follicle
endo/exogeneous GnRH cysts
Benign Neoplasms

 Benign Cystic Teratoma

(Dermoid, Mature
Teratoma)

◦ Contain elements from all

three germ layers

◦ Among the most common

ovarian neoplasm

◦ Account for >90% of germ

cell tumors
◦ Represent 20 -25% of all ◦ Arise from a single germ
ovarian neoplasms, 33% cell after the first meiotic
of all benign tumors division (totipotential
stem cell)
◦ May be single or multiple,
often pedunculated ◦ 46,XX chromosomal
make-up
◦ Heavy than normal, seen
in the cul-de-sac or ◦ Composed of mature cells
anterior to the broad from the three germ
ligament layers

◦ Usually unilocular ◦ Treatment is cystectomy

with preservation of
ovarian tissue
 Endometrioma

◦ Associated with
endometriosis in other
areas in the pelvic cavity

◦ Vary from small,

superficial, blue-black
implants to large
multiloculated,
hemorrhagic cysts
◦ Pelvic pain, dyspareunia, ◦ Medical vs. operative tx:
and infertility  Patient’s age
 Future reproductive plans
◦ On pelvic exam, ovaries  Severity of symptoms
are often tender and
immobile, secondary to
associated inflammation ◦ Medical therapy rarely
and adhesions successful in ovarian
enlargement
◦ Densely adherent to
surrounding structures
 Fibroma

◦ Most common benign,

solid neoplasm of the
ovary

◦ Low malignant potential

<1%

◦ Extremely slow-growing
tumor; ave diameter is 6
cm

◦ 90% unilateral
◦ Often presents in a ◦ Pelvic symptoms include
postmenopausal woman – pressure and abdominal
average age is 48 enlargement

◦ Arise from ◦ No change in menstrual

undifferentiated fibrous pattern
stroma of the ovary

◦ Commonly found in
women with rare genetic
transmitted basal cell
nevus syndrome
◦ Meig’s syndrome –

 Ovarian fibroma

 Ascites – transudation of fluid from the ovarian fibroma

incidence of ascites is directly related to the size of the
fibroma

 Hydrothorax – develop secondary to a flow of ascitic fluid into

the pleural space via the lymphatics of the diaphragm
◦ Management of fibroma

 Any woman with a solid ovarian neoplasm should have an

exploratory operation soon after the tumor is discovered

 In postmenopausal women – bilateral salpingo-oophorectomy

and total abdominal hysterctomy
 Transitional cell
Tumors
 Brenners Tumors

◦ Rare, small smooth, solid,

fibroepithelial ovarian
tumor

◦ Usually occur in women

age 40 to 60
◦ Luteinization of the ◦ Management is operative
stroma produces – simple excision
estrogen with resulting
hyperlasia

◦ May be associated with

postmenopausal bleeding
– endometrial hyperplasia
a coexisting abnormality
 Adenofibroma And
Cystadenofibroma

◦ Benign firm tumors

consist of fibrous and
epithelial components
◦ Usually occuring in
◦ Preponderance of postmenopausal women
connective tissue
◦ Bilateral in 20 -25 %
◦ Small fibrous tumors
arising from the surface ◦ May reach up to 15 cm in
of the ovary diameter