Benign Gynecologic Tumors

Dr. M. Rusda Harahap, Sp.OG

Sub Department Fertility Endocrinology Reproduction
Department of Obstetric and Gynecology
School of Medicine University of Sumatra Utara
1. Benign Vulva and Vagina Tumors
2. Benign Ovarian Tumors
3. Benign Uterus and Cervix Tumors
Benign Vulva and Vagina tumors
 Vulva
Epidermoid and sebaceous cysts can be difficult
to differentiate.
 Management involves excision of the cyst.
 Cysts may also arise from the duct of the
Bartholin’s gland that lies in subcutaneus tissue
below the lower third of the labium majorum.
 Incision and marsupialization of the abscess
and antibiotic therapy give excellent results.
 The pus from the abscess should be sent for
culture in media suitable for the detection of
gonococcal infection.
Vulva
Epidermoid cyst
Vulva
Sebaceous cyst
Vulva
Bartholin’s cyst
Vulva
Bartholin’s cyst
 Vulva
Condyloma acuminata

 CA are small papules that are sometimes

sessile and often polypoid.
 These are due to infection by the HPV and
may be seen over the whole perineal region.
 Treatment :
Trichloroacetic acid
Podophyllin less effective & more toxic but
may also be used
Occasionally electrodiathermy is required to
remove these warts.
Vulva
Condyloma acuminata
Vagina

Tumors in the vagina are uncommon, The

commonest are Condyloma acuminata
(warts)
Vagina
Condyloma acuminata (warts)
Benign ovarian tumors
 Understanding the pathophysiology
Pathology of benign ovarian tumors
Physiological cysts
 Follicular cyst
 Luteal cyst

Benign germ cell tumors

 Dermoid cyst
 Mature teratoma
Understanding the pathophysiology (cont.)

Pathology of benign ovarian tumors

Benign epithelial tumours
 Serous cystadenoma
 Mucinous cystadenoma
 Endometrioid cystadenoma
 Brenner tumour
 Clear cell tumour

Benign sex cord stromal tumours

 Granulosa cell tumour
 Theca cell tumour
 Fibroma
 Sertoli-Leydig cell tumour
 Physiological cysts
 Follicular cyst:
 The commonest benign ovarian tumor and is
most often found incidentally
 It results from the non-rupture of a dominant
follicle or the failure of atresia in a non-dominant
follicle
 Can persist for several menstrual cycles and
may achieve a diameter of up to 10 cm
 Occasionally, they may continue to produce
oestrogen, causing menstrual disturbances and
endometrial hyperplasia.
Physiological cysts
 Follicular cyst:
Physiological cysts
 Follicular cyst:
Physiological cysts
 Follicular cyst:
Physiological cysts
 Luteal cyst:

 Less common than follicular cysts

 More likely to present with
intraperitoneal bleeding
 They may also rupture, usually
happens on days 20-26 of the cycle.
 Corpora lutea are not called luteal
cysts unless they are more than 3 cm in
diameter.
Benign germ cell tumors
 Dermoid cyst:
The benign dermoid cyst is the only benign germ cell
tumor that is common. It results from differentiation into
embryonic tissues.
 Usually a unilocular cyst < 15 cm in diameter, in which
ectodermal structures are predominant.Thus it is
often lined with epithelium like the epidermis and
contains skin appendages, teeth, sebaceous material,
hair and nervous tissue.
 Endodermal derivatives include thyroid, bronchus and
intestine
 Mesoderm may be represented by bone, cartilage and
smooth muscle.
 Benign germ cell tumors
 Mature (solid) teratoma:

 These rare tumors contain mature

tissues just like the dermoid cyst, but
there are few cystic areas.
 They must be differentiated from
immature teratomas, which are
malignant.
Benign epihtelial tumours
 Serous cystadenoma:

 The most common BET and is bilateral in

about 10 per cent of cases
 Usually a unilocular cyst with papilliferos
processes on the inner surface and
occasionally on the outer surface.
 The cyst fluid is thin and serous
 They are seldom as large as mucinous
tumours.
Benign epihtelial tumours
 Mucinous cystadenoma:

 They are typically large, unilateral,

multilocular cysts with a smooth inner
surface; A recent specimen at the
Hammersmith Hospital (London) weighed
over 14 kg.
 The cyst fluid is generally thick and
glutinous
Benign epihtelial tumours
 Mucinous cystadenoma:
Benign epihtelial tumours
 Endometrioid cystadenoma:
Difficult to differentiate from ovarian
endometriosis.
 They may be associated with pelvic
pain and deep dyspareunia due to
adhesions
 They present a typical appearance on
transvaginal sonography with an
absence of pupillae and typical ‘ground
glass’ contents of unclotted blood.
Benign epihtelial tumours
 Brenner Tumours:

 These account for only 1-2 % of all ovarian

tumours, and are bilateral in 10-15 % of
cases.
 They probably arise from Wolffian metaplasia
of the surface epithelium.
 Although some can be large, the majority is <
2 cm in diameter
 Some secrete oestrogens and abnormal
vaginal bleeding is a common presentation.
Benign epihtelial tumours
 Brenner Tumours:
Benign epihtelial tumours
 Brenner Tumours:
Benign epihtelial tumours
 Clear cell (mesonephroid) tumours

 These arise from serosal cells showing

little differentiation, and are only rarely
benign
 The typical histological appearance is
of clear or ‘hobnail’ cells arranged in
mixed patterns
 Benign sex cord stromal tumours
 Granulosa cell tumour

 These are all malignant tumors but are

mentioned here because they are generally
confined to the ovary when they present and so
have a good prognosis.
 They do grow very slowly and recurrences are
often seen 10-20 years later.
 They are largely solid in most cases.
 Some produce oestrogens and most appear to
secret inhibin.
 Benign sex cord stromal tumours
 Theca cell tumour:

 Almost all are benign, solid and unilateral,

typically presenting in the sixth decade.
 Many produce oestrogens in sufficient
quantity to have systemic effects such as
precocious puberty, postmenopausal
bleeding, endometrial hyperplasia and
endometrial cancer.
 Benign sex cord stromal tumours
 Fibroma:

 These unusual tumors are most frequent

around 50 years of age.
 Most are derived from stromal cells and are
similar to thecomas.
 They are hard, mobile and lobulated with a
glistening white surface.
 Less than 10 % are bilateral.
Benign sex cord stromal tumours
 Sertoli-Leydig cell tumour:

 Rare, less than 0,2 % of ovarian tumors.

 Difficult to distinguish from other ovarian tumors
because of the variety of cells and architecture
seen
 Many produce androgens and signs of
virilization are seen in three-quarters of patients.
 They are usually small and unilateral
Symptoms
Presentation of benign ovarian tumours:

 Asymptomatic (found incidentally)

 Pain (torsion, rupture, hemorrhage or infection)
 Abdominal swelling
 Pressure effects (GI or urinary symptoms)
 Menstrual disturbances (may be coincidence)
 Hormonal effects (androgen >> hirsutism &
acne)
 Abnormal cervical smear
Torsion
Abdominal swelling
 Differential diagnosis
Pain: Ectopic pregnancy
Spontaneous abortion
PID
Appendicitis
Meckel’s diverticulum
Diverticulitis

 Abdominal Swelling:
Pregnant uterus
Fibroid uterus
Full bladder
Distended bowel
Ovarian malignancy
Colorectal carcinoma
Differential diagnosis (cont)

Pressure effects:
Urinary tract infection
Constipation
Hormonal effects:
All other causes of menstrual irregularities,
precocious puberty and postmenopausal
bleeding
Investigation
 Gynecological history
 General history and examination
 Abdominal examination
 Bimanual examination
 Ultrasound
 Ultrasound-guided diagnostic ovarian cyst
aspiration
 Radiological investigation
 Blood test and serum markers
Management

The management will depend upon the severity

of the symptoms, the age of the patient and
therefore the risk of malignancy and her
desire for further children.
Criteria for observation of an
asymptomatic ovarian tumors

 Unilateral tumor
 Unilocular cyst without solid elements
 Premenopausal women-tumor 3-10 cm
 Postmenopausal women-tumor 2-6 cm
 Normal Ca125
 No free fluid or masses suggesting
omental cake or matted bowel loops.
 Benign
uterus and cervix tumors
Benign disease of the cervix and body of the
uterus is extremely common. Cervical
ectropion, fibroids and adenomyosis cause
symptoms that women present with in almost
every gynecological out-patients clinic.
Epithelium: the uterine cervix
Cervical ectropion

The presence of a large area of columnar

epithelium on the ectocervix can be
associated with excessive mucus secretion,
leading to a complaint of vaginal discharge.

 Management: discontinuing the oral

contraceptive pill or alternatively ablative
treatment under local anesthesia using a
thermal probe.
 Epithelium: the uterine cervix
Nabothian follicles
 Within the transformation zone of the ectocervix the
exposed columnar epithelium undergoes squamous
metaplasia.

 Glands contained within columnar epithelium may

become roofed over with squamous cells, resulting in the
formation of small (2-3 mm) mucus-filled cysts visible on
the ectocervix.

 Nabothian follicles are occasionally identified

coincidentally during TVU scanning.

 No pathological significant no require treatment.

Endometrium
Endometrial polyps

These typically occur in women aged over

40 years.
Endometrium
Endometrial polyps
 Myometrium
Uterine fibroids
 A fibroid is a benign tumour of uterine smooth muscle,
termed a leiomyoma.

 Etiology  unknown but growth is oestrogen

dependent

 The gross appearance is of a firm, whorled tumor

located adjacent to and bulging into endometrial cavity
(submucous fibroid), centrally within the myometrium
(intramural fibroid), at the outer border of the
myometrium (subserosal fibroid) or attached to the
uterus by a narrow pedicle containing blood vessels
(pedunculated fibroid)
Uterine fibroids
Uterine fibroids
Uterine fibroids
Clinical features

Risk factors:
Nulliparity
Obesity
A positive family history
African racial origin
 Uterine fibroids
Clinical features (cont)

 Common presenting complaints are menstrual disturbance

and pressure symptoms, especially urinary frequency
 Menorrhagia  submucous fibroids distorting the
endometrial cavity and increasing the surface area are truly
causal.
 Subfertility  mechanical distortion or
occlusion of the fallopian tubes
 submucous fibroids may prevent
implantation of a fertilized ovum.
 Abdominal exam. might indicate the presence of a firm
mass arising from the pelvis.
Uterine fibroids
Differential Diagnosis

Pregnancy
Ovarian tumor
Leiomyosarcomas
Uterine fibroids
Investigation

 A Hb concentration will help to indicate

anemia if there is clinically significant
menorrhagia.
USG is useful to distinguish a uterine
from an ovarian mass.
Uterine fibroids
Treatment

 Conservative management is appropriate

where asymptomatic fibroids are detected
incidentally.
Repeat clinical exam. or ultrasound after a 6-
12 month interval.
 Ovarian suppression using a GnRH agonist
 A bulky fibroid uterus causes pressure
symptoms, the options are myomectomy with
uterine conservation, or hysterectomy.
Adenomyosis

Condition in which functioning endometrial

tissue has penetrated the myometrium by
direct spread from the uterine lining.
 Adenomyosis
Management
Symptoms and enlargement

Negative Positive
No treatment Hysterectomy

Hysterectomy is usually the preferred treatment since adenomyosis

does not respond well to hormonal treatment
mrusdaharahap@yahoo.com