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
Bartholins 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
Bartholins cyst

Vulva
Bartholins 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
Meckels 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
Concervative management is appropriate
where asymptomatic fibroids are detected
incidentally.
Repeat clinical exam. or ultrasound after a 612 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
No treatment

Positive
Hysterectomy

Hysterectomy is usually the preferred treatment since adenomyosis

does not respond well to hormonal treatment

mrusdaharahap@yahoo.com