OBSTETRICS AND GYNECOLOGY II
Module 16
BENIGN GYNECOLOGICAL LESIONS 2
Dr. Maria Carmelita J. Nadal-Santos
TRANS 07
PART 4
I. UTERUS
TOPIC OUTLINE
I. Uterus
A. Endometrial Polyps
i. Diagnosis
ii. Differential diagnosis
iii. Management
B. Leiomyoma/Myoma
i. Symptoms
ii. Diagnosis
iii. Differentials
iv. Treatment and management
C. Adenomyosis
i. Standard criterion
ii. Pathologic presentations
iii. Symptoms
iv. Management
v. Pregnancy
II. Fallopian tubes
A. Paratubal Cyst
i. Hydatid cyst of Morgagni
B. Acute torsion
C. Adenomatoid tumor
III. Ovary
A. Functional cysts
i. Follicular cysts
ii. Corpus luteum cysts
iii. Theca lutein cysts
B. Germ cell tumors
i. Benign cystic teratoma
ii. Dermoid cyst
iii. Mature cystic teratomas
C. Sex cord stromal tumors
i. Fibroma
D. Epithelial cell tumors
i. Serous cystadenoma
ii. Mucinous cysts
IV. Summary
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Lecturer’s additional notes =
(e.g Trivia, nice-to-know)
Disclaimer =
(e.g. not included nor discussed)
important terms = Bold and black text
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A. ENDOMETRIAL POLYPS
Figure 1. Endometrial polyp
● Localized overgrowths of endometrial glands and stroma
that project beyond the surface of the endometrium
● They are soft, pliable and may be single or multiple
● Mostly arise from the fundus of the uterus
● They vary in size from a few millimeters to several
centimeters in diameter
● It is possible for a single large polyp to fill the endometrial
cavity
● They may be broad based termed sessile or attached to a
pedicle which is called pedunculated
● May protrude from the external cervical os
● Peak incidence is at 40-49 years old but can occur in all
age groups
● The cause of endometrial polyp is unknown but since it is
often
associated
with
endometrial
hyperplasia,
unopposed estrogen has been implicated
● Most common symptoms of endometrial polyps are
Menorrhagia, Premenstrual or postmenstrual staining
and Scanty postmenstrual spotting
➜ No single abnormal bleeding pattern is diagnostic
● Majority of endometrial polyps are asymptomatic
● Malignancy in an endometrial polyp is related to
➜ Patients age
➜ Most often low stage and grade
● Endometrial abnormalities associated with chronic
administration of the non-steroidal anti-estrogen Tamoxifen
include:
➜ Polyps
➜ Endometrial hyperplasia
➜ Endometrial carcinoma
DIAGNOSIS
● Endometrial polyps may be discovered by Transvaginal
ultrasound during diagnostic workup of an abnormal
uterine bleeding
➜ With or without hydrosonography
➜ Hysteroscopy
➜ Hysterosalpingography
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OBSTETRICS AND GYNECOLOGY II : Benign Gynecological Lesions 2
● Endometrial polyps are often confused with endocervical
polyps
● A well defined uniform hyperechoic mass that is <2cm
in diameter identified by transvaginal ultrasound within the
endometrial cavity is usually a benign endometrial polyp
DIFFERENTIAL DIAGNOSIS
●
●
●
●
●
Submucous leiomyoma
Retained products of conception
Endometrial hyperplasia
Carcinoma
Uterine sarcomas
MANAGEMENT
● Optimal management is removal by Hysteroscopy with
Dilation and Curettage
➜ Because of the common association of endometrial
polyps and other endometrial pathologic conditions
B. LEIOMYOMA/MYOMA
Figure 2. Leiomyomas
● Benign tumors of muscle origin
● Fibroids or fibromyomas are misnomers since they contain
vary amounts of fibrous tissue which is believed to be
secondary to the generation of some of smooth muscle
cells
● Most common benign neoplasm of the uterus
● Symptoms:
➜ Abnormal and excessive uterine bleeding
➜ Pelvic pain and pressure
➜ Bladder and bowel dysfunction
➜ Infertility, recurrent miscarriage
➜ Abdominal protrusion
● Risk factors: increasing age, early menarche, low parity
tamoxifen use, obesity, high fat diet
● African American women - highest incidence. This
appears to be a familial tendency to develop myoma.
● They have a limited malignant potential <1%
transformation to malignancy.
● Leiomyomas arise throughout the body in any structure
containing smooth muscle. In the pelvis the majority are
found in the corpus of the uterus.
12A
Module 16 - Trans 07
● Myomas may be single but most often are multiple. They
vary greatly in size from microscopic to multinodular uterine
tumors and literally fill the patient's abdomen.
● Myomas are classed into subgroups by their relative
anatomic relationship and position to the layers of the
uterus. The 3 most common types of myoma are
intramural, subserous and submucous.
➜ SUBMUCOSAL - Myomas located just below the
endometrium. They are clinically troublesome.
Submucosal tumors may be associated with abnormal
vaginal bleeding, or distortion of the uterine cavity that
may produce infertility or miscarriage. At times,
submucosal
myoma
enlarges
and
becomes
pedunculated. The uterus would try to expel it and the
prolapse myoma may protrude through the external
cervical os.
➜ SUBSEROSAL - Myomas beneath the serosa. They
gave the uterus the knobby contour during pelvic
examination. Further growth of a subserosal myoma may
lead to a pedunculated myoma wandering in the
peritoneal cavity. This myoma may outgrow its uterine
blood supply and obtain a secondary blood supply from
another organ such as the omentum and become a
parasitic myoma.
● The origin of uterine myomas is incompletely understood.
Cytogenetic studies show a single muscle cell, a progenitor
myocyte carrying multiple chromosomal abnormalities
which results from somatic mutation. The mutation
affects cytokine that affects cell growth. Growth may also
be influenced by levels of estrogen and progesterone
where receptors are found in higher concentration in uterine
myoma.
● Myomas are rare before menarche and diminish in size
after menopause. They often enlarge during pregnancy and
to oral contraceptive therapy.
● The severity of the discrepancy between its myomas
growth and blood supply determines the extent of the
generation namely degeneration of:
➜ Hyaline - mildest form
➜ Myxomatous, calcific, cystic, fatty
➜ Red or carneous - most acute form causing severe
pain and localized peritoneal irritation occurring during
pregnancy in approximately 5-10% of gravid women with
myoma.
● It is unknown as to whether myomas degenerate into
sarcomas given the very high prevalence of myomas. Most
investigators believe that sarcomas arise continuously from
myomatous uterine
● The possibility of a tumour being a leiomyosarcoma is 10x
greater in a woman in her 60s than in a woman in her 40s
SYMPTOMS
● Rapid growth of a myoma after menopause is a classic
symptom of a leiomyosarcoma
● Severity depends on number, location, and size of myomas
➜ Pressure from enlarging mass (most common)
➜ Pelvic mass
➜ Pain
➜ Dysmenorrhea
➜ Abnormal uterine bleeding (AUB)
● ⅔ of women with uterine myomas are asymptomatic
● Anterior myoma pressing on the bladder may produce
urinary frequency and urgency
● Large myomas and broad ligament myomas may produce
unilateral/bilateral hydroureter
● Most
common
abnormal
bleeding complaint is
menorrhagia
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➜ Intermenstrual spotting and disruption of normal
menstrual pattern are also common complaints
➜ Theorized because myomas result in abnormal
microvascular growth pattern, dysfunctional vessels,
and endometrial hyperplasia
DIAGNOSIS
● Clinical and Physical examination
● Palpation may show enlarged, firm, irregular uterus
● UTZ
➜ Can easily differentiate fibroids from a pregnant uterus or
adnexal mass
Module 16 - Trans 07
C. ADENOMYOSIS
● Derived from aberrant glands of the basalis layer of the
endometrium.
● The disease is associated with increased parity, particularly
uterine surgeries, and traumas
● Pathogenesis is unknown but theorized to be associated
with disruption of the barrier between the endometrium and
myometrium.
STANDARD CRITERION
● Endometrial glands and stroma
● >LPF (low power field) - 2.5mm from the basalis layer of the
endometrium
PATHOLOGIC PRESENTATIONS
Figure 3. Myomas on UTZ.
● Submucosal myomas may be diagnosed by vaginal UTZ,
sonohysterography, hysteroscopy, or as a filling defect
in hysterosalpingography
● There are two pathologic presentations of adenomyosis:
➜ Diffuse Adenomyosis
◆ Most common - diffuse involvement of both anterior
and posterior walls of the uterus
◆ Uniformly enlarged uterus, 2-3x the normal, and
difficult to distinguish from uterine leiomyomas Ultrasound appearance helps to distinguish the two
◆ Not encapsulated
DIFFERENTIALS
● Pregnancy, Adenomyosis, Ovarian Neoplasm
● Myxomatous uteri that extend laterally may make palpation
of normal ovaries difficult making the mass as to a myoma
or as to a ovarian neoplasm hard
➜ The mobility of the pelvic mass and wether the mass
moves independently or as part of the uterus may be
helpful diagnostically
TREATMENT AND MANAGEMENT
● Myomectomy
➜ Long standing infertility + recurrent miscarriages
➜ Submucous myoma that distort the uterine cavity are the
myomas that may affect reproduction
● For small, asymptomatic myomas
➜ Observation
● Myomectomy vs Hysterectomy
➜ Determined by age, parity, and reproductive plans
● Prolapse of a myoma through the cervix
➜ Removed through vaginal removal and ligation of the
base of the myoma with antibiotic coverage
● Medical Management - reducing the circulating estrogen
and progesterone (most of the size reduction occur w/in 3
months)
➜ GnRH agonist
➜ Medroxyprogesterone acetate (Depo-Provera)
➜ Danazol
➜ Aromatase Inhibitors
➜ Antiprogesterone RU 486
➜ After cessation of therapy, myomas gradually resume
their pretreatment size. By 6 months after treatment,
most myomas will have returned to their original size.
● Surgery
➜ No validated medical treatment is yet able to eliminate
fibroids therefore surgery is the most effective treatment
for symptomatic fibroids.
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Figure 4. Diffuse Adenomyosis
➜ Adenomyoma
◆ Focal area
◆ Asymmetric uterus
◆ Pseudocapsule
Figure 5. Adenomyoma
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SYMPTOMS
Module 16 - Trans 07
HYDATID CYST OF MORGAGNI
● Secondary dysmenorrhea - increases with disease
progression
● Menorrhagia
● Symptomatic adenomyosis usually presents in women
between the ages of 35-50.
● Ultrasound and MRI - differentiate adenomyosis and uterine
myomas in a young woman desiring future childbearing
MANAGEMENT
● No proven satisfactory medical treatment
● Hysterectomy - definitive treatment (if appropriate for
woman’s age, parity, and plans for future reproduction)
PREGNANCY
● Women who became pregnant with adenomyosis are at
increased risk of pregnancy complications such as:
➜ Premature labor and delivery
➜ Low birth weight
➜ PPROM (preterm premature rupture of membranes)
PART 5
II. FALLOPIAN TUBES
A. PARATUBAL CYST
● Often incidental discoveries during gynecologic
operations for other abnormalities and during ultrasound
● Commonly multiple and size varies from 0.5cm - > 20 cm in
diameter
● Most cyst are small, asymptomatic,and slow growing and
occur during the third and fourth decade of life
Figure 7. Hydatid cyst of Morgagni
● Pedunculated paratubal cysts near the fimbrial end of the
fallopian tube
● Translucent
● Contain a clear or pale yellow fluid
● Symptom: dull pain
● PARATUBAL CYST VS. OVARIAN MASS
➜ Pelvic examination: The distinguished paratubal cyst
from an ovarian cyst is difficult
➜ Intraoperatively, the oviduct is found stretched over a
large paratubal cyst; in such a case, the oviduct should
not be removed as it will return to its normal size after the
paratubal cyst is excised
● PARATUBAL CYST IN PREGNANCY
➜ May grow rapidly in pregnancy as it increases the
number of torsion of the cyst during pregnancy of the
puerperium
➜ Treatment: Excision
B. ACUTE TORSION
Figure 6. Paratubal Cyst
Figure 8. Torsion
Rare
Occurs in both normal and abnormal ovarian tubes
Pregnancy is a predisposing
Tubal torsion usually accompanies torsion of the ovary
because they have a common vascular pedicle
● Torsion of the fallopian tube is secondary to an ovarian
mass in 50-60% of patients
● Right fallopian tube torsion is more common than the left
● Intrinsic causes:
1. Congenital Abnormalities
- Increased tortuosity caused by excessive length of
the tube
●
●
●
●
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● Pathologic processes:
1. Hydro/hematosalpinx
2. Tubal Neoplasms
3. Tubal ligation
- Distal end is most commonly affected
● Symptoms
➜ Acute lower abdominal and pelvic pain
➜ Most common important symptom
➜ Sudden onset (usually), but also be gradual
➜ Pain usually located in the right iliac fossa with radiation
to the thigh and flank
➜ Duration of pain occurs less than 48 hours
➜ Associated with nausea and vomiting in 2/3 of cases
➜ Pain secondary to hypoxia. It is intense that adequate
pelvic examination is difficult to perform
➜ A Specific mass is impalpable unless there is associated
torsion of the ovary
● Diagnosis
➜ Preoperative diagnosis has increased due to
Transvaginal ultrasound
● Differential Diagnoses
1. Acute Appendicitis
2. Ectopic Pregnancy
3. Pelvic Inflammatory Disease
4. Rupture/Torsion ovarian cyst
● Treatment
1. Excision of gangrenous tubes
2. Untwisting
- Twisted tubes were usually filled with bloody or
serous fluid
- Manual untwisting can possibly restore circulation
3. Suture
- Tube is sutured to a secured position to prevent
recurrence
C. ADENOMATOID TUMOR
Module 16 - Trans 07
● Ovarian masses are common findings on pelvic examination
and pelvic imaging. The task of the clinician is to determine
whether the mass should be removed or managed
expectantly. Symptoms from the mass, its spontaneous
resolution, nature whether benign or malignant are the
factors to consider. Three functional cysts will be discussed.
Figure 10. Ovary
A. FUNCTIONAL CYSTS
FOLLICULAR CYSTS
● Most common cystic structures in normal ovaries. They
may be present as early as 20 weeks gestation in female
fetuses and throughout a woman's reproductive life
● Often multiple, ranging from few mm to large as 15 cm in
diameter
● Not neoplastic and Dependent on gonadotropins for
growth
● They are translucent, thin walled and filled with a watery,
clear to straw colored fluid
● Result from either the Dominant mature follicles failing
to rupture termed as persistent follicle or an immature
follicle failing to undergo the normal process of atresia
Figure 9. Adenoid Tumor
●
●
●
●
Most prevalent tumor of the oviduct
Also known as Angiomyoma
Nodule measuring 1-2 cm in diameter
Usually unilateral under the tubal serosa and they do not
produce pelvic symptoms.
● No malignant transformation- This tumors does not
become malignant, however may be mistaken for neoplasm
during frozen section
PART 6
III. OVARY
12A
Figure 11. Follicular cyst
A. MANIFESTATION
● Asymptomatic and are discovered during ultrasound
imaging or a routine pelvic examination
● Menstrual irregularities and Abnormal uterine bleeding
may be associated which produce elevated blood estrogen
levels . this is manifested as regular cycle with prolonged
intermenstrual interval followed by menorrhagia or heavy
menstrual bleeding
● Larger follicular cyst may cause vague, dull sensation or
heaviness in the pelvis of some woman
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B. MANAGEMENT
● Initial management of suspected follicular cyst is
conservative observation. Majority of them disappears
spontaneously by either reabsorption of the cyst fluid or
silent rupture within 4-8 weeks of initial diagnosis
● Transvaginal ultrasound
➜ Examination helps in differentiating simple vs complex
cyst
➜ Provide dimension if the cyst is increasing in size during
conservative management
➜ Removal of cyst
◆ When the diameter of the cyst remains stable for >10
weeks or enlarges neoplasia should be ruled out
◆ The evaluation of an asymptomatic cyst found
incidentally is based on the principle that the cyst
should be removed if there is suspicious of
malignancy
◆ In most cases simple small cyst may be observed
◆ In general, complex cyst or persistent simple cyst
which are >10 cm should be evaluated
◆ A cyst in a perimenopausal or postmenopausal
woman should be removed if the cyst is not simple
➜ Abnormal CA-125 >35 units/mL
➜ Persistent cyst
➜ Cyst >10cms
➜ Observation
◆ Simple cyst
◆ Cyst <5 cms
◆ Normal CA-125
◆ Follow up ultrasound with CA-125 testing every 6
months for 2 years
◆ If unchanged, routine monitoring can be stopped
➜ Cystectomy
◆ In premenopausal women with non-malignant cyst
CORPUS LUTEUM CYSTS
● Less common, clinically more important
● Corpora lutea of at least 3 cm in diameter
● May be associated with either normal endocrine function or
prolonged progesterone secretion
● Associated menstrual pattern
➜ Normal
➜ Delayed menstruation (several days to weeks)
➜ Amenorrhea
● Most corpus luteum cyst are small
➜ The average diameter being 4 cm
● Symptoms vary from asymptomatic masses to massive
intraperitoneal bleeding associated with rupture
● Produce dull, unilateral lower abdominal and pelvic pain
● The enlarged ovary is moderately tender on pelvic
examination
PATHOGENESIS
Corpora lutea develop from mature graafian follicles
Intrafollicular bleeding does not occur during ovulation
However, 2-4 days later, during the stage of vascularization,
thin-walled capillaries invade the granulosa cells from the
theca interna
● Spontaneous but limited bleeding fills the central cavity of
the maturing corpus luteum with blood
● Subsequently, this blood is absorbed forming a small
cystic space
➜ When the hemorrhage is excessive, the cystic space
enlarges
➜ If the hemorrhage is brisk, intracystic pressure increases
and rupture of the corpus luteum is a possibility
➜ If rupture does not occur, the size of the resulting corpus
luteum cyst usually varies between 3-10 cms
B. HALBAN’S CLASSIC TRIAD
● Syndrome of a persistently functioning corpus luteum cyst
● TRIAD: Delayed menses followed by spotting, Unilateral
pelvic pain, Small tender adnexal mass
C. MANAGEMENT
● Transvaginal ultrasound: useful in establishing a
pre-operative diagnosis
● Cystectomy: operative treatment of choice with
preservation of the remaining portion of the ovary
● Conservative: for unruptured corpus luteum cyst
THECA LUTEIN CYSTS
● Least common of the three types of physiologic ovarian
cyst
● Arised from prolonged/excessive stimulation of the ovaries
endogenous or exogenous gonadotropins or increased
ovarian sensitivity to gonadotropins
● Almost always bilateral
● Produce moderate to massive enlargement of the ovaries
● Hyperreactio luteinalis
➜ Condition of ovarian enlargement secondary to the
development of multiple luteinized follicular cysts
● Approximately 50% of molar pregnancies and 10% of
choriocarcinomas have associated bilateral theca lutein
cyst
➜ In these patients, the hCG from the trophoblasts
produces luteinization of the cells in immature, mature,
and atretic follicles
● The cysts are also discovered in the later months of
pregnancy such as twin gestations, diabetes and RH
sensitization
● Women receiving medications to induce ovulation
iatrogenically produce theca lutein cyst
FIgure 12. Theca Lutein Cyst
A.
●
●
●
12A
Module 16 - Trans 07
Lifted from Dr. Opulencia’s lecture 2023
● MANIFESTATION
➜ Asymptomatic
➜ Pelvic Pressure
➜ Ascites
➜ Increasing abdominal girth
➜ The smaller cysts are usually asymptomatic. However,
the larger cysts produce a sense of pelvic pressure.
Ascites and increasing abdominal girth may also be
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Module 16 - Trans 07
seen. Some cysts may persist even when the HCG
levels become normal.
FIgure 15. Germ Cell Tumor
DERMOID CYST
FIgure 13. Theca Lutein Cyst
● Grossly, the external surface of the ovary appears lobulated
and the small cysts contain a clear to straw colored or
hemorrhagic fluid.
D. DIAGNOSTICS
● Palpation - establish presence of theca lutein cyst
● Ultrasound examination - confirmatory
● 80% of dermoids are <10cm in diameter and often
pedunculated
● The cyst makes the ovary heavier than normal thus they
are usually discovered either in the cul-de-sac or anterior to
the broad ligament
● On palpation, these tumors both have cystic and solid
components have a doughy consistency
● Unilocular
● Walls are smooth, shiny, opaque white in color
● When open, takes sebaceous fluid pours with tangled
masses of hair and firm areas of cartilage and teeth
➜ The sebaceous material is a thick fluid at body
temperature but solidifies when it cools in room air
FIgure 14. Ultrasound of Theca Lutein Cyst
B. MANAGEMENT
● Conservative because theca lutein cyst gradually regress
B. GERM CELL TUMORS
Figure 16. Dermoid Cyst
BENIGN CYSTIC TERATOMA
● Among the most common ovarian neoplasm
● 90% germ cell tumors of the ovary
● Slow growing tumors occurring from infancy to post
menopausal years
● Usually cystic structures that in histologic examination
contain elements from all 3 germ layers
● Teratomas from the ovary may be:
➜ Mature teratomas - benign, composed of mature cells
➜ Immature teratoma - malignant, composed of immature
cells
12A
A. PATHOGENESIS
● Dermoid begins in fetal life some time after the first
trimester
● Belief to arise from a single germ cell after the first
meiotic division
● They developed from totipotent stem cells and they are
neoplastic sequelae from a transformed germ cell
● They have a chromosomal makeup of 46 XX
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MATURE CYSTIC TERATOMAS
● Prominence or Tubercle of Rokitansky
➜ protrusion or nipple (mammilla) in the cyst wall where
most solid elements arise and are contained
➜ may be visualized by ultrasound as an echodense region
aiding in the sonographic diagnosis
Module 16 - Trans 07
B. COMPLICATIONS
● Specific complications
➜ torsion
➜ rupture
➜ infection
➜ hemorrhage
➜ malignant degeneration
● Struma ovarii
➜ a teratoma in which the thyroid tissue has overgrown
other elements and is the predominant tissue
➜ Less than 5% of women with struma ovarii develop
thyrotoxicosis
◆ may be secondary to the production of increased
thyroid hormone by either the ovarian or the thyroid
gland
FIgure 17. Prominence of Tubercle of Rokitansky (yellow
asterisk)
● Characteristic ultrasound picture
➜ a dense echogenic area within a larger cystic area
➜ a cyst filled with bands of mixed echoes
➜ an echoic dense cyst.
Figure 19. Struma Ovarii
● Rupture
➜ perforation of the contents of a dermoid into the
peritoneal cavity or an adjacent organ
➜ potentially serious complication
➜ may occur:
◆ Catastrophically - produces an acute abdomen
◆ By a slow leak of the sebaceous material - produces a
severe chemical granulomatous peritonitis
● Torsion
➜ most common complication
➜ Because of its weight, the benign teratoma is often
pedunculated, which may predispose to torsion
Figure 18. Ultrasound findings of a dermoid cyst.
A. MANIFESTATION
● Asymptomatic
➜ 50% to 60% of dermoids are discovered during a routine
pelvic examination
➜ coincidentally visualized during pelvic imaging, or found
incidentally at laparotomy
● Presenting symptoms include pain and the sensation of
pelvic pressure
● Three medical diseases also may be associated with
dermoid cysts
➜ thyrotoxicosis
➜ carcinoid syndrome (Rare)
➜ autoimmune hemolytic anemia (Rare)
12A
C. MANAGEMENT
● Cystectomy
➜ Operative treatment
➜ with preservation of as much normal ovarian tissue as
possible
● Conservative Management
➜ When a teratoma is diagnosed incidentally during
pregnancy
➜ Dermoids have a higher incidence of torsion and potential
for rupture during pregnancy
➜ Aggressive approach to asymptomatic teratomas less
than 10 cm offers NO ADVANTAGE for the mother or
pregnancy
● Cystectomy with a small periumbilical minilaparotomy
➜ for symptomatic teratomas needing surgical intervention
during pregnancy
➜ faster, less traumatic approach
➜ reduced intraoperative time
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C. SEX CORD STROMAL TUMORS
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FIBROMA
●
●
●
●
●
Most common benign solid neoplasm of the ovary
Low malignant potential - 1%
Size varies from small nodules to huge pelvic tumor
Extremely slow growing tumors
Diameter of a fibroma is important clinically
➜ incidence of associated ascites is directly proportional to
size of tumors
● Misdiagnosed as leiomyoma preoperatively
● Average age of a woman with an ovarian fibroma is 48 and
often presents in post menopausal women
● Arise from the undifferentiated fibrous stroma of the ovary
A. PELVIC SYMPTOMS
● Pressure
● Abdominal Enlargement
➜ Both may be due to the size of the tumor and ascites
● Meig’s Syndrome
➜ Association of an ovarian, ascites and hydrothorax
➜ Both the ascites and hydrothorax resolve after the
removal of the ovarian tumor
➜ Ascites results from transudation of fluid from the ovarian
stroma
➜ Hydrothorax is due to the flow of ascitic fluid into the
pleural space via the lymphatics of the diaphragm
Figure 21. Serous Cystadenoma
MUCINOUS CYSTS
● 2nd most common epithelial tumor that occurs in the
reproductive age group
● Size vary
● Consists of epithelial cells that resemble the endocervix or
mimic intestinal cells and contain mucin
Figure 20. Meig’s Syndrome
B.
●
●
●
GROSS APPEARANCE
Heavy and solid
Well encapsulated and grayish white
A cut surface demonstrate a homogenous white or
yellow-white solid tissue with trabeculated/whorled
appearance similar to that of myomas
C. MANAGEMENT
● Management is straightforward in a sense that any woman
with a solid ovarian neoplasm should have an exploratory
operation soon after the tumor is discovered
● Simple Excision
➜ There is resolution of all symptoms including ascites
● TAHBSO
➜ Since this is commonly discovered in menopausal
women, often a bilateral salpingo oophorectomy and total
abdominal hysterectomy are performed
D. EPITHELIAL CELL TUMORS
Figure 22. Mucinous Cyst
SEROUS CYSTADENOMA
● Most common epithelial tumors during reproductive
years
● Consisting of epithelial cells resembling the fallopian tube
and containing serous fluid
● Usually asymptomatic
● Present as a unilateral adnexal mass
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● Pseudomyxoma Peritonei
➜ complication of mucinous cystadenoma secondary to
perforation and rupture of the cyst, which can lead to the
deposit and growth of mucinous-secreting epithelium in
the peritoneal cavity
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Module 16 - Trans 07
end of the oviduct measuring 0.5 cm. What is the MOST likely
diagnosis?
a. Corpus luteum cyst
b. Follicular cyst
c. Adenomatoid tumor
d. Hydatid cysts of Morgagni
Answer: b, d, b
A. PAST EXAM (2023)
*different lecturer*
Figure 23. Pseudomyxoma Peritonei
A. TREATMENT
● Cystectomy or Oophorectomy for those who have not
completed family life
● TAHBSO for postmenopausal women
V. SUMMARY
● Common benign gynecologic lesions in the female
reproductive tract (vulva, vagina, cervix, uterus, fallopian
tubes, ovaries) in terms of their clinical manifestations,
differential diagnoses, appropriate diagnostic examination,
treatment and complications.
REFERENCES
● Dr. Maria Carmelita J. Nadal-Santos’s Lecture on Benign
Gynecological Lesions 2
● Comprehensive Gynecology, Lentz et al., 8th edition,
Chapter 18
TRANSCRIBERS
● Group 12A
PROOFREADERS
● MCD, VS
REVIEW QUESTIONS
A. LECTURE
*Answer at your own risk*
1. A 25 year old nulligravid presented with pelvic pressure.
Transvaginal ultrasound revealed a 7 x 5 cm adnexal unilocular
cystic mass with bands of mixed echoes. What is the MOST
likely diagnosis?
a. Ovarian carcinoma
b. Mature cystic teratoma
c. Paratubal cyst
d. Serous cyst adenoma
2. A 55 year old underwent hysterectomy due to heavy
menstrual bleeding and pelvic pain. Upon cut section of the
uterus, the masses were pearly white in appearance with whorl
like configuration. What is the MOST likely diagnosis?
a. Adenomyosis
b. Uterine carcinoma
c. Leiomyosarcoma
d. Leiomyoma
3. A 35 year old, G3P2 underwent elective repeat cesarean
section. There was an incidental finding of pedunculated thin
walled translucent cyst containing clear fluid near the fimbrial
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1. A child was brought at the ER because of straddle injury.
Initial examination showed a tender four-centimeter right vulvar
hematoma and a noticeable increased in size after two minutes
of observation. What is the next best step in the management?
a. Send the patient home and place ice compress
b. Surgical exploration
c. Continue observation and assure the patient
d. Start antibiotic analgesics
2. A 3- week-old female neonate has a 4 centimeter cyst in the
lower abdomen as seen by ultrasound. Which of the following
is the recommended management?
a. Monthly ultrasound monitoring
b. Laparoscopic resection
c. Reassure the mother for spontaneous resolution
d. Correlation with serum tumor markers
3. A 16-year-old female is undergoing an operation for a 7
centimeter dermoid cyst. What is the ideal procedure for this
case?
a. Oophorectomy
b. Oophorocystectomy plus sampling of the normal
contralateral ovary
c. Salpingo-oophorectomy
d. Ovarian cyst resection
4. A 31-year old nulligravid presented with transvaginal
ultrasound results of 12x10x10 cm left ovarian cyst with
homogeneous low-level echoes. What is the appropriate
management?
a. Oral contraceptives pills
b. GnRH antagonist
c. Ovarian cystectomy
d. Oophorectomy
5. A 44-year-old G0 consulted for irregular vaginal bleeding.
She is obese and is a known diabetic maintained on metformin
for the past 2 years. She had a transvaginal ultrasound done
revealing a thickened endometrium. There is also a well
circumscribed heterogeneous structure at the anterior wall
measuring 1x2 cm. Bilateral ovaries have multiple follicles
(>20) each <1cm in diameter. Which among the following
would be the most probable explanation for the patient's type
of abnormal uterine bleeding?
a. There is sustained exposure of the endometrium to
estrogen causing it to outgrow its blood supply
b. There is an increase in the overall surface area of the
endometrial cavity.
c. There is increased uterine prostacyclin causing altered
uterine contractility and platelet aggregation
d. There is altered uterine contractility
6. A 42-year-old G3P3 (3003) consulted for profuse vaginal
bleeding.
Bleeding
started
when
a fleshy mass
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suddenlyprotruded out of her vagina. Internal examination
showed a smooth doughy mass protruding out of the vagina
which seems to originate from within the uterine cavity. The
mass easily bleeds to touch. Which among the following would
be the most probable explanation for the patient's type of
abnormal uterine bleeding?
a. There is increased uterine prostacyclin causing altered
uterine contractility and platelet aggregation
b. There is sustained exposure of the endometrium to estrogen
causing it to outgrow its blood supply
c. There is altered uterine contractility
d. There is increase in the overall surface area of the
endometrial cavity
7. A 37-year-old G5P5 presented with a 3 x 3 cm painless
cystic mass at the 7 o’clock position of the vulva. What is the
appropriate management?
a. Excision
b. Observation
c. Antibiotics
d. Incision and Drainage
8. What is the benign solid tumor of the vulva that arises from
the deeper connective tissue?
a. Adenomatoid tumor
b. Lipoma
c. Bartholin’s cyst
d. Fibroma
9. What is the most likely diagnosis of a 2 x 2 cm soft mass
located periclitorally?
a. Lipoma
b. Gartner’s cyst
c. Fibroma
d. Bartholin’s cyst
10. A 30-year-old G3P3 presented with a 4 x 4 cm soft mass
within the labia majora of 2 years duration. What is the
appropriate management?
a. Lipoma
b. Hemangioma
c. Bartholin’s cyst
d. Hematoma
12. A 28-year-old G1P1 consulted for Pap smear. PE showed
a mediolateral episiotomy scar and a 1 x 1 cm soft light-yellow
mass at the right lateral vaginal wall. What is the most likely
diagnosis?
a. Mucinous cyst
b. Sebaceous cyst
c. Inclusion cyst
d. Mucous cyst
13. A 32-year-old nulligravid for Pap smear had an incidental
finding of a painless sausage-shaped cystic mass at the left
lateral lower third of the vagina. What is the most likely
diagnosis?
a. Observation
b. Complete surgical excision
c. Excision biopsy
d. Vulvectomy
11. A 2-year-old child was brought to the ER due to fall. PE
showed a 3 x 2 cm tender bluish mass on the left vulva. What
is the most likely diagnosis?
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OBSTETRICS AND GYNECOLOGY II : Benign Gynecological Lesions 2
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cyst (D in image). What is the appropriate management for the
cyst?
a. Gartner duct cyst
b. Bartholin’s duct cyst
c. Cystocoele
d. Enterocoele
14. A 40-year-old G3P3 presented with a painful and tender
cystic fluctuant mass at the right lateral vaginal wall. What is
the appropriate management?
a. Excision
b. Incision and drainage
c. Marsupialization
d. Analgesics
15. What is the management of asymptomatic translucent
cysts in the cervix?
a. Electrocauterization
b. No treatment
c. Cryotherapy
d. Incision and drainage
16. A 31-year-old multipara consulted because of postcoital
bleeding. On speculum examination, a 2 x 1 cm reddish mass
is seen protruding out of the external cervical os with light
yellow vaginal discharge. What is the appropriate
management?
a. Observation
b. Polypectomy
c. Gram stain
d. Pap smear
17. A 30-year-old G2P2 presented with dysuria and urgency. IE
revealed a 3 x 3 cm firm mass in the anterior cervical lip. What
is the most likely diagnosis for the mass?
a. Endocervical polyp
b. Cervical polyp
c. Cervical myoma
d. Nabothian cyst
a. Aspiration
b. No treatment
c. Excision
d. Salpingectomy
20. A 28-year-old G1P1 presented with sudden right lower
quadrant pain after shifting position while sleeping. IE: cervix
closed, corpus small, 6 x 6 cm tender right adnexal cyst.
Transvaginal ultrasound result is a 6 x 6 cm thin walled
unilocular anechoic cyst with whirlpool pattern by color Doppler
no on the right adnexa. What is the most likely complication of
the cyst?
18. A 45-year-old G5P5 consulted because of chronic pelvic
pain of 6 months duration associated with intermittent vaginal
spotting after she underwent electrocauterization of the cervix.
Transvaginal ultrasound showed hematometra and normal
ovaries. What is the most likely diagnosis?
a. Hemorrhage
b. Rupture
c. Torsion
d. Infection
21. What is the most prevalent benign tumor of the Fallopian
tube?
a. Adenomatous tumor
b. Angiomyoma
c. Hydatid cyst of Morgagni
d. Fibroid
a. Cervical agenesis
b. Endometriosis
c. Vaginal agenesis
d. Cervical stenosis
19. During a primary cesarean delivery for breech primi,
inspection of the adnexa revealed a 15 x 12 cm left paratubal
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22. A 60-year-old asymptomatic menopause had an ultrasound
result of a left simple ovarian cyst measuring 4.5 cm. What is
the appropriate management?
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a. Perform hysterectomy with bilateral salpingo-oophorectomy
b. Request for CA-125
c. Repeat ultrasound after 3 months
d. Perform salpingo-oophorectomy
c. Conservative
d. Thoracostomy
23. A 28-year-old G2P2 presented with vaginal spotting, left
lower quadrant pain after 6 weeks of amenorrhea. IE: cervix
closed, corpus small, 3cm tender left adnexal mass.
Pregnancy test is negative. What is the most likely diagnosis?
a. Corpus luteum cyst
b. Follicular cyst
c. Serous cyst
d. Theca lutein cyst
answers: 1b, 2a, 3d, 4c, 5a, 6d, 7b, 8d, 9a, 10b, 11d, 12c, 13a,
14c, 15b, 16b, 17c, 18d, 19c, 20c, 21b, 22b, 23a, 24c, 25c,
26d, 27c
De La Salle Medical and Health Sciences Institute
College of Medicine
BATCH 2024
24. A 37-year-old infertile nulligravid preseted with mild
hypogastric pain 2 weeks after taking ovulation induction
medication. Transvaginal ultrasound showed 8x8 cm bilateral
multilocular cysts. What is the appropriate management?
a. Bilateral salpingo-oophorectomy
b. Bilateral ovarian cystectomy
c. Conservative
d. Combined oral contraceptive
25. What will be the size of a benign teratoma in mm after 10
years if the present size is 20mm?
a. 35
b. 55
c. 40
d. 22
26. A 48-year-old asymptomatic, menopause for 2 years
presented with a right lower quadrant mass. IE: cervix closed,
corpus small. normal left ovary and right 10cm movable solid
mass. Transvaginal ultrasound result was normal uterus and
left ovary and a 10x10 cm right solid ovarian new growth. What
is the most likely diagnosis?
a. Benign teratoma
b. Pedunculated myoma
c. Brenner’s tumor
d. Ovarian fibroma
27. What is the appropriate management in a patient
diagnosed with Meig’s syndrome experiencing dyspnea due to
bilateral hydrothorax?
a. Thoracotomy
b. Pleurodesis
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