Histo-physiological characteristics of the cervix in different periods of age
The portion of the cervix that projects into vagina is covered with stratified squamous
epithelium, which resembles the vagina epithelium. This portion is called exocervix. It
is very easy to examine it in a speculum. Exocervix is covered by mucous membrane of
pink colour with smooth shining surface. Endocervical portion is situated above vaginal
portion of cervix and is called endocervix. Cervical canal is covered by single columnar
epithelium, which is placed on lamina propria. Epithelium forms the crypts that form
cervical glands. Mucous membrane of the cervical canal is bordered from the side of
isthmus by histological internal uterine os, and outside by the region of external cervical
os.
The cervix is covered by two genetically different types of epithelium. The squamous
epithelium changes to a simple columnar epithelium in the transition zone. In infant
squamocolumnar junction is situated on the ectocervix surface. This zone is found at
about the level of the external cervical os in the juvenile period and puberty. In the
majority of them in adolescence it is situated on the level of external os of cervical
canal, however, approximately in 30 % of young women the junction zone is found
outside the external os. Although, it is found higher from the endocervical canal in
menopausal and postmenopausal women. This zone comes to lie upward into the
endocervical canal, often out of direct visual contact.
So, presence of the "garland" of columnar epithelium around the external cervical os in
women before 20-21 years, that is interpreted by some authors as «congenital erosion»,
is not a pathological phenomenon. It does not require treatment, especially
electrocoagulation.
However, if ectopic epithelium undergoes harmful influences, especially mechanical
traumatization (early begining of sexual life, induced abortions), infection, caused by
associations of microorganisms and viruses (which happens at frequent change of
sexual partners), the part of exocervical epithelium can be transformed into metaplastic
flat one with formation of new junction zone. Metaplastic changes take place in this
zone. This region is called transformation zone. In some patients carcinogen exposure
may cause the abnormal maturation process at the transformation zone and begin the
process of intraepithelial neoplasia.
BENIGN CERVICAL LESIONS
True cervical erosion
True cervical erosion is a pathological process,which is a result of damage and
following exfoliation of original stratified squamous epithelium. Absence of epithelium
on cervical vaginal part appears. Most frequently endocervicitis and endometritis are the
causes of true erosions. The area of epithelial defect is exposed to purulent secretions
and irritants which are common in endocervicitis and endometritis, cause secondary
inflammation and exfoliation of epithelium from cervical surface. Harmful examination
can cause traumatization of the cervical epithelium.
Clinic. Main clinical signs are chiefly the features of the basic disease. Patients
complain on purulent discharge which is common after gynecological examination and
sexual intercourse (contact bleeding).
Diagnosis is based on data of clinical picture, colposcopy, and cytological examination.
Erosion is revealed during speculum examination. The fleshy reddened tissue area on
the posterior (more rarely than on anterior) cervical lip and concomitant bleeding are
common. Erosion fundum is swollen by the connective tissue with subepithelial vessels.
Colposcopic criteria such as inflammatory changes, abnormal vascular patterns, vessel
dilation, edema, and fibrin precipitation on erosion surface help to identify such areas.
This disease is referred to the short-term processes, true erosion exists no longer than
for 2-3 weeks. There is the epithelium defect owing to neogenic squamous columnar
epithelium. Due to the fact that columnar epithelium has higher regenerative ability,
than the squamous one, predominate part of true erosion is replaced by single columnar
epithelium thanks to growing on its surface from the cervical canal. The process
transforms into the following stage called pseudoerosion.
Treatment Treatment of diseases which cause the formation of true cervical erosion.
Doctor determines the pathogenic organism and prescribes treatment directed on its
elimination and decreasing of inflammatory reaction in tissues. Optimal conditions for
erosion elimination are created. Tampons with cod-liver oil, dog-rose and sea-buckthorn
oil should be used. Laser therapy for increasing the regenerative ability of the cervical
tissue and improving the organic specificity of neogenic epithelium is indicated.
Helium-neon or semi-conductor lasers are applied for this purpose. Each region is
exposed to rays during 1-2 minutes, general exposition is 6-8 minutes. Treatment course
takes 6-8 days.
Cervical pseudoerosion
Cervical pseudoerosion is a benign pathological process, which is characterised by
presence of original columnar endocervical tissue on exocervical surface.
The disease is polyetiologic. Hormonal correlation in female organism play role in
appearing of cervical pseudoerosion. Autoimmune theory of cervical pathology
pathogenesis has proved the connection between local humoral immunity with the
degree of morphological changes in cervix. It confirms possible effect of
immunoglobulins of different classes on appearing and progressing of benign lesions.
Congenital, posttraumatic and dyshormonal ectopia are distinguished. Pseudoerosion is
formed from the true one when the columnar epithelium spreads on the devoided of
stratified squamous epithelium exocervical surface canal. The reserve cells, which are
situated under epithelium of cervical canal and its glands (crypts) are the source of
ectopic (placed outside the borders of its usual localization) epithelium. Cervical
epithelium regeneration passes from these undifferentiated elements. Having
biopotential properties reserve cells can transform both into columnar and into
squamous epithelium. Columnar epithelium penetrates deep in, forming ramified
glandular passages, reminding the glands of mucous membrane of cervical canal. The
glands produce mucus that is exuded by excretory ducts. As a result of ducts closing
during epidermization process mucus accumulates inside the glands. Retention cysts,
so-called Nabothian cysts are formed. Their dimensions are different, they shine
through cervical epithelium as yellow humps.
Papillary, follicular, glandular and mixed pseudoerosions are distinguished according to
morphological signs.
Clinic. Usually patients have no complaints. There can be complaints on vaginal
discharge, pain in lower abdomen, sometimes contact bleeding as a result of presence of
concomitant diseases (inflammatory processes of the uterus, adnexa, vagina). Speculum
examination reveals on its back lip a spot of red colour, from 3-5 to 30-50 mm in size
with "velvet" surface. In touch it slightly bleeds around external cervical os.
Diagnosis is based on the data of speculum cervical examination, simple and broadened
colposcopy and biopsy. During the simple colposcopy one can see acinar accumulation
of scarlet and long papillae. The papillae become more relief, pale and acquire clear
appearance, reminding a bunch of grapes, as a result of momentary vessels' constriction
and epithelium edema during broadened (after applying on erosion surface 3% solution
of acetic acid) colposcopy
The erosion has lightly-pink colour during the Shiller's test (applying on the cervix 3%
Lugol's iodine solution or 5% spirit iodine solution). This test gives a possibility to find
the most altered epithelium areas for taking biopsy by scalpel or special instruments.
The biopsy material is fixed in 5-10% formalin solution and is sent to laboratory.
Treatment. The underlying concept in the treatment of benign cervical lesions is in
excision or removal of the superficial precursor lesion avoiding progression to
carcinoma:
 women with congenital epithelial ectopy are subject to supervision till 23 years.
They need no treatment
 treatment of erosions begins from the treatment of diseases, such as endocervicitis, endometritis, salpingoophoritis, ectropion, vaginitis, endocrine disorders.
Etiotropic treatment should be prescribed after authentication of the pathogenic
organism. It depends on its species (trichomoniasis, chlamidiosis, gonorrhoea).
 stimulation of regenerative process of stratified squamous epithelium by
application tampons, moistened with cod-liver oil, dog-rose and sea-buckthorn oil
to the cervix after elimination of inflammatory process in vagina, and laser
therapy by Helium-Neon or semiconductor lasers — ANP-2, Lika-3 should be
used. Treatment course takes 6-8 days
 medical destruction of pathological substratum by the following remedies such as
Solcovagyn (Solcogyn), Vagotyle, or electrocoagulation, cryodestruction of
erosive surface should be performed if after concervative therapy erosion doesn't
heel over. The biopsy is recommended before electrocoagulation or
cryodestruction
 radical surgical intervention is recommended (cone-biopsy or cervical
amputation)
The polyps of mucous membrane of cervical canal
The polyps of mucous membrane of cervical canal are created from the mucous of the
external os, middle or upper third part of endocervix. They can have a pedicle or wide
base. Depending on the dominance in their structure of glandular or connective tissue
glandular,
glandular-fibrose
and
adenomatous
polyps
morphologically
are
distinguished. Their consistency also depends on the tissue presence (dense in fibrous
polyps and soft in glandular ones). A polyp colour depends on its blood supply. At
sufficient blood supply polyp has pink or pale pink colour. Polyp can be changed from
red to cyanotic in such complications as hemorrhage, necrosis and inflammation.
Clinic. Polyps are common in 40 aged women. The uncomplicated polyps have no
symptoms, they are found mostly during monitoring. Mucous or insignificant bloody
discharge from vagina can appear in some women.
Diagnosis. During speculum examination the rounded formation, that is situated in the
cervical canal is visualized. The colposcopy should be performed for specification of
diagnosis. If polyp is covered with columnar epithelium, then during the broadened
colposcopy it has a typical papillary surface; if polyp is covered by stratified squamous
epithelium (epidermal polyp) then its surface is smooth with divaricated vessels. The
polyps, originating from mucous membrane of endocervix aren't tinctured by Lugol's
iodine solution.
Treatment The polyp is removed by screwing it off with the following coagulation of
its pedicle, if its base is visible. If polyp pedicle's base is situated inside the cervical
canal, endocervical curettage with the following histological examination is performed.
Cryodestruction of polyp's base is indicated. Patients need consultation of
oncogynecologist in the case of polyp's recurrence.
Cervical papilloma
This disease is caused by human papillomavirus (HPV). There are 18 types of
papillomavirus, but only some of them are able to cause lesion of female sexual organs.
The HPV-infections most frequently occur in young women which are relating to early
sexual life and neglecting the rules of personal hygiene.
There are three types of HPV-lesions of the cervix:
 condyloma acuminata (exophytic type)
 condyloma lata
 inverted ones (endophytic type)
There are no clinical signs specific for HPV-infection. It is manifested by signs of
vaginitis such as discharge from genital tract and itching. Papillomas are found during
pelvic examination or during speculum examination of the cervix. Typical cytological
sign of viral invasion are the phenomena of koilocytosis, that is found as enlightening of
the cytoplasm around the nucleus.
Treatment. Papillomatous growth of large sizes requires the biopsy. Laser coagulation
by high-intensive laser or cryodestruction by liquid Nitrogen should be performed after
this. Small excrescences on the pedicle are treated by means of electrocoagulation of
papilloma's pedicle with the following histological research of the tissue taken.
Conservative methods include powdering by Resorcin, processing with Podophillin,
Condylin or Pherisol.
Ectropion
The ectropion is an inversion of cervical mucous as a result of badly renewed cervix
after labour trauma. These traumas rarely occur after abortion.
A surface, that is formed in the result of rupture, heals over thanks to the columnar
epithelium of the cervical canal.
Clinic. In some cases patients have no complaints. At complicated forms of the
ectropion patients complain on aching pain in the lower abdomen, discharge from
genitals, of menstrual dysfunction in the form of hypermenstrual syndrome and
menorrhagias.
Diagnosis. Presence of old rupture of the cervix, its deformation, the erosive edges are
found during the speculum examination. Unlike the erosion the ectropion "disappears"
when they draw together the edges of rupture. It can be seen only during breeding of the
anterior and posterior lip of the cervix.
Colposcopy diagnoses the atypical picture caused by the chronic inflammatory process.
Dysplasia may be present frequently in strong deformation coexisting with considerable
histological changes. Complex examination of the patient, except the broadened
colposcopy, includes cytological research, cervical biopsy, and endocervical curettage.
The question about the volume of treatment is decided after taking into account the
received data.
Treatment. Medical arrangements, directed on the renewing of cervical structure start
from vaginal flora normalisation. At small dimensions of the rupture, after elimination
of inflammatory process in vagina and cervix, electrocoagulation of the eroded surface
of the ectropion is performed. Growing of connective tissue leads to constriction of the
external os and formation of the exocervix. Reconstructive-plastic surgeries, specifically
Emmet's operation is performed at considerable deformation of the cervix and deep
lacerations. Presence of the dysplasia is an indication for more radical treatment —
cone- or wedge-shaped amputation of the cervix.
Cervical leukoplakia
Leukoplakias belong to hyperkeratoses. Leukoplakia is a pathological state of
epithelium that is characterized by its thickness and comification. Etiology of this
disease is connected with hormonal insufficiency, the involutional changes in the female
organism, and vitamin A deficiency.
Clinic. The disease does not have typical clinical picture. Patients have no complaints
Leukoplakia is found during the medical monitoring or during the gynecological
examination. In some cases patients complain on the great amount of discharge from the
genital tract and contact bleeding (this is a sign of possible malignization).
Diagnosis. Leukoplakia, located on the cervix and vaginal walls, is found m the result
of speculum cervical examination It looks like a white film or plague, sometimes with
pearl colour, that can be flat or slightly prominent over the level of cervical epithelium .
The film can be removed from the cervix, and the base of leukoplakia in the initial
stages of the process becomes visible. In colposcopy it looks like Iodine-negative region
with crimson dots, that is represented by connective tissue papillae in stratified
squamous epithelium with loops of capillary vessels. The fields of leukoplakia during
colposcopy look like multiangular areas, divided by threads of capillaries that create the
mosaic drawing.
Layers of polygonal keratinized cells with picnotic nucleus of irregular form —
dyskeratocytes are presented during cytological research in smears-imprints
Biopsy is the basic method of diagnostics. It is made under control of colposcopy from
the most altered areas of the cervix. The regions of squamous metaplasia can be situated
also in the cervical canal. That's why it is necessary to perform the endocervical
curettage.
Treatment. It is necessary to normalise the vaginal flora, taking into account the
pathogenic organism's species if leukoplakia is combined with the inflammatory
diseases of vagina and cervix. Application of methods influencing on tissue exchange
and regeneration (dog-rose and sea-buckthorn oil, aloe, etc.) is not recommended
because of stimulation of the proliferative processes of these medecines. It causes
dysplastic changes in the cervix.
Solkovagyn deserves special attention from group of the chemical coagulants. This
remedy is a mixture of organic and inorganic acids and has coagulative action on
columnar epithelium. It penetrates into the tissue on 2,5 mm, that is sufficient for
destruction of pathologically altered epithelium, and does not cause rough scar changes.
Surgical diathermy should be applied in leucoplakia treatment, but numerous
disadvantages of this method (implantative endometriosis, bleeding during scab
exfoliating, rough changes in the cervix at extremely deep coagulation) can occur. They
limit the usage of this method. Electroexcision should be performed in the limited areas
of leukoplakia. Progesterone in tampons is also used. Such methods as cryodestruction
and high-intensive action of Carbon laser have higher effectiveness. There are the
methods of combination of cryodestruction with the following irradiation by lowintensive semiconductor laser. Maximum organo-specificy of the renewed after
cryodestruction tissue, decreasing of relapses is reached.
PRECANCEROUS CERVICAL DISEASES
Dysplasia
According to the degree of epithelium stinging, cultural atypia and saving of epithelial
layer architectonics three degrees of dysplasia have been distinguished. There are:
 mild (CIN I)
 moderate (CIN II)
 severe (CIN III)
Hyperplasia and basal cell atypia occupies 1/3 of epithelium layer at CIN 1, at CIN II
the changes take about the half of mucous layer, and at CIN III all the epithelium or not
less than 2/3 of its layer is altered. The expressed atypia of the superficial layers is
considered to be the severe dysplasia.
The following types of epithelium changes are distinguished at colposcopy. They are:
•
areas of dysplasia:
areas of stratified squamous epithelium
areas of columnar epithelium metaplasia
•
papillary zone of dysplasia:
papillary zone of stratified squamous epithelium hyperplasia
papillary zone of columnar epithelium metaplasia
precancer transformation zone
Diagnosis. Cytological research of smears allows to find the cells of basal and parabasal
layers with signs of dyskariosis.
Histochemical research in patients with dysplasia show a drastic lowering of glycogen
in cells up to full its absence and changes of tissue enzymes activity.
Cytogenetic researches testify that under this pathology the cells with tetraploid and
pentaploid number of chromosomes appeared.
Transition of dysplasia into cancer in situ is observed in 40-60 % of patients. CIN 1
precedes the invasive carcinoma by approximately 5-6 years and CIN 3 — about one
year.
Leukoplakia with atypia
Clinically it does not differ from the simple leukoplakia. The processes of
keratinization of the cells in this disease are mistologicaly marked to be reinforced as
compared with leukoplakia. Cytological research of the stratified squamous epithelium
reveals cells without nucleus at simple leukoplakia. Basal and parabasal cells without
nucleoses are also present in the patients with leukoplakia and atypia.
Erythroplakia
It is a prettily heterogeneous form of dyskeratoses. The changes of cervical mucous
membrane are in thinning and keratinizing of epithelium. It looks like scarlet area in the
result of translucence of the basal membrane cells through thinned epithelial layer. It
easily bleeds at contact. The seats are single or plural with transition on fornices and
vaginal walls. Thinning of epithelial layer to 1-2 layers with nuclear atypia and cellular
polymorphism is revealed during the histological research.
Glandular hyperplasia with atypia
Local hyperplasy of the glands that looks like a clew, similar to endometrial glands at
histological research are found. The glands which have different form and size are
covered by epithelium, that is unlike the cervical one. It frequently occurs in the first
trimester of pregnancy, and disappears after delivery. The adenomatosis frequently
transforms into cancer in situ outside the pregnancy.
Treatment of precancer lesions is made by diathermic excision, cryosurgical and laser
destruction. The most radical and less traumatic method is laser coagulation. It is
bloodless, painless, and can be performed without anaesthesia in outpatient conditions.
Patients who are treated for benign cervical lesions need to be followed more frequently
than the patients presenting for annual health examination.
The patients with benign cervical lesions after 2 months of appropriate treatment should
be encouraged to avail themselves of annual health care checkups to include the Pap
smear.
The patients with precancerous lesions after radical therapy usually receive repeates Pap
smear and colposcopic assessment at 1, 5, 6 and 12 months. If Pap smears and
colposcopic findings remain normal, patients may resume having annual Pap smear
assessments at the beginning of the third year.
UTERINE MYOMA
Uterine myoma (fibromyoma, leiomyoma) — is a benign tumor which contains
varying amounts of muscle and fibrous elements.
Concerning gynecologic diseases benign tumors are found in 10-25% of all the cases,
although during the last years the tendency of increasing the quantity of these tumors is
observed.
Tumor histogenesis and structure. Uterine myoma belongs to tumors, which are
growing from mesenchyma. It has three consecutive stages in its morphogenesis. They
are:
 active region of growth formation
 growing of tumor without differentiation
 growing of tumor with differentiation and maturation
The areas of growth are formed mainly around the vessels. These regions are
characterized by a high level of metabolism and increased capilary and tissual
permeability which stimulate the tumor growing. Uterine fibroid has in its development
parenchymal-stromal features of that layer, from which it has been educed, therefore the
parenchyma and stroma ratio in a tumor is different. Leiomyoma is developed at
predominance of muscle elements, in the structure of fibromyoma fibrous tissue is
predominant. The consistency of tumor depends on fibrous and muscle tissue ratio: the
more there are muscle fibers, the more the tumor is mild at palpation.
Myomas are classified according to histologic structure as myoma, fibromyoma,
angiomyoma and adenomyoma. According to the speed of growing there are the tumors
which are growing slowly and quickly. According to histogenesis peculiarities there are
distinguished simple and proliferative myomas. Proliferative myomas contain much
more atypical muscle elements, where is a great number of plasmatic and lymphoid
cells and increased mitotic activity. The incidence of proliferative myomas happen
twice more often in the patients with fast growing tumors.
Very often uterine fibroids arise in places of complex interlacing of muscle fibers of
uterus — near tubal angles, on uterine center line. The myoma is characterized by the
effusive growing. As compared with cancer fibroids they move apart tissue without
destroying it. Tumor is growing simultaneously with tissue mass surrounding it.
Uterine fibroids have few veins, basic amount of vessels is situated in pseudo-capsule.
Uterine fibroids' lymphatic system is atypical without absorbent vessels. Uterine
fibroids are deprived of nervous terminals, choline and adrenergic nervous frames.
According to their location in the uterus myomas are classified into:
 subserosal — subperitoneal uterine fibroids, which are growing under the outer
serosal layer of the uterus, may have a wide or thin pedicle. It has been estimated
that 10-16% of all myomas are subserosal ones
 interstitial (intramural, intraparietal)—uterine fibroids, which are growing within
the muscular wall of the uterus, their frequency is 40-45%
 submucosal (fig. 129 d,e, 130) — uterine fibroids which are growing under the
uterine mucous into the uterine cavity, their frequency is 20% of all the patients
 atypical forms of uterine fibroids location: retrocervical myoma grows from the
posterior surface of the uterine cervix, it is situated within a retrocervical fat;
paracervical myoma grows from the lateral part of uterine cervix, it is situated in
the paracervical fat; intraligamentary myoma grows from the uterine body or
cervix within the broad ligaments.
The fibromyoma can have one fibroid (nodulosus fibromyoma), many fibroids (multiple
fibromyoma) and diffuse growth (diffuse fibromyoma).
Hormonal status of the patients with fibromyoma. They are considered hormonally
depend tumors because the growth of these tumors is related to estrogen production. In
the majority of cases these patients have an hormonal dysfunction of ovaries which is
characterised by anovulatory cycles, corpus luteum insufficiency. It leads to
hyperestrogenemia and lowering of progesterone level. Small cystic changes in ovaries
occur due to hormonal disordes. Uterine endometrium and myometrium are under the
influence of estrogenic hormones. Their excessive amount in blood can lead to
endometrial hyperplastic processes and cystic changes in myometrium. Recent
researches have shown that in patients with fibromyoma even with normal level of
estrogenic hormones in a peripheral blood the contents of estradiol in uterine vessels is
higher, than in other parts of vascular system.
Such local hyperhormonemia leads to pathological hypertrophy of myometrium. Not
only sexual hormones synthesis, metabolism and interaction impairment, but also the
state of the myometrial receptors especially large activity of the estrogen receptors as
compared with progesterones receptors, take part in a pathogenesis of uterine
fibromyoma.
Fibromyoma grows slowly without any proliferative changes at presence of small cystic
changes in ovaries with nonsignificant hyperestrogenemia. Follicular cysts of
appreciable sizes have been found in the patients with fast growing fibromyoma with
the presence of proliferative centers in it.
Fibromyoma growing depends on its type, location, blood supply and patient's age.
Fibromyoma grows quickly in young patients, particularly during pregnancy, as the
fetoplacental complex synthesizes large amount of estrogenic hormones, which are
tumor stimulating growing factor. Quite often fibromyoma accelerates its growing in
climacterium, when there is a rearrangement of woman's hormonal system. Ovaries
undergo polycystic degeneration at that time. When the menstrual function is over then
the menopause and processes connected with it develop. Production of estrogenic
hormones decreases, fibromyoma growth is retarded, uterine fibroids undergo
involution. These processes develop due to the decreased pituitary gland gonadotropic
function and changing of estrogenic effects into androgenic.
Clinic. Clinical manifestation of fibromyomas depends on uterine fibroid's location,
size of tumour, rate of its growing, and also presence of complications.
Of the most myomas there are not any symptoms at the initial stages. Tumor should be
revealed during the routine maintenance or when consulting the gynecologist for some
other reason. The symptoms associated with uterine fibroids frequently make women
seek for a medical advice.
The main symptoms are pain, bleeding, sensation of pelvic heaviness in the lower part
of the abdomen, progressive increase in pelvic pressure, infertility, frequent urination,
pressure on the rectum. These symptoms most commonly occur during the excessive
growth of tumor, and sometimes they testify development of secondary degenerative or
inflammatory changes in fibromyoma tissue.
Menstrual function in the patients does not variate in case if tumor is sub-serosal
because attached to the uterus by only a stalk or on a wide basis under a peritoneal
integument and it is practically outside of uterine borders. Therefore, uterine contractile
function does not suffer, the mechanism of menstrual bleeding is also not disturbed.
Pain symptoms may be the result of rapid enlargement of myoma, pressure of large
tumors on the adjacent viscera, in areas of tissue necrosis,or subnecrotic ishemia which
contribute to alteration in myometrial responce to prostaglandines. Occasionaly, such
complications as torsion of pedunculated myoma, uterine fibroid necrosis, uterine
fibroid adhesion with parietal viscera can occur resulting in acute pain.
Another spectrum presentation includes patients with
 atypical (subperitoneal) location of uterine fibroids
 Intraligamentary tumor
 intramural tumors
Submucosal location of uterine fibroid
Diagnosis. History of the patients includes hereditary predilection (myoma in mother
and other reproductive organs tumors in close relatives); menstrual dysfunction, late
beginning of menarche and metabolism infringement (obesity, diabetes mellitus).
Reproductive dysfunction (infertility, pregnancy loss), induced abortions (mucous and
myometrium trauma should lead to endometrial receptor device changes), extragenital
diseases, which caused endocrine and ovarian disordes, in particular can be present in
these patients.
Bimanual examination in uterine fibromyoma has characteristic signs. It includes the
presence of a large midline mobile pelvic mass with the regular contour. The mass
usually has a characteristic "hard" feel or solid quantity.
Additional methods of investigation are used for confirmation of the diagnosis.
They are: uterine sounding (enlargement of endometrial cavity of the uterus, rough
relief, presence of submucous fibroids are revealed) and curettage of uterine cavity
(relief changes, presence in uterine cavity of submucous fibroid, endometrial
hyperplastic processes). Nevertheless, these methods for diagnosis are not recommend
to use routinely, as they can lead to submucous fibroid trauma.
Hysterography gives a possibility to diagnose submucous nodes which distort the cavity
of the uterus.
Hysteroscopy may be used to evaluate the enlarged uterus by directly visualising the
endometrial cavity. The increased size of the cavity can be found and submucous
fibroids can be visualized.
Laparoscopy is applied seldom, mainly to make differential diagnostics of subserous
fibroid and ovarian tumor, and also for diagnosis of such complications as torsion of
pedunculated myoma and fibroid' necrosis.
Pelvic ultrasonography is the most common method to confirm the uterine myomas
presence. The ultrasonographer may suggest location, quantity, size of uterine fibroids,
their sructure, presence of destructive changes. Dynamic observation enables to
supervise efficiency of the conservative therapy, tumor growing, or, on the contrary, its
reduction under the influence of treatment.
Uterine fibroids' complications
Prolapse of submucous fibroid (cervical protruding myoma)
Submucous fibromyoma is accepted by uterus as an ectogenic body. Fibroid descent to
the inferior portion of uterus, irritating the isthmus receptors. It results in myometrial
contractions, cervical dilation and uterus pushes out fibroid into vagina. Pedunculated
tumor is connected with uterus. If pedicle is short, it can result in difficult complication
— oncogenetic inversion due to prolapse of the submucous fibroid. Speculum
examination should be performed for confirmation of this diagnosis: cervical protruding
myoma is visible.
Treatment Submucous tumor can be easily removed by the incision of long pedicle by
clamping the base through the cervix. The pedicle is then ligated. Such removal of
fibroid can lead to uterine perforation when the pedicle is short and wide. These patients
need hysterectomy.
Torsion of uterine fibroid
Torsion of uterine fibfoid is a very common in subserous location. Clinically it is
characterized by crarfiping pain, signs of peritoneal irritation, fever, urinary frequency
and symptoms of rectal pressure. In this situation necrosis and infection are common.
Surgical treatment Myomectomy is more commonly done when abdominal myoma
location. Myomectomy should be the operation of choice in case of single subserous
pedunculated tumor. A clamp should be put on the lower place of torsion. One should
remefnber that it is dangerous to untwist the tumor. For most of patients the treatment
should be total or subtotal hysterectomy.
Uterine fibroid’ necrosis
Necrosis of uterine fibroid results from blood supply disorder of the tumor,
ccurring
due to rapid growing, pregnancy, mechanical accident, and postmenopausal atrophy. It
leads to tumor edema and pseudocapsule hemorrhages
Clinically it is characterized by cramping pain which enforces during palpation. Signs
of peritoneal irritation are found. Fever and leukocytosis accompany severe
degeneration.
Treatment is surgical removal.
Uterine fibroid’ suppuration
Uterine fibroid's suppuration arises primarily very seldom. Sometimes it is a result of
necrosis. Submucous and interstitial uterine fibroids may be suppurated. The serious
septic state demands supracervical hysterectomy (subtotal) or total hysterectomy.
Pseudocapsule' and uterine fibroid' vessels rupture
Pseudocapsule' and uterine fibroid' vessels rupture happens very seldom. It is
accompanied by severe pain, signs of intraabdominal hemorrhage (hemorrhagic shock).
Malignant degeneration of uterine fibromyoma
The malignant degeneration of uterine fibromyoma in sarcoma arises in 5-7% of cases.
Uterine myoma and pregnancy
Pregnancy at fibromyoma of uterus comes mainly at subserous and interstitial location
of uterine fibroids. Submucous fibroids manifest with pregnancy progressing.
Diagnosis of pregnancy in such patients represents appreciable difficulties. The test for
pregnancy and ultrasound examination are necessary, because only with their help it is
possible to establish the duration of gestation. Abortions and premature labors
frequently happen in the patients with fibromyoma. Approximately half of women can
bear a child. During the pregnancy there is a threat of its interrupting as the result of
fibroid blood supply disorder (its necrosis, pseudocapsule hemorrhage). The function of
urinary bladder and rectum is broken. Fetal position is frequently incorrect — oblique or
transversal one. Breach presentation is common if the myoma does not let the fetal head
get into pelvic inlet. Preterm rupture of amniotic fluid, primary and secondary dystocia
of labor are common.
Cesarean section should be pcrfoimed if the nodes are placed behind the course of the
genital canal and block the plane of pelvic inlet. Vaginal delivery is recommended in all
other cases of labor. Postpartum hemorrhage happens in the third period of labor (in
case of placental implantation in the area of uterine fibroid), therefore it is necessary to
perform manual removal of placenta and manual revision of the uterine cavity.
Hypotonic bleeding in early puerperal period is a very dangerous complication that
appear as the result of uterine contractile dysfunction. Uterine involution and regress of
fibroid take place in the late puerperal period.
Uterine fibroid should undergo involution until their complete regress in women with
high-grade lactation during the further duration of puerperium.
TREATMENT OF UTERINE MYOMA
Treatment of fibromyoma should be operative and conservative.
Indications to operative treatment are: myomatous uterus larger than 12-week of
pregnancy, acceleretion of tumor growing, presence of such symptoms as pam,
bleeding, secondary anemia; myoma's complications; suspicion on malignant
degeneration and combining with endometriosis and endometrial hyperplasia. Operative
treatment is performed in case when the patients have contraindication to hormonal
treatment. These contraindications are: thromboembolism and thrombophlebitis,
varicose phlebectasia, hypertension, operation concerning malignant tumors m the past,
no effect from hormones.
Surgical interventions are divided into radical and conservative — plastic ones.
Radical operations are in uterine removal — total hysterectomy or supracervical
hysterectomy.
Hysterectomy should be performed in 45-year-old women and older during tumor
growing in menopause, presence of cervical and endometrial pathological changes
(dysplasia, erosion, polyps, scars), combination of fibromyoma with precanserous
lesions of uterine cervix and uterus, endometriosis, cervical and isthmic myoma
Supracervical hysterectomy is performed in all other cases
Conservative-plastic operations are carried out for reduction or preserving of female
menstrual and reproductive functions Their using is justified m young women for
anatomo-functional safety of uterus, fallopian tubes, ovaries and ligaments
Myometrectomy (incision of myometnal part with fibroid) or its type — defundation
(incision of a myometnal part above a level of fallopian tubes fixation), conservative
myomectomy (incision of a single myomatous node) are used very often Pedunculated
submucous fibroid should be removed by endoscopic way through uterine cervix
Fibromyoma relapse is not excluded after conservative-plastic operations Nevertheless
preserving of menstrual function, and sometimes, when fibroid has been prevented
fertilization, implantation or normal pregnancy duration — the reduction of
reproductive function justify their application in young women.
Conservative treatment of uterine fibromyoma has been confirmed patho-genetically
and is directed on correction of hormonal state, treatment of anemia and metabolic
dysorder, inhibition of tumor growing
Indications. Conservative treatment is recommended at any age, lr case of myoma
duration with poor symptoms or without any symptoms, at presence of
contraindications to operative treatment
Conservative therapy includes a diet with the usage of products, which contain
A,E,K,C vitamins, such microelements as copper, zincum, lodum, iron, antianemic
therapy, vitamin therapy, uterotomc drugs for decreasing of menstrual hemorrhage,
lodium drugs should provoke inhibition of estrogenic secretion at ovaries 0,25%
solution of potassium iodide should be taken in a dose of 15 ml once or twice per day
continuously during 6-10 months It is nessesary to combine lodium drugs with
phytotherapy — 60 ml of potato juice per day. Electrophoresis of 1-2% solution of
potassium iodide is commonly used 40-60 procedures are needed for the treatment
course.
Hormonal therapy. Gyfotocyn is given intramusculary in the dose of 1 ml during 1215 days since 5-7 day of menstrual cycle during 6-8 cycles This medicine is
recommended at menorrhagia of the patient at any age
Androgens could be applied at uterine myoma in the period of penmeno-pause Its effect
can be achieved by pituitary gland suppresion Androgens can result in reduction of
uterine size, endomenal atrophy, ovaries follicular depressing. Methylandrostendiolum
is prescribed 50 mg per day during 15 days in the follicular phase of reproductive cycle
for 3 to 4 months. Methyltestosterone is administrated in 2 pills under the tongue three
times per day during 20 days with 10-day time-out for at least 3 months.
In case of small sizes of myoma and severe menstrual hemorrhage at the women older
than 48-year menostasis is recommended: Testosteron propionate in a dose of 50
mg/week for the first 2 weeks, then 50 mg/twice a week for the next 2 weeks, and 50
mg once per week until the general dose of 1000 mg should be taken after the arrest of
bleeding or uterine curettage.
Hestagens have been used in uterine fibromyoma because of its antiestrogenic effect.
First line progestines are Progesterone in a dose of 5-10 mg intramusculary once per day
for 10-12 days in luteal phase of a reproductive cycle or 2 ml 12,5 % solution of 17Hydroxyprogesterone Capronate intramusculary on 12-14 day of a cycle for at least 3
months are prescribed.
The second line progestines are Noretisterone acetas, Norcolutum that have been taken
from the 5-th till the 25-th day of menstrual cycle in the patients of reproductive or
climacteric age with menstrual dysfunction and uterine myoma combined with
endometrial hyperplasia.
Various progestine preparations should be given according to the standard regimen:
since the 5-th till 26-th day of a menstrual cycle or since the 5-th day after uterine
currettage. Such hestagens of prolonged action as Depo-Provera— 150 mg once per
month or 50 mg once per week for at least 3-6 months should be taken.
Pharmacologic removal of the ovarian estrogen source can be achieved by suppresion of
the hypothalamic-pituitary ovarian axis by the use of gonadotropin-releasing hormone
(GnRH) agonists. Buzerelinum, gozerelinum and gestrmol belong to the essentially new
medicines that are a gonadotropin-releasing luteal hormone agonists. Buzerelinum in a
dose of 200 mg is administrated subcutane-ously for the first 14 days of reproductive
cycle, then endonasal prescription in the dose of 400 mkg per day for 6 months.
Zoladex-Depo is applied subcutaneous in a dose of 3,6 mg once a month for at least 6
months. This treatment is commonly used for 3 to 6 months before the planned
hysterectomy, but it can also be used as a temporizing medical therapy until the natural
menopause comes. GnRH agonists can not only result in reduction of uterine size, but
also lead to a technically easier surgery with significantly diminished blood loss.
HYDATIDIFORM MOLE
(Molar pregnancy)
Hydatidiform mole is one of the forms of trophoblastic disease (pathology of
conceptus) which is characterised by abnormal proliferation of syncytiotro-phoblast and
replacement of normal placental trophoblastic tissue by hydropic placental villi.
It is displayed by sharp increasing of villuses dimensions and their hydropic
degeneration which have been containing light fluid. Hydropic villi are up to 3 cm in
diameter and look like a mass of grape-like vesicles.
The ethiology and pathogenesis of trophoblastic disease is unknown. It has been
observed that molar pregnancy is developed from unnucleated ovum's fertilization. It is
more common in very young women and in women at the ^nd of their reproductive age.
Molar pregnancy may be divided into complete mole and incomplete (partial)
hydatidiform mole. Complete hydatidiform mole is identified macroscopically by
edema and swelling of virtually all chorionic villi with a lack of fetus or amniotic
membranes. It is developed during the first weeks of pregnancy. Incomplete (partial)
hydatidiform mole is often associated with the identifiable fetus or with amniotic
membranes. Grossly, placenta has a mixture of normal and hydropic villi that look like
mosaic.
The diagnosis of invasive mole (also called chorioidcarcinoma detruens) rests on the
demonstration of complete hydatidiform mole. Hydropic villi invade into the
myometrium on different distances destroying muscle elements and vessels. It is similar
to tumor growing.
Clinic. Hydatidiform mole is characterised by such main symptoms as:
 uterine size/dates discrepancy (uterine enlargement greater than expected for
gestational dates)
 tigh-elastic uterine consistancy
 numerous painless spotting with the fragments of edematous trophoblast
(absolute sign)
 other signs and symptoms, including visual disturbances, severe nausea,
vomiting, marked pregnancy-induced hypertension (preeclampsia), proteinuria
 absence of positive signs of pregnancy (fetus is not found by ultrasound and
physical examination, heart tones of the fetus are absent)
 "snowstorm" appearance of hydatidiform mole during the ultrasound examination
 great increasing of hormones in urine
 presence of large adnexal masses (theca lutein cysts) as the result of high levels
of ChGT
Treatment. In most cases of molar pregnancy the definite treatment is removal of
intrauterine contents. Uterine curettage is do by dilation of the cervix followed by
suction curettage (large danger for perforation), vacuum aspiration, digital removal of
mole (in the case if cervical canal passes 1-2 fingers) with the following curettage.
With cases involving 24 weeks' gestational size, an alternative to suction evacuation is
induction of labor by prostaglandin and Oxytocin. Hysterectomy should be performed
in case of excessive bleeding. All removed tissues should undergo histologic
examination.
After reception of histological research results, that confirm the diagnosis, the woman is
sent to oncologist's consultation where they will decide whether chemotherapy
(Methotrexatum) is necessary. Such patients demand careful medical supervision during
1,5-2 years because they have a risk of choriocarcinoma development During the first
year the patient is examined monthly with definition of ChGT During the second year
she is examined every three months At normal pregnancy the level of ChGT is reduced
to normal m 20 days, at molar pregnacy — in 4 months If the reaction on ChGT has
appeared positive in later terms, it testifies to preserving of trophoblast activity, then the
patient should be reexamined and cured Pregnancy is contramdicated for 2 years
ENDOMETRIAL ADHESIONS
Presence of adhesions inside uterine cavity is called as intrauterine adhesions. They
arise after the careful uterine curettage, especially after the repeated ones Frequently
they are the cause of infertility and spontaneous abortions (miscarriage)
Diagnosis is based on the data of gysteroscopy, gysterography and sounding of uterine
cavity
Treatment is surgical Endoscopic intervention consists of cutting of adhesions
PRECANCEROUS UTERINE DISEASES
(uterine carcinoma precursors)
According to international classification (1982), such processes as glandular
endometrial hyperplasia, cystic glandular endometrial hyperplasia, endometrial polyps
belong to benign endometrial diseases.
Glandular endometrial hyperplasia with cellular proliferation, adenomatous hyperplasia
and adenomatous polyps are precancerous utenne diseases.
Cystic glandular hyperplasia, which is found in postmenopausal women or in
reproductive period belongs to precancerous uterine lesions
Glandular endometrial hyperplasia and cystic glandular endometrial hyperplasia are
different stages of the same process Difference between them is presence or absence of
cysts in endometrial hyperplasia Atypical cellular signs at these diseases are not present
The common endometrial polyp is made up of endometrial tissue
Atypical adenomatous hyperplasia is characterized by structural rearrangement and
more intensive proliferation of glandular elements comparing with other types of
hyperplasia. Glandular cylindrical epithelium is multinucleated It forms projections
inside the glands, nuclei are enlarged There is plenty of pathological mitosis amount At
the expressed form of adenomatosis glands are closely connected with each other, there
is no stroma between them There is polymorphism in multilayer glandular epithelium
Some forms of this pathology belong to uterine carcinoma potentialities.
Ethiology. The main causes of endometrial hyperplastic processes are different
hormonal disorders at hypothalamic-pituitary-ovanan levels The correlation between
estrogen production and endometrial growth is direct Endometrial proliferation
represents a normal part of the menstrual cycle and occurs during the follicular or
estrogen — dominant phase of the cycle with the continued estrogen stimulation
through either endogenous mechanisms (hyperglycemia, obesity, conversion of
androstenedione) or by exogenous administration (medications).
Clinic. The precancerous processes manifest with acyclic uterine bleeding which can be
either appreciable or insignificant, but they are continuous More often these bleedings
arise after some weeks or months delay of menses Cyclic bleedings which appear
during menses and last for a long period of time may be also present Reproductive age
women complain of infertility as a result of anovulation
Diagnosis. Bimanual examination doesn't find out abnormalities Sometimes,
insignificant enlargement of uterus may be revealed at the examination
Ultrasound examination of uterine cavity determines the endometrial depth At
glandular-cystic hyperplasia echogenic inclusions are up to 1cm in size, madenomatosis
— up to 2-3 cm. Endometrial heterogenity, presence of small amount of inclusions are
the characteristic signs for endometrial processes Endometrial polyp is characterised by
legible contours and distinct borders between the formation in uterine cavity and its
walls Hysteroscopy, hysterography can also be used for diagnosis that gives a
possibility to research uterine cavity, determine the location of pathological process
Hysteroscopic characteristics depend on the type of hyperplasia, patient's age, phase of
reproductive cycle In case of diffuse hyperplasia endometnum is pink or red-coloured
with the large amount of folds and crests on its surface Polypoid hyperplasia looks like
a local gross of mucous membrane, its vascular network is more expressed
Adenomatous hyperplasia has a sign of "melting snow" Endometnum is rough and of a
dirty red colour During the contact endometrium can easily bleed
One of the diagnosis methods is the cytological research of the smears from uterine
cavity
The diagnosis of endometrial hyperplasia can be made by taking a sample of the
endometrium for histological evaluation during uterine and cervical curettage. Cystic
glandular endometrial hyperplasia is characterised by the increased number of glands,
some of which look like cysts.
It is necessary to start the treatment from the uterine curettage. Indication to hormonal
therapy is histological confirmation of uterine hyperplasia. Progestins are the
medications of choice because of hyperestrogenemia. Oxyprogesterone acetate should
be taken on the 12-14 days of reproductive cycle once per month during 5-6 cycles at
reproductive age. In case of polyposis it should be taken twice per month at 12 and 19
days of reproductive cycle. In menopausal women it should be prescribed once or twice
per week during 5-6 months, then the dose is gradually reduced. Androgens may be
prescribed these menopausal patients. Surgical intervention should be performed in case
of no efficiency from hormonal therapy, its contraindications.
All the patients with endometrial hyperplasia should be monitored during 5 years. Intherm treatment of precancerous endometrial lesions is the main factor in cancer's
prevention.
BENIGN OVARIAN TUMORS
OVARIAN TUMORS CLASSIFICATION
Only histologic signs can give a possibility to distinguish benign and malignant ovarian
tumor. From the prognostic or survival standpoint, however tumor grade remains the
most important factor for all the ovarian tumors.
Histologic classification of ovarian tumors is presented below.
I. Epithelial tumors:
A. Serous
B. Mucinous
C. Endometriod
D. Clear cell
E. Brenner
F. Mixed epithelial
G.Undifferentiated
H. Unclassified.
There are benign and malignant tumors in each of these groups of neoplasms.
II. Sex cord stromal tumors:
A. Granulosastromal cell
B. Androblastoma
C. Gynandroblastoma
D. Unclassified
Lipid cell tumors
Germ cell tumors:
A. Dysgerminoma
B. Endodermal sinus tumor
C. Embryonal carcinoma
D. Polyembryoma
E. Choriocarcinoma
F. Teratoma
G. Mixed forms
V. Gonadoblastoma:
A. Only blastoma (without any forms);
B. Mixed with disgerminoma and other forms of germ cell tumors.
VI. Soft tissue tumors not specific to the ovary.
VII. Unclassified tumors.
VIII. Secondary (metabolic) tumors.
VIII. Tumor-like conditions:
A. Pregnancy luteoma
B. Ovarian stroma hyperplasia and hyperkeratosis
C. Considerable ovarian edema
D. Functional follicle cyst and luteal cyst
E. Multiple luteal follicle cysts and (or) luteal cysts
F. Endometriosis
G. Superficial epithelial cysts-inclusions
H. Simple cysts
I. Inflammatory processes
J. Paraovarian cysts
Corpus luteum cyst
Corpus luteum cyst is an unilateral cystic enlargement which exceeds 8 cm in diameter.
The cyst is filled with yellow fluid or blood. It may be found at the age from 16 to 55
years old.
Clinic. Symptoms are related to large size or complications of torsion, rupture or
hemorrhage. The main complaint of the patient is abdominal pain as a result of
concomitant inflammatory processes of uterine adnexa. Special clinical signs are absent.
Bimanual examination reveals unilateral ovarian enlargement with tuberculosis uneven
consistency. During pregnancy the corpus luteum becomes truly cystic with growth and
continued function. At the absence of pregnancy, the corpus luteum normally collapses
and is eventually replaced by hyaline connective tissue.
Treatment. More commonly luteum cysts produce no symptoms and undergo
absorption or regression. It is necessary to make observation for 2-3 reproductive
cycles. Surgical intervention should be recommended in the case if corpus luteum cyst
regression doesn't occur.
Theca lutein cysts belong to retential ovarian cysts. These cysts are almost bilateral and
the enlargement may exceed up to 15 cm. They should be present during pregnancy,
hydatidiform mole or choriocarcinoma. They are growing very quickly. They can
dissolve after the main disease treatment — hydatidiform mole or choriocarcinoma.
Parovarian cyst
Parovarian cyst is formed as a result of fluid retention in ovarian adnexa which has
been situated in the broad ligament. It arises at the age of 20-40 years old because only
in reproductive period ovarian epoephoron is well developed and it undergoes atrophic
changes in climacteric women. Intraligamentous cysts may be small or may reach 8-10
cm or more in diameter. They are thin-walled and unilocular with solid consistency,
they have smooth surface with vessels which are situated outside, it is filled with fluid.
Clinic. Pain in the lower abdomen and sacral region may be present. Symptoms of
adjacent organs compression are present if the tumor reaches large sizes. Symptoms of
acute abdomen are common in the case of parovarian pedicle cyst torsion. At bimanual
examination pelvic mass with smooth surface and elastic consistency which is palpated
near uterus is found. It is painless and immobile.
Treatment. Surgical removal of parovarian cyst. It is very necessary to store the
ovarian function. Puncture of the cyst should be indicated in some cases.
Thus, retential cysts are more often found in young women. After exception of true
ovarian tumor such diagnosis is made in climacteric women. Ultrasonography and
laparoscopy should be prescribed for diagnostics.
Patients with ovarian cysts should undergo careful monitoring. Retential cysts of small
sizes may undergo spontaneous regression under the effects of anti-inflammatory drugs.
Thus, they may be treated within 4-6 weeks. One should remember that interm
diagnosis and treatment of retential cysts is the prevention to ovarian cancer.
BLASTOMATIC PROLIFERATIVE OVARIAN TUMORS
(ovarian cystadenomas)
Serous cystadenoma
Serous cystadenoma is unilocular unilateral benign cystic neoplasm derived from the
surface epithelium of the ovary and lined by epithelium that resembles the mucosa of
the oviduct. It contains clear yellow fluid. The benign serous cystadenoma is usually
between 5-15 cm in diameter. Occasionally it fills the entire abdomen. Tumor growing
may lead to the enlargement of abdomen, adjacent organs function impairment. No
symptoms are specific for this tumor. Rarely, patient may complain on dull abdominal
pain. Reproductive cycle is normal. The symptoms of peritoneal irritation are present in
the case of pedicle torsion. These tumors are revealed during monitoring.
Pelvic examination reveals mobile, painless and unilateral tumor with smooth external
surface. Ultrasonography and laparoscopy may confirm the diagnosis.
Treatment is surgical because of the relatively high rate of malignancy. In the patients
after the childbearing age (after 40 years old) treatment should consist of bilateral
salpingoophorectomy and hysterectomy not only because of chance of future
malignancy, but because of the increased risk of similar occurrence in the contralateral
ovary. In the younger patients with smaller tumors an attempt can be made to perform
an ovarian cystectomy to try to minimize the amount of ovarian tissue removed. For
large, unilateral serous tumors in young patients, unilateral oophorectomy with
preservation of the contralateral ovary is indicated to maintain fertility.
Papillary serous cystadenomas
The papillary projections of ovarian cystadenomas may grow inside and outside of the
tumor capsule. There are also mixed tumors when these projections are placed into
internal and external surfaces of the tumor. Papillary projections may involve
peritoneum in the case of malignant degeneration. These tumors are multilocular, they
rarely reach large sizes, have a short pedicle. They may be situated intraligamentously.
The tumor contains serous or sometimes serous-hemorrhaged fluid. Tumor may coexist
with ascites.
No characteristic symptoms are specific for this tumor. Frequently, it is revealed during
monitoring. The diagnosis is based on the results of bimanual examination,
ultrasonography and laparoscopy.
Bimanual examination reveals immobile painless lobulated tumor which is situated near
uterus. Frequently it resembles the subserosal uterine fibroid. These tumors have high
frequency of malignant change.
Treatment is surgical and it is the same as in case of serous cystadenomas.
Mucinous cystadenoma
Mucinous cystadenoma is a benign epithelial tumor which may be present in women
of different age. It may reach large sizes, sometimes it is multilocular, with round or
oval form. The cut surface shows the individual cysts or lobules of various sizes that
contain sticky slimy or viscid material of yellow or brown color.
Clinic. No symptoms are specific for this tumor even in case of large sizes Pain in the
lower part of the abdomen and back region may be present in case of intraligamentous
location Symptoms of adjacent organs compression are present if a tumor is huge
Ascites is rare Bimanual research reveals elastic tumor with lobular surface in the
adnexal region Laparoscopy and ultrasonography can be used for diagnostics
The usual treatment for the obviously benign mucinous cystadenoma is unilateral
oophorectomy In older women after 45 bilateral oophorectomy and hysterectomy are
preferable Total hysterectomy with bilateral salpmgoopho-rectomy are indicated m case
of coexisting cervical pathology
Pseudomyxoma
Pseudomyxoma is one of the kinds of mucinous cystadenoma The incidence of these
tumors is low The tumor is multilocular and has a thm wall It can be ruptured
spontaneously or during the pelvic exam. Pseudomyxoma peritoneal is the complication
that may result if the contents of mucinous cyst is spilled into the peritoneal cavity by
rupture, extension or at surgery Sticky slimy material which is spilled into the peritoneal
cavity doesn't absorb Diffuse implants develop into all the peritoneal surfaces with
tremendous accumulation of mucinous material within the peritoneal cavity .
Clinic. Pain is the main characteristic sign of pseudomyxoma The clinical course is
usually progressive malnutrition and emaciation The palpation of the abdomen is
painful.
Pelvic exam reveals elastic tumor, frequently of large sizes which is situated near uterus
The diagnosis is proved during operation.
Treatment is surgical. The fluid is difficult to remove because of its viscosity Repeated
chemotherapy may be required in postoperative period.
Cystadenofibroma
Cystadenofibroma is a benign tumor which is developed from ovarian stroma It has
round or oval form, it is firm and unilateral and may reach the sizes of fetal head The
age distribution is 40-50 years old It has asymptomatic duration or sometimes it is
accompanied by ascitis Hydrothorax and anemia may be present in rare cases (Meigs
Syndrome)
The treatment is surgical — removal of the tumor
SPECIAL FORMS OF OVARIAN TUMORS
Androblastoma (arrhenoblastoma)
Clinic. Breast, uterine and female external genitalia atrophy are the characteristic signs.
Uterine and ovarian hyporplasia, endometrial atrophy are common. Amenorrhea and all
masculinizing features are present. The combination of masculinizing and feminizing
symptoms is possible.
Diagnosis. Ultrasonography, laparoscopy and ovarian biopsy play an important role at
confirmation of diagnosis.
Treatment is surgical — removal of the tumor.
In the majority of cases prognosis is favorable.
Thecoma (Theca cell tumor)
Thecoma belongs to the feminizing tumors. It occurs at all ages but is common after
40 years old and later. The evidence indicates that thecomas arise from the ovarian
cortical stroma. Theca cell tumors are unilateral and in most cases they are not
malignant. Their sizes may vary from small to those of fetal head. The external surface
is firm, ovoid or round, smooth, and gray, occasionally streaked with yellow. Symptoms
are related to estrogen production.
Diagnosis is based on clinic, bimanual research, ultrasonography, laparoscopy and
hysteroscopy.
Treatment is surgical.
Prognosis is good in favorable duration and it is unfavorable during the malignant
course.
Folliculoma
Folliculoma is a hormonal active tumor which produces estrogenic components and
may be manifested in patients through feminizing characteristics. It varies from
microscopic inclusions to 40-50 cm in diameters, they are yellow-colored.
Clinic. Symptoms depend on the level of hyperestrogenemia and on the women age.
The girls have the signs of precocious puberty In reproductive age group women
amenorrhea, acyclic bleeding, and later menopausal uterine bleeding may be present.
Combination of feminizing syndrome with infertility and menstrual function
impairment testifies the presence of hormonal active tumor.
Diagnosis is based on the ultrasonography results, laparoscopy, histologic examination
of tissue.
Treatment is surgical. In malignant duration of the disease total hysterectomy with
omentum major incision should be performed. Chemotherapy is prescribed in III-IV
stages of cancer.
Benign cystic teratoma (Dermoid cyst)
Dermoid cysts are almost always ovarian tumors. The tumors may occur at any age
Dermoids are bilateral and have 5-10 cm in diameter At operation, the tumors are found
to be round with smooth, glistening, grey surface At body temperature, they have the
consistency of other tensely cystic tumors
Clinic. No symptoms are common for small sizes tumors. Pain is present in case of
large tumors. Ultrasonography, laparoscopy are used for diagnosis.
Treatment is surgical. It consists of excision of the cyst, conserving the remaining
portion of the ovary.
Prognosis is favorable. In 0,4-1, 7% of patients malignant degeneration of tumor is
present.
Brenner tumor
The Brenner tumor is a fibroepithelial tumor with gross characteristics similar to those
of fibroma. It constitutes approximately l%-2% of all the ovarian tumors and is rarely
malignant. Brenner tumors have been reported in patients older than 50. Frequently a
tumor is unilateral, its shape, sizes and consistency are similar to fibroma.
Clinic. A few Brenner tumors are associated with postmenopausal bleeding, and it is
suggested that some may contain hormonally active stroma. Bimanual examination,
ultrasonography and laparoscopy are diagnostics.
Treatment consists in simple excision or oophorectopmy.
Diagnosis of benign ovarian tumors.
General and pelvic examination should be performed. Differential diagnosis should be
made with uterine fibromyoma, endometriosis, inflammatory tuboovarian tumors and
moving kidney.
Additional methods of investigation such as uterine probbing, culdoscopy, cystoscopy,
urography, X-ray examination, ultrasonography and laparoscopy should be performed.
Thus, benign ovarian tumors have some common peculiarities of clinical course,
such as:
 for a long period of time they are asymptomatic, they are growing into direction
of abdominal cavity. Pain is a common symptom in case when the tumor is
growing intraligamentously
 in the majority of cases cysts and cystadenomas are mobile as a result of pedicle
presence. The anatomical and surgical pedicles are distinguished. The anatomical
pedicle is composed of the infundibulopelvic ligament, the ovarian ligament and
mesoovarium. Surgical ligament composes of all of these structures and fallopian
tube with its nerves vessels. During tumor removal the clamps should be put on
the surgical pedicle below the place of torsion
 the signs of adjacent organs compression are present during tumor' growing
 the tumors are palpated as a rule in the lateral sides of the uterus
Ovarian cysts and cystadenomas' complications
Malignant degeneration. It is most commonly found in serous and papillary
cystadenomas, frequently — in mucinous cystadenomas and very rare in dermoid
ovarian cysts. It is very difficult to reveal the moment of tumor' malignant degeneration,
that's why it is very important to remove the tumor at early stages.
Torsion. If the torsion is incomplete, the result is congression and enlarr gement of the
neoplasm and thrombosis of the vessels. If the torsion is complete and obstructs the
arterial blood supply, a gangrenous necrosis can appear as a result. The symptoms may
be gradual pain and tenderness in the region of the tumor or the abrupt onset of pain
typical of an acute abdominal condition. Immediate surgery is necessary to remove the
compromised tissue.
Purulention. High temperature, symptoms of peritoneal irritation, abdominal pain are
common. Immediate surgery is recommended.
Rupture. In the result of hemorrhage or torsion ovarian cyst may rupture and spill its
contents into the abdominal cavity resulting in intensification of the symptoms. Rupture
of suspected neoplasm should initiate immediate laparotomy for a prudent removal of
the neoplasm
All ovarian tumors warrant surgical removal because of their potential for malignancy,
but it is very difficult to reveal this tumor at early stages.
PRECANCEROUS DISEASES OF THE VULVA
To precancer diseases of the vulva belong:
 leukoplakia
 vulvar kraurosis
 Bowen's disease
 Paget's disease
 pigmented spots, inclined to growth and ulceration
Vulvar leukoplakia
Vulvar leukoplakia is a process, that is characterised by proliferation and violation of
differentiation of stratified squamous epithelium. Histologically hyperkeratosis,
parakeratosis, acanthosis without expressed cellular and nuclear polimorphism are
found.
Clinically it is manifested by itching, burning, that becomes a cause of skin
traumatizing, infecting of vulva, its ulceration.
Treatment. Sedative therapy (preparations of bromide, valerian) and also hormonal
therapy (androgens, sometimes with small doses of estrogens) are prescribed. Local
treatment is performed by corticosteroid ointments. Good effect has magneto-laser
therapy. Sometimes X-ray therapy is used.
Vulvar kraurosis
Vulvar kraurosis is a disease, that manifests itself by atrophy of labia major and
minor, clitoris, by corrugation of the skin and mucous membrane of the external genital
organs, coming out of hair. Skin and mucous membranes become dry, easilly
traumatized, acquire dull pearl colour with grey-blue hue. During the colposcopy the
expressed telangiectases are found.
Clinical manifestations. Patients complains of itching, burning and pain during
urination. Frequently they scratch skin, that can lead to the secondary infection.
Constant itching causes irritability, sleep disturbances and other vegetative disorders.
Treatment Replacement therapy, psychotherapy, sleeping-draughts, sedative remedies
are prescribed. Baths with camomile decoction, predmsolon ointment, oxycort, ointment
with anesthesin are prescribed locally. Treatment is not always effective. From nonmedicinous methods magneto-laser therapy, gas and semiconductor apparates have been
also used.
Bowen's disease
Bowen's disease is followed by appearing on the external genitals skin of flat or
slightly rising above skin level spots with clear margins. Histologically the signs of
hyperkeratosis and acanthosis are found.
Paget disease. At Paget disease during gynecological examination on skin of vulva
scarlet eczema-like spots with granular surface are found. Treatment is surgical.
Vulvectomy is recommended.