BENIGN DISEASES OF THE FEMALE SEXUAL ORGANS

BENIGN CERVICAL LESIONS

True cervical erosion - 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.

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).

Algorithm for investigation for all cervical lesions

        Speculum exam

        Pap smear, bacterioscopy

        Visual inspection after application acetic solution

        Colposcopy

        Biopsy

Treatment.

-         Destruction of erosion by electrocoagulatio

-         Destruction by chemical agents – Solcovagyn

Till 23 years old cervical erosion doesn’t need treatment because of its dyshormonal origin – normalization of hormonal state.

 

Cervical pseudoerosion is a benign pathological process, which is characte­rised by presence of original columnar endocervical tissue on exocervical surface.

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).

Diagnosis –the same as erosion

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:

l women with congenital epithelial ectopy are subject to supervision till 23 years. They need no treatment

l 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).

-         Destruction of erosion by electrocoagulatio

-         Destruction by chemical agents – Solcovagyn

Polyps of mucous membrane of cervical canal are created from the mu­cous of the external os, middle or upper third part of endocervix.

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).

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 as in previous situations  

Treatment.

-         screwing it off with the following coagu­lation of its pedicle, if its base is visible

-         endocervical curettage with the following histolo­gical examination is performed

-         cryodestruction of polyp’s base .

 

Cervical endometriosis is characterized by the presence on the cervical sur­face of rust colored, dark brown spots those have been described as “mulberry” or “raspberry”.

 

Cervical ectropion is an inversion of cervical mucous as a result of badly renewed cervix after labour trauma

A surface, that is formed in the result of rupture, heals over thanks to the columnar epithelium of the cervical canal. So, the ectopic epithelium finds itself outside of endocervix borders in acid vaginal, is infected, leads to chronic endo­cervicitis and the cervical hypertrophy. Cervical barrier function is disturbed, microorganisms get into the uterus, causing endometritis development in subacute or chronic form.

Clinic. In some cases patients have no complaints.

Diagnosis - as in previous situations  

Treatment.

-   Recon­structive-plastic surgeries- 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 Leukoplakias without atypia belong to hyperkeratoses. Leukoplakia is a pathological state of epithelium that is characterized by its thickness and cornification. 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.

Diagnosis - as in previous situations  

Treatment.

·        Electroexcision should be performed in the limited areas of leukoplakia.

·        Estrogens  in tampons

·        Cryodestruction and high-intensive action of Carbon laser have higher effecti­veness.

UTERINE MYOMA

Uterine myoma (fibromyoma, leiomyoma) — is a benign tumor which con­tains varying amounts of muscle and fibrous elements.

According to their location in the uterus myomas are classified into:

l 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

l interstitial (intramural, intraparietal)— uterine fibroids, which are growing within the muscular wall of the uterus, their frequency is 40-45%

l submucosal— uterine fibroids which are growing under the uterine mucous into the uterine cavity, their frequency is 20% of all the patients

l 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).

Clinic. Clinical manifestation of fibromyomas depends on uterine fibroid’s location, size of tumour, rate of its growing, and also presence of complications.

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 sub­serosal 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.

Excessive bleeding (hypermenorrhagia) and development of progressively heavy menstrual flow that lasts longer than the normal duration (polymenorrha­gia), may result from the increased surface area of the endometrium when intra­mural tumors enlarge and distort the endometrial cavity. Large tumors, especially mul­tiple myomas make mechanical interference with the blood supply to the endo­metrium, and the presence of intramural tumors may interfere with the ability of the uterus to contract and effectively occlude blood vessels at the time of menstru­ation.

Cyclic menstruation is present but it is painful (algome­norrhea).

Submucosal location of uterine fibroid is characterized by cramping cyclic menorrhagia which has been changed into acyclic bleeding.

Monthly appreciable bleeding leads to the secondary iron deficiency anemia.

Uterine myoma is frequently connected with the other gynecololic and extra­genital diseases. They are obesity (64%), diseases of cardiovascular system (60%), diseases of stomach, intestine, liver (40%), idiopathic arterial hypertension (19%), neuro­ses (11%), endocrinopathy (4,5% of the patients).

Diagnosis of uterine myoma

·        Speculum investigation

·        Bimanual examination

·        Uterine sounding and curettage of uterine cavity (relief’ changes, presence in uterine cavity of submucous fibroid, endomet­rial hyperplastic processes).

·        Ultrasography

·        Hysteroscopy

·        Laparoscopy

Uterine fibroids’ ñomplications:

·        Prolapse of submucous fibroid
(cervical protruding myoma)

·        Torsion of uterine fibroid

·        Uterine fibroid’ necrosis

·        Uterine fibroid’ suppuration

·        Pseudocapsule’ and uterine fibroid’ vessels rupture

·        Malignant degeneration of uterine fibromyoma

TREATMENT OF UTERINE MYOMA

Treatment of fibromyoma should be operative and conservative.

Indications to operative treatment of uterine myoma are:

·        myomatous uterus larger than 12-week of pregnancy,

·        acceleretion of tumor growing,

·        presence of such symp­toms as pain, bleeding, secondary anemia; myoma’s complications;

·        suspicion on malignant degeneration and combining with endometriosis and endometrial hyper­plasia.

·        Fast growing myoma

Surgical interventions are divided into radical and conservative — plastic ones.

Radical operations are in uterine removal — total hysterectomy or subtotal 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 in  young women for anatomo-functional safety of uterus, fallopian tubes, ovaries and ligaments.

·        Myometrectomy (incision of myometrial part with fibroid)

·        Defundation (incision of a myometrial part above a level of fallopian tubes fixation)

·        Conservative myomectomy (incision of a single myomatous node)

·        Pedunculated submucous fibroid should be removed by endo­scopic way through uterine cervix.

 

Conservative treatment of uterine fibromyoma has been confirmed patho­genetically 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, in case of myoma duration with poor symptoms or without any symptoms, at presence of contraindications to operative treatment.

        Gonadotropin-Releasing Hormone Agonists -  should be restricted to a 3- to 6-month interval, following which regrowth of fibroids usually occurs within   12 weeks.

        estrogen–progestin combinations

        Gestagens (depot medroxy-progesterone acetate (Depo-Provera), IUD - MIRENA

        Danazol has been associated with a reduction in volume of the fibroid in the order of 20% to 25%.

Uterine fibroid embolization (UFE) is a minimally invasive treatment. The procedure is also sometimes referred to as Uterine Artery Embolization (UAE), but this term is less specific and, as will be discussed below, UAE is used for conditions other than fibroids.

In a UFE procedure, physicians use an x-ray camera called a fluoroscope to guide the delivery of small particles to the uterus and fibroids. The small particles are injected through a thin, flexible tube called a catheter. These block the arteries that provide blood flow, causing the fibroids to shrink. Nearly 90 percent of women with fibroids experience relief of their symptoms.

Because the effect of uterine fibroid embolization on fertility is not fully understood, UFE is typically offered to women who no longer wish to become pregnant or who want or need to avoid having a hysterectomy which is the operation to remove the uterus.

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

III. Lipid cell tumors

IV. 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

Unblastomatic unproliferative
ovarian tumors

(ovarian cysts
)

Follicle ovarian cyst is a single tumor with a thin membrane of mobile consis­tency with a straw-colored fluid. Its formation is a result of fluid retention in atre­tic follicles.

Clinic. The main symptom is the low abdominal pain, rarely menstrual cycle impairment or uterine bleeding as a result of hyperstimulation from exo­genous gonadotropins is observed. Signs of acute abdomen are present in the case of ovarian cyst torsion. Bimanual examination reveals ovarian enlargement up to 10 cm. it is mo­bile, cystic, unilateral mass. Sometimes inflammatory processes in uterine ad­nexa are present. Follicle cysts rarely produce any symptoms and diagnosis is often made during monitoring.

Treatment. Observation for 2-3 menstrual cycles is necessary. If a spon­taneous resolution doesn’t occur, surgical intervention — ovarian resection or oophorectomy — should be recommended. It is very necessary because before surgical intervention it is difficult to make a differential diagnosis of ovarian cyst and serous cystadenoma.

Additional therapy is not recommended after operation.

Corpus luteum cyst is an unilateral cystic enlargement which exceeds 8 cm in dia­meter. Grossly, the cyst protrudes from the contour of the ovary and the wall appears convoluted and thick. 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 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.

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.

Blastomatic proliferative ovarian tumors  (ovarian cystadenomas)

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 – salpingooophorectomy.

The papillary ovarian cystadenomas -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 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 salpingo­opho­rectomy are indicated in case of coexisting cervical pathology.

Pseudomyxoma is one of the kinds of mucinous cystadenoma.

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 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 which is usually masculinizing tumor is reported to produce masculinization. It occurs very rarely and its duration is also malignant. Andro­blastoma is unilateral tumor with smooth or lobular surface. It has small sizes and pedicle and it is mobile.

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.

Thecoma belongs to the feminizing tumors. It occurs at all ages but is com­mon after 40 years old and later.

In women of reproduc­tive age group such symptoms as impairment of menstrual function, infertility and pregnancy loss are common. Menopause bleeding, enlarged sizes of uterus and breasts, increasing libido are present in these patients. Ascites may be present in favorable and unfavorable duration of disease. Malignant degeneration of tumor is frequen­tly common in young patient.

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 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. Folliculoma may have good as well as malignant potential. It is always uni­lateral with lobular surface. They occur at all ages but are common in women older than 40. Uterine fibromyoma and uterine cancer can coexist with folliculoma.

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.

Dermoid cysts are almost always ovarian tumors.

On sectioning, they are usually unilocular and filled with thick sebaceous material and tangled masses of hair .  In 30% to 50% of cases cysts contain the formed teeth. Slow growing, without any symptoms, as a rule, is a characteristic feature of the tumor.

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.

The Brenner tumor is a fibroepithelial tumor with gross characteristics similar to those of fibroma. Brenner tumors have been reported in patients older than 50. Frequently a tumor is unilateral, its shape, sizes and consis­tency are similar to fibroma. According to the most widely accepted theory of histogenesis, Brenner tumors arise from the Walthard cell rests which are
a mo­dification and inclusion of the surface or germinal epithelium of the ovary).

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

·        Speculum investigation

·        Bimanual examination

·        Uterine sounding .

·        Ultrasography

·        Laparoscopy

Ovarian cysts and cystadenomas’ complications

·        Malignant degeneration-  most commonly found in serous and papillary cysta­denomas, frequently — in mucinous cystadenomas and very rare in dermoid ovarian cysts.

·        Torsion of cystoma

·        Purulention - high temperature, symptoms of peritoneal irritation, abdominal pain are common. Immediate surgery is recommended.

·        Rupture - 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