UP PGH 2019 Interns Review 1 Benign Gyne

Review
of Benign
Gynecologic Lesions
Maria Julieta V. Germar ,M.D., FPOGS, FSGOP

Section of Gynecologic Oncology
UP College of Medicine
1
1
GERMAR September 2018
Review Outline
• Reproductive Anatomy
• Menstrual Cycle
• Physiology
• Abnormal bleeding
• Amenorrhea
• Benign Gyn Lesions
2
Reproductive Anatomy
External Genitalia : VULVA
mons pubis, clitoris, urinary meatus, skene’s ducts ,Labia Majora, Labia minora,
vestibule, Bartholin’s glands , periurethral glands , vestibular bulbs
Internal Genitalia :
VAGINA, uterus, cervix, oviducts, ovaries, suporting structures, true pelvis
3
Where are GARTNER DUCTS located ?

• LATERAL walls of the vagina
Junction of lower and middle third
• ANTERIOR lower third of the vagina
• The greater vestibular glands are also known
by what name?
Bartholin glands.
• Where are Bartholin glands located?
4 and 8 o’clock. They drain between the
hymenal ring and labia minora.
4
Reproductive Anatomy VAGINA
• The Normal vagina does NOT have glands

• What is the source of vaginal lubrication during
intercourse ?
• Transudate produced by engorgement of the vascular
plexuses that encircle the vagina
• Rich vascularity make it easy for suppositories to be
absorbed bypassing the liver
5
Reproductive Anatomy CERVIX
• It is usually 2.5 to 3 cm in length and 7 to 8
mm at its widest point.
• The major arterial supply to the cervix is
located in the lateral cervical walls at the
3 and 9 o'clock positions.
• Ectocervix devoid of nerve endings; biopsy
cautery with no pain
• Endocervix:The pain fibers from the cervix
accompany the parasympathetic fibers to S2-
S4 Referred pain from cervical inflammation is
characterized as low back pain.; reflex
bradycardia; VASOVAGAL response
• The transformation zone of the cervix
encompasses the border of the squamous
epithelium and columnar epithelium. 6
Reproductive Anatomy UTERUS
• The uterus of a nulliparous woman is approximately 8cm x 5
cm x 2.5 cm and weighs 40 to 50 g.
• In a multiparous woman each measurement is approximately
1.2 cm larger and normal uterine weight is 20 to 30 g heavier.
• anteverted in respect to the long axis of the vagina &
anteflexed in relation to the long axis of the cervix.
• The arterial blood supply of the uterus is provided by the
uterine and ovarian arteries.
• Afferent nerve fibers from the uterus enter the spinal cord at
T11-T12 Referred uterine pain is often located in the lower abdomen.
7
Reproductive Anatomy UTERUS
• Arterial blood supply to the

uterus is derived from what
arteries?
UTERINE and OVARIAN arteries.
The uterine from hypogastric
(aka internal iliac) Ovarian
artery directly from the aorta
• Terminal branch of the
hypogastric artery
INTERNAL PUDENDAL artery (
supplies rectum, labia, clitoris ,
perineum)
8
9
Hematoma on r lateral
vaginal wall
Most vulvar hematomas
result from injuries to
branches of the pudendal
artery (inferior rectal,
perineal, posterior labial,
and urethral arteries; the
artery of the vestibule; and
the deep and dorsal
arteries of the clitoris)
that occur during
episiotomy or from
perineal lacerations
Vulvar trauma such as
straddle injuries frequently
results in
large hematomas or profuse
external hemorrhage. The
richness
of the vascular supply and
the absence of valves in
vulvar veins
contribute to this
complication.
11
• Course of arterial blood supply from the aorta to
the uterus
• Common iliac --- hypogastric/internal iliac---
uterine artery
13
Reproductive Anatomy • The extent of collateral
circulation after
hypogastric artery
ligation depends on the
site of ligation and may
be divided into three
groups:
• branches from the aorta,
branches from the
external iliac arteries, and
branches from the
femoral arteries.
14
The right ovarian vein opens into what structure?
The inferior vena cava.
The left ovarian vein flows into what structure?
Left renal vein.
Name the posterior branch of the hypogastric artery,
which is responsible for gluteal ischemia at the time of
hypogastric artery ligation.
Superior gluteal artery.
15
• Name the external genital muscles whose primary
function appears to be sexual response.
Ischiocavernosus, bulbocavernosus, and superficial transverse
perineal muscles.
• What three muscles constitute the levator ani muscle?
Pubococcygeus , puborectalis and iliococcygeus muscles.
• Innervation of the levator ani is from which nerves
S3-S5
16
Fast Fact
• Upper 2/3 of vagina devoid of nerve endings- forgotten tampon,
foreign body
17
4 Points of Ureteral Injury
1. Clamping or ligating of the

infundibulopelvic vessels
2. Clamping and ligating
cardinals
3. Wide suturing of Ligation of
endopelvic fascia Infundibulopelvic
ligaments
4. Clamping of uterine arteries
18
Common sites of injury
§ During adnexectomy, the
infundibulopelvic ligament is ligated 2 to
3 cm above the adnexa. The ureter lies in
close proximity to these vessels and may
inadvertently be included in the ligation.
§ During hysterectomy, the ureter is

susceptible to injury as it passes under
During Ligation of the uterine artery
pelvic infundibulo
dissection pelvic
ligament § sutures placed during vaginal cuff
closure, where the ureter lies on the
anterior vaginal wall before its entry into
the bladder during anterior
colporrhaphy
80% of ureteral injuries occur during hysterectomy at
Dissection of the level of the internal cervical os and cardinal
Ligation of bladder and
uterine vessels vagina ligament.
Ibeanu OA, Chesson RR, Echols KT, et al. Urinary tract injury during hysterectomy
GERMAR September 2018 based on universal cystoscopy. Obstet Gynecol2009; 113:6.
Prevention of ureteral injury
• Adequate exposure
• Be aware of the ureter
• Visualize and protect the
ureter. Be gentle.
• Be careful about using the
cautery along the ureter
• Cool instruments that
generate heat before
touching the ureter

Factors to consider:
§Skip preoperative IVP in most cases
This measure does not appear to reduce the likelihood of
ureteral injury, even in the face of obvious gynecologic disease.
A stent may not be helpful

stents do not clearly reduce the risk of injury and, in some
cases, may increase the risk by providing a false sense of
security and predisposing the ureter to adventitial injury during
difficult dissection
Magrina JF. Preventing ureteral injury at hysterectomy: Expert

approach . OBG Management 2014
§Identify the ureter
before you clamp the
infundibulopelvic
ligament
§To avoid injury at the
infundibulopelvic
ligament level, visual
confirmation of ureter
course is vital.
. Infundibulopelvic
ligament
Ureter
Illustration from Cundiff et al. Te Linde’s Atlas of Gynecologic Surgery 2014
§ Identify the ureter
before you clamp the
infundibulopelvic Infundibulopelvic
ligament ligament
§ To avoid injury at the

infundibulopelvic
ligament level, visual ovary
confirmation of ureter
course is vital. FallopianTube
Ureter
.
MJV GERMAR 3 March 2017

GERMAR September 2018Management of Intraoperative Complications
• During hysterectomy, mobilize
the bladder and ureter
• Mobilize the soft tissues that
contain the bladder and ureters
caudally and laterally,
respectively, creating a U-
shaped region.
• During division of the
paracervical tissues, the
surgeon must remain within
this region
Magrina JF. Preventing ureteral injury at hysterectomy: Expert approach .

GERMAR September 2018 OBG Management 2014
Contained within the broad ligaments are the following
structures:
1.oviducts
2.ovarian ligament
3. round ligament
4. Ureters
5. ovarian arteries
6. uterine arteries and veins
7.parametrial tissue
8. embryonic remnants of the mesonephric duct and
wolffian body
The cardinal ligaments provide the major
support to the uterus.
25
Menstrual Cycle Physiology
26
MENSTRUAL CYCLE PHYSIOLOGY
Average duration of menstrual cycle
28 days [21-35 days]
Average duration of menstrual flow
4 days
Ave menstrual blood loss
35-60mL
Average iron loss due to menses
13 mg
Extremes of reproductive life (after menarche and
perimenopause) - characterized by a higher percentage
of anovulatory or irregularly timed cycles
Abnormal uterine bleeding
Bleeding fromthe uterine corpus that is
abnormal in regularity, volume, frequency, or
duration and occurs in the absence of pregnancy
May be acute or chronic
Munro MG, Critchley HO, Broder MS, Fraser IS. FIGO classification system (PALM-COEIN)
for causes of abnormal uterine bleeding in nongravid women of reproductive age.
FIGO Working Group on Menstrual Disorders. Int J Gynaecol Obstet 2011
Diagnosis of abnormal uterine bleeding in reproductive- aged women. Practice Bulletin No. 128. American
College of Obstetricians and Gynecologists. Obstet Gynecol 2012
28
DEFINITION OF MENSTRUAL CYCLE IRREGULARITIES (old terminology)
IRREGULARITY DEFINITION
OLIGOMENORRHEA Infrequent IRREGULARLY timed episodes of bleeding usually occurring at
intervals of more than 35 days
POLYMENORRHEA Frequent but REGULARLY timed episodes of bleeding usually occuring at

intervals of 21 days or less
MENORRHAGIA REGULARLY timed episodes of bleeding that are EXCESSIVE in amount

HMB (> 80 ml) and duration of flow (> 5 days)
METRORRHAGIA Irregularly timed bleeding or bleeding between periods

Intermenstrual Bleeding
MENOMETRORRHAGIA EXCESSIVE, PROLONGED bleeding that occurs at IRREGULARLY timed
frequent intervals
HYPOMENORRHEA REGULARLY timed bleeding that is decreased in amount
INTERMENSTRUAL Bleeding usually not of an excessive amount that occurs between

BLEEDING/SPOTTING otherwise normal menstrual cycles 29
Cyclic Changes of the Endometrium
§ Decidua functionalis - superficial 2/3 & cycling portion of the
endometrium; proliferates and is ultimately shed with each cycle
if pregnancy does not occur.
§ Stratum compactum - superficial compact zone the endometrium. Mostly stroma. Site of
blastocyst implantation.
§ Stratum spongiosum - deeply situated intermediate zone. Mostly glands . . Maintains
integrity of the mucosa .
§ Stratum basale - deepest region of endometrium. It does not
undergo significant monthly proliferation & do NOT desquamate
during menstruation

New Terminology
• Heavy Menstrual Bleeding
• Acute
• Chronic > 6 months
• Intermenstrual Bleeding

CAUSES OF BLEEDING BY APPROXIMATE
FREQUENCY AND AGE GROUP
(LIFE CYCLE APPROACH)
Birth 10 20 30 40 50 60
1 4 6
Estrogen withdrawal Anovulation Atrophic vaginitis
Central, intermediate, gonadal Carcinoma (uterine, ovarian)
Functional Estrogen replacement
Blood dyscrasia, hypothyroidism, luteal dysfunction
2 Latrogenic
Anticoagulation, contraception (hormonal intrauterine),
Foreign body hemodialysis
Infection Pregnancy
Sarcoma botryoides Abortion, ectopic, placental polyp, retained products,
Ovarian tumor trophoblastic disease
Trauma Uterine
Infection, structural (fibroids, hyperplasia, neoplasia,
polyps)
3 5
Blood dyscrasia Carcinoma
Hypothalamic immaturity (cervical, uterine)
Inadequate luteal function Climacteric
Psychogenic (including anorexia and bulimia) Polyps
Shwayder JM. Obstet Gynecol Clin North Am. 2000;27(2):219-234.

Birth 10 20
1
Estrogen withdrawal
2
Foreign body
Infection
Sarcoma botryoides
Ovarian tumor
Trauma
3
Blood dyscrasia
Hypothalamic immaturity
Inadequate luteal function
Psychogenic (including anorexia and bulimia)

10 20 30 40 50 60
4
Anovulation
Central, intermediate, gonadal
Functional
Blood dyscrasia, hypothyroidism, luteal dysfunction
Latrogenic
Anticoagulation, contraception (hormonal
intrauterine), hemodialysis
Pregnancy /Accidents of Pregnancy
Abortion, ectopic, placental polyp, retained
products, trophoblastic disease
Uterine
Infection, structural (fibroids, hyperplasia,
neoplasia, polyps)

40 50 60
6
Atrophic vaginitis
Carcinoma (uterine, ovarian)
Estrogen replacement
5
Carcinoma
(cervical, uterine)
Climacteric
Polyps

PALM-COEIN
FIGO Classification System (PALM-COEIN) for causes of AUB in non
gravid women of reproductive age
Structural vs. Non-Structural
Developed to create a universally accepted nomenclature

Published in 2011 and used by 2012
37
PALM
Structural Causes
can be measured visually with imaging techniques and/or
histopathology,
P- Polyp (AUB-P)
A- Adenomyosis (AUB-A)
L- Leiomyoma (AUB-L)
Submucosal myoma (AUB-LSM)
Other myoma (AUB-LO)
M- Malignancy & hyperplasia (AUB-M)

COEIN
Non-Structural Causes
related to entities that are not defined by
imaging or histopathology (non-structural).
C- Coagulopathy (AUB-C)
O-Ovulatory dysfunction (AUB-O)
E- Endometrial (AUB-E)
I- Iatrogenic (AUB-I)
N- Not yet classified (AUB-N

40
Management of AUB
• Achieve initial goals of therapy.
ØControl the bleeding.
ØTreat anemia (if present).
ØRestore quality of life.
• Primary etiology should be treated.
• Medical therapy: preferred initial treatment
41
Medical Treatment of Acute AUB
Drug Suggested Dosing schedule
dose
Conjugated equine 25 mg IV q 4–6 hrs for 24 hrs
estrogen 2.5 mg PO q 6 hrs
Combined oral Monophasic 3x/day for 7 days
contraceptives COC 3x/day
Medroxyprogesterone 20 mg orally 3x/day for 7 days
acetate
Tranexamic acid 1.3 g PO or 3x/day for 5 days
10 mg/kg IV (every 8 hours )
DeVore GR, Owens O, Kase N. Use of intravenous Premarin in the treatment of DUB:
a double-blind randomized control study. Obstet Gynecol 1982
Munro MG, Mainor N, Basu R, Brisinger, Barreda L. Oral medroxyprogesterone acetate and combination oral
contraceptives for acute uterine bleeding: a randomized controlled trial. Obstet Gynecol 2006
James AH, Kouides PA, et al. Evaluation and management of acute menorrhagia in women with and without underlying
bleeding disorders: consensus from an international expert panel. Eur J Obstet Gynecol Reprod Biol 2011 42
VULVAR LESIONS
43
SKENES CYST
These are cystic dilations
of the Skene glands,
typically located adjacent
to the urethral
meatus within the vulvar
vestibule. Although most
are small and often
asymptomatic,
they may enlarge and
cause urinary
obstruction, requiring
excision
44
Behçet’s Disease • This systemic condition is
characterized by genital and
oral ulcerations with ocular
inflammation and many
other manifestations
• The cause and the most
effective therapy are not well
established
• anti-inflammatory and
immunosuppressive
therapies may be effective
45
RED OR WHITE PATCHES
AND PLAQUES

Candidiasis
Intense Pruritus
Etio- Candida albicans
pathogenesis
Symptoms Intense pruritus vulvae, pqin,
dyspareunia, cottage cheese-like
discharge
PE Bright red, sometimes eroded

patches and plaques involving
varying portions of the vulva and
the upper inner thighs
Diagnosis History and PE
Microscopy of a wet saline or KOH
prep of vaginal fluid shows
hyphae, pseudohyphae, or
budding yeast ( spaghetti and
meatballs )
Management Fluconazole 150 mg SD
Topical antimycotics
Miconazole suppository

Lichen simplex chronicus
Incessant scratching / localized atopic
dermatitis
Etio- Vulvar tissue is more permeable
pathogenesis than exposed skin due to
differences in structure, occlusion,
hydration, and susceptibility to
friction
Symptoms severe pruritus. Incessant
scratching leads to more itching
"itch-scratch cycle."
PE Red brown, poorly marginated,
excoriated or lichenified
(whitened)plaques predominately
involving the labia majora and the
outer aspect of the labia minora;
Diagnosis History and PE
Management Behavioral modification

medium potency topical
corticosteroid ointments
Lichen sclerosus
Severe pruritus in hypoestrogenic states
Etio- highest incidence during low-
pathogenesis estrogen physiologic states, such as
the premenarchal child and the
postmenopausal woman
Symptoms Itching is usually prominent, but it can
be replaced by pain if there is
widespread erosion
PE white patches, close inspection
shows slight wrinkling : “cigarette
paper “ wrinkling. Notable on labia
majora but also involve the perineum
and perianal skin in a figure of 8
pattern
he whitened tissue becomes
increasingly thickened as the disease
progresses
Diagnosis Clinical
Management Behavioral modification
topical corticosteroid ointments-
Clobetasol
Vulvar Intraepithelial Neoplasia
Premalignant Vulvar lesion
Risk Factors Human papillomavirus (HPV) infection,
cigarette smoking, and immunodeficiency
or immunosuppression
Symptoms asymptomatic
PE varying numbers of red or red-brown,
sharply marginated, flat-topped papules
anywhere on the vulva
a solitary, white to pink, red, skin-colored,
or brownish papule or nodule 2 to 5 cm
in diameter, located on the vulva, usually
within the vestibule
Diagnosis Biopsy
Management Wide local excision
Skinning vulvectomy
Ablative therapy
Topical treatment
Pagets Disease of the Vulva
occurs only in women over the age of 60 years
Etio- an intraepithelial adenocarcinoma,
pathogenesis accounts for less than 1 percent of all
vulvar malignancies
Symptoms Pruritus
PE Hyperemic tissue
Cake icing effect GE
RM
one or more red patches or plaques. AR
The surface of the lesions usually Vul
demonstrates multiple shallow var
an
erosions d
Va
gin
Diagnosis Biopsy al
evaluate for synchronous neoplasms, Lesi
ons
as 30 % have adenocarcinoma involving
AS
breast, rectum, bladder, urethra, cervix,
MP
or ovary H
Jan
uar
y
Management wide local excision or vulvectomy 23,
201
7
Benign Lesions of the Cervix
Endocervical Polyp
Nabothian Cyst
Cervical Myoma

Endocervical Polyps
• Most common benign
neoplasm of the cervix
• Usually found in the 4th to
6th decade of life.
• May be single or multiple
and may be pedunculated
lesion on a stalk of varying
length.
• May be cervical or
endocervical

Endocervical polyps • Polyps may arise from either the
endocervical canal (endocervical
polyp) or ectocervix (cervical
polyp).
• Endocervical polyps are more
common than are cervical
polyps.
• Polyps whose base is in the
endocervix usually have a
narrow, long pedicle and occur
during the reproductive years,
whereas polyps that arise from
the ectocervix have a short,
broad base and usually occur in
postmenopausal women.

Endocervical polyps
Etiopathogenesis:
• abnormal focal responsiveness to hormonal stimulation or local
inflammation
• The color of the polyp depends in part on its origin, with most
endocervical polyps being cherry red and most cervical polyps grayish
white.

Endocervical Polyps CLINICAL PRESENTATION
• Polyps bleed easily to touch
• Usually asymptomatic but may also
present as abnormal bleeding: post coital
bleeding, menorrhagia, postmenopausal
bleeding
DIAGNOSIS
• Speculum examination then Biopsy
MANAGEMENT
• Polypectomy,
surgical dilatation and curettage,
hysteroscopic polypectomy

Endocervical Polyps
Nabothian Cyst
Cervical Myoma

Nabothian Cysts
• mucus-filled lesions ,multiple
translucent or opaque, white
or yellow lesion ranging from
2mm to 10mm in size.
• retention cysts of
endocervical columnar cells
occurring where a tunnel or
cleft has been covered by
squamous metaplasia.
• These cysts are so common
that they are considered a
normal feature of the adult
cervix
Nabothian cysts
• The area of the
transformation zone of the
cervix is in an almost
constant process of repair,
and squamous metaplasia
and inflammation may block
the cleft of a gland orifice.
• The endocervical columnar
cells continue to secrete,
and thus a mucous
retention cyst is formed.

Nabothian Cysts CLINICAL PRESENTATION
• asymptomatic
• tend to occur following
natural tissue regrowth after
minor trauma or
after childbirth.
DIAGNOSIS
• Clinical, Speculum exam
MANAGEMENT
• usually asymptomatic and
need no treatment.
Endocervical Polyps
Nabothian Cyst
Cervical Myoma

Cervical Myoma • A cervical myoma is usually a
solitary growth
• Because of the relative paucity of
smooth muscle fibers in the
cervical stroma, the majority of
myomas that appear to be cervical
actually arise from the isthmus of
the uterus.
• CLINICAL PRESENTATION:
• Vaginal Bleeding
• dysuria,urgency, obstruction and
dyspareunia
Cervical Myoma
DIAGNOSIS
• Speculum, Pelvic
examination, Biopsy
MANAGEMENT
• if reproductive age : GnRH
agonists ( to shrink myoma),
excision
• If completed family size:
Hysterectomy

Benign Lesions of the Uterus
Endometrial Polyps
Adenomyosis
Leiomyoma

Endometrial polyp
• Hyperplastic overgrowth of endometrial glands and

stroma projecting beyond the surface of endometrium
with a vascular stalk
• Metrorrhagia (irregular
bleeding) - most common
presentation
•Treatment:
•Hysteroscopic resection
followed by curettage (gold
standard)
•GnRH agonists - short-term
Adenomyosis
• Ectopic endometrial
glands and stroma within
the uterine musculature
• Menorrhagia and
dysmenorrhea with a
symmetrically enlarged,
tender, and boggy uterus
• Rarely enlarges beyond 14
weeks size
• Tx: hysterectomy
Uterine Leiomyomas
• Benign tumors of the smooth
muscle cells (myometrium) of
the uterus
• Found in 20–30% of
reproductive-age women
• Each individual myoma is
monoclonal arising from a
single muscle cell. Stimulus for
growth is unclear but partially
related to estrogen stimulation

Fibroid
Classification
• From Munro MG, Critchley HO, Broder MS, et

al. FIGO Working Group onMenstrual
Disorders. FIGO classification system (PALM-
COEIN) for causes of abnormal uterine
bleeding in nongravidwomen of reproductive
age. Int J Gynaecol Obstet 2011;113:3–13)
68
The “MOST COMMON”
Most common cause of • FOREIGN BODY IN THE

vaginal bleeding in
CHILDHOOD VAGINA
Most common cause of
vaginal bleeding in
REPRODUCTIVE age • ACCIDENTS OF PREGNANCY
women
vaginal bleeding in
POSTMENOPAUSAL • ATROPHIC ENDOMETRIUM
women
69
Most common benign

cervical neoplasia • ENDOCERVICAL POLYP
Most common pelvic

tumor • LEIOMYOMA

vaginal bleeding in
POSTMENOPAUSAL • ATROPHIC ENDOMETRIUM
women
70
BENIGN GYN LESIONS
71
71
Causes of pelvic mass by approximate
frequency and age group
PREPUBERTAL ADOLESCENT REPRODUCTIVE PERIMENOPAUSAL POSTMENOPAUSAL
Functional cyst Functional cyst Functional cyst Fibroids Ovarian tumor

(malignant or
benign)
Germ cell Pregnancy Pregnancy Epithelial Functional cyst
tumor ovarian tumor
Dermoid/other Uterine fibroids Functional cyst Bowel,
germ cell malignant tumor
tumors or inflammatory
Obstructing Epithelial Metastases
vaginal or ovarian tumor
uterine
anomalies
Epithelial
ovarian tumor

Benign Ovarian
Lesions
73
73
Functional Ovarian Cysts
• Benign anatomic variations
resulting from irregularities
in normal ovarian function
• Follicular cysts
• Corpus luteum cysts
• Theca lutein cysts
• Expectant management
• Unless there is severe pain or
when there is suspicion of
malignancy, rupture or torsion

FOLLICULAR CYSTS
Most frequent cystic structures in normal ovaries
Common among young menstruating women
May result either from:
Dominant mature follicle's failing to rupture (persistent follicle)
Immature follicle's failing to undergo the normal process of atresia
Majority are asymptomatic, slight discomfort

FOLLICULAR CYSTS
• Diagnosis: TVS to differentiate simple from complex cysts
• Treatment:
Conservative observation
• majority disappear spontaneously
• reabsorption of the cyst fluid
• silent rupture within 4-8 weeks of initial diagnosis

CORPUS LUTEUM CYSTS
• Arise from hemorrhage within a persistent mature
corpus luteum → accumulating hematoma →
secondary cystic change
• May be associated with either normal endocrine
function or prolonged secretion of progesterone
• Vary from being asymptomatic

masses to those causing
catastrophic & massive
intraperitoneal bleeding
associated with rupture

CORPUS LUTEUM CYSTS
Halban's syndrome
◦ persistently functioning corpus luteum cyst
◦ clinical features similar to an unruptured ectopic pregnancy
delay in a normal period followed by spotting
unilateral pelvic pain
small tender adnexal mass
Management:
Usually managed conservatively or by surgery
◦ Cystectomy - operative treatment of choice

THECA LUTEIN CYSTS
• Theca layer undergoes
marked luteinization
under the influence of
luteinizing gonadotropic
hormones
• Almost always bilateral
• Produce moderate to
massive enlargement of
the ovaries

THECA LUTEIN CYSTS
• Associated with pain / discomfort, amenorrhea, bleeding
• Associated conditions
• Molar pregnancies
• Choriocarcinoma
• Conditions with large placentas (twins, DM, Rh sensitization)
• Intake of drugs inducing ovulation
• Juvenile hypothyroidism
• Conservative treatment ⇒ gradually regress

Benign Cystic Teratoma / Dermoid cyst
• Benign ovarian teratomas comprise
20-25% of all ovarian neoplasms and
are believed to arise in fetal life from
a single germ cell of a 46XX
karyotype

Benign Cystic Teratoma / Dermoid cyst
• Fluid in the dermoid cyst is usually
sebaceous contained in a protrusion
in the cyst wall prominence or
tubercle of Rokitansky
• Struma ovarii is a teratoma in which
the thyroid tissue has overgrown the
other elements

Fibroma
• Fibromas - most common
benign solid ovarian
neoplasm
• Ascites may be associated
in half of the cases if size
>6 cm
• MEIGS syndrome: fibroma,
ascites, hydrothorax

SEROUS CYSTADENOMA
• MOST Common epithelial tumor
• Bilateral in 12-20% of cases
• Most are unilocular
• Size may vary up to 30 cm in
diameter, mean size of 10cm
• Smooth external
surface
• Contains clear,
colorless, thin fluid
• Smooth, thin lining +/-
small papillae

SEROUS CYSTADENOMA
Microscopic Description
• Lining epithelium is composed of columnar cells
with abundant cilia
• Histologically indistinguishable from TUBAL
epithelium
§ Symptoms of
heaviness or
pressure if large
§ Treatment:
cystectomy

MUCINOUS CYSTADENOMA
• Occurs in the 3rd to 5th decades of
life
• Bilateral in 2-3 % of cases
• Can become particularly large
• Gigantic tumors measuring up to 50 cms and
weighing up to 100 kg.
• Possible complications = perforation
and rupture
• Result in deposit and growth of mucin
secreting epithelium in peritoneal cavity →
PSEUDOMYXOMA PERITONEI
Gross Findings
• smooth external
surface
• unilocular cyst
or one with few
septae
• contains clear,
yellow, slimy
fluid

Microscopic Findings
Lining is composed of tall columnar cells with
Epithelium identical to that of endocervical or
intestinal epithelium
Cells resemble goblet cells of the bowel

Most common adnexal
mass in women of
• FOLLICLE CYSTS OF THE
reproductive age OVARY
Most common benign • BENIGN CYSTIC TERATOMA

neoplastic tumors of the
ovary • SEROUS CYSTADENOMA*
Most common benign

cystic neoplasm of the • BENIGN CYSTIC TERATOMA
ovary in the reproductive
( 20-44 year old) age • SEROUS CYSTADENOMA*
group
GERMAR September 2018 * Most common epithelial tumor of the ovary 89

Most common
benign solid
tumor in •FIBROMA
reproductive age
women
Most common
abdominal •WILMS’ TUMOR
tumors in
childhood •NEUROBLASTOMA
90
Most common
MALIGNANT • SEROUS
tumor in all CYSTADENOCARCINOMA
age groups
Most comon
solid adnexal • DYSGERMINOMA
tumors in • BENIGN CYSTIC TERATOMA
young women
91
Review of Benign
Gynecologic Lesions
Maria Julieta V. Germar ,M.D., FPOGS, FSGOP

Section of Gynecologic Oncology
UP College of Medicine
92
92
Embryology
Sexual
Differentiation
93
93
SEXUAL DIFFERENTIATION
• The first step in sexual differentiation is the determination of
genetic sex (XX or XY)
• MALE sexual development depend on the presence of

functioning testes & responsive end organs
• FEMALE sexual development does not depend on the presence

of ovaries. In the absence of a gonad, development will be
female in nature.
• FEMALE exposed to androgens in- utero will be musculanized

GENETIC SEX IS DETERMINED
AT FERTILIZATION
• All embryos that possess at least one Y chromosome develop as
males.
• The presence of SRY or sex-determining region of the Y
chromosome causes the fetus to develop the testes
• The secretion of testosterone and anti Mullerian Hormone
(AMH) from the testes steers the development of the rest of the
genital tracts
• A key gene in ovary development is DAX-1.

EXTERNAL GENITALIA
EXTERNAL GENITAL DEVELOPMENT
(9th-12 th WEEK)
• By 12th wk gestation ♂ & ♀ genitalia can be differentiated

• In the absence of androgens [FEMALE external genitalia develop
• In male fetuses, testosterone secreted by the testes must be
converted to 5a-dihydrotestosterone (DHT) for masculinization
of the external genitalia to occur.

MOLECULAR GENETICS OF
GONAD DEVELOPMENT

DEVELOPMENT OF THE MALE AND FEMALE REPRODUCTIVE
TRACTS
SEXUAL DEVELOPMENT INVOLVES

GROWTH OR BREAKDOWN OF
In male PRECURSOR STRUCTURES
embryos, the
Müllerian
ducts must
regress for
the Wolffian
duct
development
to proceed

Normal male development in utero
• the testes must differentiate and function normally.
• At a critical point, AMH, produced by Sertoli cells, and
testosterone, secreted by Leydig cells, must be produced
in sufficient amounts.
• AMH acts locally in suppressing the müllerian duct system,
and testosterone acts systemically, causing differentiation
of the mesonephric duct system and affecting male
development of the urogenital tubercle, urogenital sinus,
and urogenital folds
99
DEVELOPMENT OF THE MALE AND FEMALE REPRODUCTIVE TRACTS

PRECURSOR STRUCTURES
In female
embryos, the
Wolffian ducts
must regress
for the
Müllerian duct
development
to proceed

DEVELOPMENT OF THE MALE AND FEMALE REPRODUCTIVE TRACTS

PRECURSOR STRUCTURES
In female
embryos, the
Wolffian ducts
must regress
for the
Müllerian duct
development
to proceed
A Gartner duct cyst

results from a Wolffian
duct remnant
DEVELOPMENT OF THE MALE AND FEMALE EXTERNAL GENITALIA

DEVELOPMENT OF THE MALE AND FEMALE EXTERNAL GENITALIA

DEVELOPMENT OF THE MALE
AND FEMALE EXTERNAL GENITALIA

DEVELOPMENT OF THE MALE AND FEMALE
EXTERNAL GENITALIA

Male and Female Derivatives of
Embryonic Urogenital Structures
EMBRYONIC MALE FEMALE
STRUCTURES
LABIOSCROTAL Scrotum Labia majora
SWELLINGS
UROGENITAL Urethra Labia minora
FOLDS Ventral portion of
the penis
PHALLUS Penis Clitoris
UROGENITAL SINUS Urinary bladder Urinary bladder
Prostate gland Skene’s Ducts
Prostatic utricle Urethral and
Bulbourethral glands paraurethral glands
Seminal colliculus Vagina
Greater vestbular
GERMAR September 2018 ducts
STRUCTURES
PARAMESONEPHRIC Appendix of testes Hydatid of
DUCT morgagni
Uterus and cervix
Fallopian tubes
MESONEPHRIC DUCT Appendix of epididymis Appendix vesicularis
Ductus of epididymis Duct of epoophorus
Ductus deferens Gartner’s duct
Ejaculatory duct and
seminal vesicle
METANEPHRIC DUCT Ureter, renal pelvis, Ureter, renal pelvis,
calyces and collecting calyces and collecting
system system
MESONEPHRIC TUBULES Ductuli efferentes Epoophoron

paradidymis paraoophoron
STRUCTURES
UNDIFFERENTIATED Testis Ovary
GONAD
CORTEX Seminiferous tubules Ovarian follicles

MEDULLA Rete testis Rete ovarii
GUBERNACULUM Gubernaculum testis Round ligament of
uterus

Fast facts
• Does the Mullerian duct development depend on fetal gonadal steroid
production?
No. The Mullerian duct development is independent of the ovary
• In the absence of any gonad, what type of development will occur?
Internal genitalia have intrinsic tendency to feminize, as Mullerian duct
development will occur.
• Does development of male external genitalia depend on testosterone?
No. Development of the urogenital sinus and urogenital tubercle into male
external genitalia, urethra, and prostaterequire conversion of testosterone to
DHT.
109
Fast Facts
• What is Swyer syndrome?
Swyer syndrome is characterized by bilateral dysgenesis of the testes caused by a
mutation of the SRY gene. They are found to have an XY karyotype with normal
infantile female external and internal genitalia.
110
Embryology
Genetic and
Congenital
Abnormalities
111
111
SEVERAL DISORDERS OF SEXUAL DEVELOPMENT EXIST IN HUMANS
• Anomalies of the sex chromosomal complement can result in Turner

and Klinefelter syndromes.
• Gonadal intersexuals, historically called true hermaphrodites,
possess both ovarian and testicular tissue.
• Androgen insensitivity syndrome occurs in genetic males who are
unresponsive to androgens.

Turner’s Syndrome
Sex chromosome deletion - 45
XO or XO/XX
§ amenorrhea
§ normal intelligence
§ small stature; webbing of neck
§ secondary sex characteristics
absent
§ infantile figure of female
phenotype
§ streak gonad failure of ovarian
development
§ uterus & fallopian tubes infantile

Turner’s Syndrome
Sex chromosome deletion - 45
XO or XO/XX
§ amenorrhea
§ normal intelligence
§ small stature; webbing of neck
§ secondary sex characteristics
absent
§ infantile figure of female
phenotype
§ streak gonad failure of ovarian
development
§ uterus & fallopian tubes infantile

Klinefelter’s Syndrome
Sex chromosome acquisition -
XXY, XXXY, XXXXYY
§ Physical appearance of a male
§ At puberty, testes fail to enlarge
§ Facial hair scanty, pubic hair of female
distribution
§ Some breast development
§ Infertile
§ ↑ # of X chromosomes = ↑ mental
retardation

Androgen Insensitivity Syndrome
(Testicular Feminization)
Chromosome pattern - 46 XY
• This condition is because of congenital
insensitivity to androgens and is maternal X-
linked recessive. Androgens are secreted but
tissues are insensitive and develop along female
line
• People with this disorder have a female
phenotype with a normal male karyotype
(46,XY).

Androgen Insensitivity Syndrome
(Testicular Feminization)
§ Female phenotype with tendency to eunochoid
proportions
§ Normal or large breasts with small nipples
§ Absent or scanty pubic hair, axillary hair
§ Female external genitalia with blind vagina
§ Absent or rudimentary internal genitalia
§ When the epiphyses have fused - gonads should
be excised
§ increased risk of malignancy in gonads
§ give HRT (combined estrogen & progesterone)

Mullerian agenesis
Mayer-Rokistanky-Kuster-
Hauser(M.R.K.H.) syndrome
XX, female
Result of the mullerian ducts failing to
form properly early in embryonic
development, its underlying cause is
unknown.

Mullerian agenesis
• Patients with congenital absence of the uterus have
normally functioning ovaries and therefore have
normal secondary sexual characteristics. They
often experience cyclic breast and mood alterations
compatible with ovulation.
• There is also an associated urogenital
malformations such as unilateral renal agenesis,
pelvic kidney, horseshoe kidney, hydronephrosis,
and ureteral duplication.

Hermaphroditism
Intersex conditions or hermaphroditism are classified according to
the histologic appearance of the gonads

True Hermaphroditism
Have both ovarian and testicular tissue, most
commonly as composite ovotestes but occasionally
with an ovary on one side and a testis on the other
Extremely rare condition associated with chromosomal
mosaicism, mutation, or abnormal cleavage involving
the X and Y chromosomes

Pseudohermaphroditism
§ Genetic sex indicates one sex, whereas the external
genitalia has characteristics of the other sex
§ Genetic males with feminized external genitalia,
§ most commonly manifesting as hypospadias (urethral opening
on the ventral surface of the penis)
§ incomplete fusion of the urogenital or labioscrotal folds
§ Genetic females with virilized external genitalia,
§ clitoral hypertrophy and some degree of fusion of the
urogenital or labioscrotal folds

Several Disorders of Sex Development
Exist in Humans
• Genetic females with congenital adrenal hyperplasia experience
genital masculinization due to increases adrenal androgen
production.
• Individuals with 5α-reductase deficiency cannot convert testosterone
to DHT.
• Males with hypospadias or a micropenis have a misplaced urethral
opening or small penis, respectively.

Pediatric Gynecology
124
124
§ Most common problem: vulvo-vaginitis
§ In a child, pelvic organs are not palpable
§ Cervix: uterus = 2:1
§ Vaginal infections like trichomoniasis, gonorrhea, chlamydia
suggest sexual molestation
§ There is a physiologic discharge 6-12 months before menarche
due to increasing estrogen levels

PEDIA GYN
Prior to menarche, which normally does not occur before

nine years of age, any bleeding requires evaluation.
126
127
A bloody and foul smelling discharge
suggests foreign body. Removal is done
under general anesthesia.
Genital trauma is usually caused by an
accidental fall including straddle injuries
Precocious puberty refers to sexual
maturation before 8 years of age.
Physiologic development usually follows
the normal sequence of changes of
sexual development.

Puberty Marks Sexual Maturation
• Puberty is the biological transition to sexual maturity.
• Pubertal growth spurts occur earlier in girls than in boys
• In girls, breast development proceeds through many stages
and the onset of menstruation, or menarche, is a dramatic
event in female pubertal development.
• Remember: thelarche precedes menarche

Growth velocity curves for boys and girls

Puberty
Event Mean Age
Thelarche 10.8+/- 1.10
Appearance of pubic hair 11+/- 1.21
Menarche 12.9 +/- 1.2

Typical development of breasts in girls at puberty

Hormonal control of puberty

Diagnostics for precocious puberty Determine basal gonadotropins
High levels of LH =
gonadotropin– producing neoplasm, ->
pinealoma (ectopic germinoma) or
choriocarcinoma

Determine basal gonadotropins
Diagnostics for precocious puberty
High levels of LH = gonadotropin–

producing neoplasm, -> pinealoma(ectopic
germinoma) or choriocarcinoma
Low or pubertal levels of

gonadotropins ,determine
circulating estradiol concentrations
or assess testosterone levels
Increased estradiol Increased testosterone

levels suggest an levels suggest an
estrogen–secreting androgen–producing
neoplasm, probably of neoplasm of the ovary
ovarian origin or the adrenal gland
ISOSEXUAL HETEROSEXUAL

Precocious Puberty: Work-up
n Thyroid function tests

n Bone age assessment

Precocious Puberty
§ Central (True) precocious puberty
§ GnRH prematurely stimulates increased gonadotropin secretion
§ result from a tumor, infection, congenital abnormality, or traumatic injury
affecting the hypothalamus
§ congenital malformations
§ Precocious Puberty of Peripheral Origin
§ production of estrogens or androgens from the ovaries, adrenals, or rare
steroid–secreting neoplasms leads to early pubertal development

Precocious Puberty
§ Without therapy, 50% females with true
precocious puberty will not reach a ht of 5
feet
§ Exact etiology is unknown
§ 10% - due to life-threatening CNS disease.
§ 70% - may be idiopathic or constitutional
§ Pseudo-precocious puberty is due to a
functioning ovarian tumor (60% of which
are granulosa cell tumors)

Most common cause • FUNCTIONING OVARIAN
of GnRH independent
precocious puberty TUMOR: Granulosa Cell Tumor
First sign of puberty

• BREAST BUDDING/THELARCHE
Latest sign of puberty • MENARCHE
139
Amenorrhea
• May be physiologic or pathologic which may include primary and secondary
causes
• Primary amenorrhea.
No menses by age 14 in the absence of growth or development of secondary
sexual characteristics.
Or
No menses by age 16 with the appearance of secondary sexual characteristics.
• Secondary amenorrhea.
In a menstruating women, the absence of menstruation for three previous cycle
intervals or 6 months.

Amenorrhea
Primary causes initially classified on whether absent uterus and/or breast
development are also found
BREASTS UTERUS CONDITION
ABSENT PRESENT With pituitary masses

TURNER’S SYNDROME
PRESENT ABSENT TESTICULAR FEMINIZATION (XY) AND CONGENITAL
ABSENCE OF THE UTERUS
ABSENT ABSENT MALE KARYOTYPE EITHER ENZYME DEFICIENCY OR

AGONADISM
PRESENT PRESENT HYPOTHALAMIC CAUSES, PITUITARY, OVARIAN, UTERINE

OR OUTFLOW TRACT PROBLEMS

Amenorrhea
• Secondary amenorrhea may be physiologic or pathologic. Pathologic
lesions include intra-uterine adhesions after curettage. Work up
include: HYPOTHALAMIC CAUSES, PITUITARY, OVARIAN, UTERINE OR
OUTFLOW TRACT PROBLEMS

Amenorrhea Algorithm
Pelvic Examination
Normal Absent Uterus Sexual Hair
B HCG OB Care Mullerian Androgen

agenesis Insensitivity
Prolactin TSH FSH

Increased Increased Decreased Increased Normal
Thyroid Eating disorder, Gonadal Testosterone DHEAS 17-OHP

MRI exercise , stress Failure
disorder
Increased Increased Increased
Karyotype
MRI treat TV UTZ
MRI for Congenital
Prolactinoma for
Adrenal adrenal
Ovarian
tumor tumor hyperplasia
Kallman POF/POI
Tumor
syndrome gonadal
dysgenesis
143
Pelvic Examination

Prolactin TSH FSH


disorder
Karyotype
MRI treat TV UTZ
MRI for Congenital
Prolactinoma for
Adrenal adrenal
Ovarian
Kallman POF/POI
Tumor
syndrome gonadal
dysgenesis
144
Mullerian Agenesis
(Mayer –Rokitansky Kuster Hauser Syndrome)
vs Androgen Insensitivity
145
Pelvic Examination

Prolactin TSH FSH


disorder
Karyotype
MRI treat TV UTZ
MRI for Congenital
Prolactinoma for
Adrenal adrenal
Ovarian
Kallman POF/POI
Tumor
syndrome gonadal
dysgenesis
146
Pelvic Examination

Prolactin TSH FSH


disorder
Karyotype
MRI treat TV UTZ
MRI for Congenital
Prolactinoma for
Adrenal adrenal
Ovarian
Kallman POF/POI
Tumor
syndrome gonadal
dysgenesis
147
Pelvic Examination

Prolactin TSH FSH


disorder
Karyotype
MRI treat TV UTZ
MRI for Congenital
Prolactinoma for
Adrenal adrenal
Ovarian
Kallman POF/POI
Tumor
syndrome gonadal
dysgenesis
148
Most common
cause of • ANOREXIA
amenorrhea in
adolescents
NERVOSA
Most common
cause of PRIMARY • GONADAL FAILURE
amenorrhe
Test to confirm
gonadal failure • SERUM FSH
149
Fast Facts• What is the number one cause of secondary
amenorrhea after pregnancy?
Anovulation (28%).
• What laboratory tests should you consider in a patient
with primary amenorrhea who does not have a uterus?
Karyotype, serum testosterone (Mullerian abnormality
with 46XX karyotype with normal testosterone versus
androgen insensitivity syndrome with 46XY karyotype
and male serum testosterone levels).
• What laboratory tests should you consider in a patient
with primary amenorrhea who DOES have a uterus?
• hCG, TSH, PRL, progestin challenge, FSH, LH.
150
• What is the most common chromosomal abnormality
causing gonadal failure and primary amenorrhea?
45,X (Turner syndrome—50%).
151
• What is Kallmann syndrome?
Hypogonadotropic hypogonadism because of a lack of
GnRH as a result of failure of migration of the GnRH
neuron from the olfactory bulb. These patients are
anosmic and have primary amenorrhea.
• The most common central nervous system tumor that
can lead to primary amenorrhea is:
Craniopharyngioma. It is an extracellular mass that
interferes with the production and secretion of GnRH or
stimulation of pituitary gonadotropins.
152

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Review

Maria Julieta V. Germar ,M.D., FPOGS, FSGOP

Where are GARTNER DUCTS located ?

• The Normal vagina does NOT have glands

• Arterial blood supply to the

1. Clamping or ligating of the

4. Clamping of uterine arteries

§ During hysterectomy, the ureter is

GERMAR September 2018

A stent may not be helpful

Magrina JF. Preventing ureteral injury at hysterectomy: Expert

§ To avoid injury at the

MJV GERMAR 3 March 2017

Magrina JF. Preventing ureteral injury at hysterectomy: Expert approach .

POLYMENORRHEA Frequent but REGULARLY timed episodes of bleeding usually occuring at

MENORRHAGIA REGULARLY timed episodes of bleeding that are EXCESSIVE in amount

METRORRHAGIA Irregularly timed bleeding or bleeding between periods

INTERMENSTRUAL Bleeding usually not of an excessive amount that occurs between

GERMAR September 2018

GERMAR September 2018

Shwayder JM. Obstet Gynecol Clin North Am. 2000;27(2):219-234.

GERMAR September 2018

Shwayder JM. Obstet Gynecol Clin North Am. 2000;27(2):219-234.

GERMAR September 2018

Shwayder JM. Obstet Gynecol Clin North Am. 2000;27(2):219-234.

GERMAR September 2018

Shwayder JM. Obstet Gynecol Clin North Am. 2000;27(2):219-234.

GERMAR September 2018

Structural vs. Non-Structural

Developed to create a universally accepted nomenclature

GERMAR September 2018

GERMAR September 2018

GERMAR September 2018

GERMAR September 2018

PE Bright red, sometimes eroded

GERMAR September 2018

Management Behavioral modification

GERMAR September 2018

GERMAR September 2018

GERMAR September 2018

GERMAR September 2018

GERMAR September 2018

GERMAR September 2018

GERMAR September 2018

GERMAR September 2018

GERMAR September 2018

GERMAR September 2018

• Hyperplastic overgrowth of endometrial glands and

GERMAR September 2018

• From Munro MG, Critchley HO, Broder MS, et

Most common cause of • FOREIGN BODY IN THE

Most common benign

Most common pelvic

Most common cause of

Functional cyst Functional cyst Functional cyst Fibroids Ovarian tumor

GERMAR September 2018

GERMAR September 2018

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GERMAR September 2018

• Vary from being asymptomatic

GERMAR September 2018

GERMAR September 2018

GERMAR September 2018

GERMAR September 2018

A stent may not be helpful

Structural vs. Non-Structural

Developed to create a universally accepted nomenclature