BENIGN NEOPLASM OF

OVARY

1) TYPE OF OVARIAN TUMOR

2) ULTRASOUND FEATURES OF
MALIGNANCY
3) MANAGEMENT OF OVARIAN CYST

NUR AFIQAH BINTI ABDULLAH

Types of ovarian tumor
TYPE OF OVARIAN TUMOR
 Benign ovarian tumors
Presentation:
- Can be through incidental finding (USS)

- Pain / pressure on bowel or bladder

*Acute pain may point to torsion of a cyst/
rupture or hemorrhage

Examination :
- can feel pelvic / abdominal mass separated
from the uterus
 INVESTIGATIONS
Pregnancy test (exclude pregnancy)
Ultrasound scan (transvaginal /
abdominal)
CT scan
MRI
Tumor markers
Inflammatory markers ( CRP & WCC
to exclude appendicitis & tubo-
ovarian abscess)
2) ULTRASOUND FEATURES
OF MALIGNANCY
SIMPLE ULTRASOUND BASED RULES

Derived from IOTA (international

ovarian tumor analysis) group
Sensitivity (95%) & specificity (91%)
Using the ultrasound rules:
- Beingn (B-rules)
- Malignant (M-rules)
Rules apply to premenopausal
women
TUMOR MARKERS FOR OVARIAN CA

TUMOR TUMOR TYPE USES

MARKERS
Ca 125 Epithelial ovarian CA Preoperative,
(serous) follow up
Borderline ovarian tumours
Ca 19-9 Epithelial ovarian CA Preoperative,
(mucinous) follow up
Borderline ovarian tumours
Inhibin Granulosa cell tumours Follow up
-hCG Dysgerminoma Preoperative,
Choriocarcinoma follow up
AFP Endodermal yolk sac, Preoperative,
teratoma follow up
3) MANAGEMENT OF
OVARIAN CYST
 Ovarian cyst
Common in pregnant woman, but the
incidence of malignancy is lower in
women of childbearing age.

Most common type of

pathological ovarian cyst:
- serous cyst
- benign teratoma
Causes of benign ovarian
cyst
TYPES EXAMPLE
Functional Follicular cyst
Corpus luteal cyst
Theca luteal cyst

Inflammatory Tubo-ovarian abscess

Endometrioma

Germ cell Benign teratoma

Epithelial Serous cystadenoma
Mucinous cystadenoma
Brenner tumour

Sex cord stromal Fibroma

Thecoma
 Functional ovarian cyst
3 types of functional cyst:
- Follicular cyst
- Corpus luteal cyst (most common)
- Theca luteal cyst

#Risk of getting it is reduced with usage of oral

contraceptive pill

How to diagnose (investigation): Ultrasound

- Size of cyst is more than 3 cm
- U/S shows simple unilocular cyst
 Functional ovarian cyst
Corpus luteal cyst:
- Occur following ovulation
- May grow up to few centimeters

Presentation:
- Asymptomatic
- Pain due to rupture or hemorrhage (commonly occur in late
menstrual cycle)

Mx:
1) Analgesic.
2) May require surgery to wash out pelvis & perform ovarian
cystectomy
 Functional ovarian cyst
Theca luteal cyst:
- Commonly occur in multiple pregnancy

Presentation:
- Asymptomatic (Diagnosed incidentally
through routine USS)

Mx:
- Resolve spontaneously during pregnancy
 Inflammatory ovarian cyst
Most common in young women
Associated with pelvic inflammatory disease (PID)
Inflammatory mass may involve the tube, ovary & bowel ( seen as mass/
abscess)
Tubo-ovarian mass may develop from other infective causes (appendicitis/
diverticular disease)

Diagnosis:
- Based on PID
- Inflammatory markers (helpful)

Management:
- Antibiotic
- Surgical drainage
- Excision
*definitve surgery deferred until acute infection resolve (due to risk of
systemic infection & difficulty with inflamed & infected tissue)
 Patient may also presented with
endometriomas (chocolate cysts)
from presence of altered blood within
the ovary

Findings:
- Can reach 10cm in size
- USS reveal ground glass
appearance
 Germ cell tumors
Most common ovarian tumors in young women
Peak (early 20s)

Cystic teratoma:
- Mature dermoid cyst (combination of
mesenchymal, epithelial and stroma)
- Occurred during reproductive age (80%)
- Bilateral involvement (10%)
- Can transform into malignant ( Rare <2 %)
mainly in women over 40 y/o
Presentation:
- Can be incidental
- Acute onset of pain with nausea (torsion presentation)

Investigation:
- MRI ( useful due to its high fat content in the dermoid cyst)

Management:
- Surgical excision
- Complete oophorectomy if torsion
- Laparoscopic cystectomy if ovary still viable

#Findings:
- any mature tissue type may be present (hair/ muscle/
cartilage/ bone/ teeth)
 Epithelial tumours
Occurrence increase with age
Common in peri-menopausal women

3 types:
Serous cystadenomas - Most common
- Women under 40 years old
(20-30% risk)
- Unilocular
- Rarely involve opposite ovary
Mucinous cystadenomas - Large multiloculated cyst
- Bilateral involvement
Brenner tumors - Small tumors (incidental
finding)
- May secrete estrogen
 Sex cord stromal tumors
1)Ovarian fibromas:
) More common
) A solid ovarian tumors composed of stromal cells
) In older woman with torsion due to heaviness of ovary

Presentation:
-) Meig syndrome(Pleural effusion, ascites, ovarian
fibroma)

Management:
- Removal of ovarian fibroma (pleural effusion resolve
following the its removal)
 Sex cord stromal tumors
2) Thecomas:
Benign estrogen secreting tumors
Usually present post menopause
Benign but may induce an endometrial
CA

Presentation:
Post menopausal bleeding (due to excess
estrogen production)
 Others
Fimbrial cysts
Paratubal cyst
Cyst of Morgani
COMPLICATION OF OVARIAN CYST IN
PREGNANCY

Usually occur in cases of large (>8cm

ovarian cyst)
May lead to torsion, hemorrhage or
rupture
Patient may presents with acute
abdominal pain
Can lead to miscarriage or preterm
labour ( due to pain & inflammation)
MANAGEMENT OF OVARIAN CYSTS

1) Doesnt require follow up in cases of:

-) Asymptomatic
-) Small (<50mm diameter)
-) Simple ovarian cyst
# usually physiological & resolve within 3 months cycles

2) Yearly ultrasound f/u:

-) Asymptomatic
-) Simple ovarian cyst (50-70mm diameter)

3) Further imaging (MRI) / surgical intervention:

- Larger simple cyst
MANAGEMENT OF OVARIAN CYSTS

Ovarian cyst that persist & increasing

in size are likely to be functional thus
may warrant a for surgical
management
Usage of COCP does not promote
resolution of functional ovarian cyst
MANAGEMENT OF OVARIAN CYSTS
SURGERY:
1) Laparoscopic approach (for elective surgery)
-) Lower post op morbidity
-) Shorter recovery time
-) Cost effective (early dicharge)

2) Aspiration of cyst
-studies shown that aspiration of ovarian cyst is lefss effctive &
associated with high rate of recurrence

3) Laparotomy
- Indicated in presence of large masses with solid components
(e.g: large dermoid cyst)
BENIGN NEOPLASM OF
UTERUS - FIBROIDS
 UTERINE FIBROID
Benign tumor of uterineRisk factor:
smooth muscles termed (Oetrogen dependent)
Obese
leiomyoma . Nulliparity
Its incidence increase Positive family history
African racial
with age during the
reproductive years such
that cases occur in 20%
of women over 30 years
of age
 Symptoms Pallor anaemia
Abdominal examination (if
- Usually asymptomatic large)
- Abnormal uterine Palpable mass
Local pain/ tenderness
bleeding (excessive Inferior border cannot be
and prolong bleeding) palpate
- Mass effect symptoms Well defined margin
Firm
- increase freq of Mobile to side to side
urination Bimanual pelvic examination
- Weight gain Tenderness
Attached to uterus
- Bloated abdomen firm
- Dyspareunia Mobility
 Investigation

Full Blood Count anemia

Ultrasound uterus size, endometrial
thickness, & to differentiate types of
fibroid
Coagulation profile TRO others
causes of bleeding
Renal profile , LFT, CXR pre
operative workup
 Management
Conservative (asymptomatic)
Monitor uterine size

Medical (symptomatic)
Usually treat the heavy menstrual bleeding
NSAID for dysmenorrhea, excessive bleeding and pelvic pain.
Transxemic acid is effective in reducing heavy menstrual bleeding who not
able to tolerate hormone.
Contraception such as levonorgestrel IUCD or oral contraception
Progesterone for 21 days is effective in reducing the menstrual blood loss.

Plan for surgery which need for shrinkage the fibroid before surgery
GnRH agonist (reversible hypoestrogenic state reduce total uterine volume)
(max duration is 6 months due to side effect) (only use for myomectomy)
Surgical
Hysterectomy
Myomectomy
Uterine artery embolisation.
Inject embolism particle in both uterine artery
underangiogram
It will cause ischemic necrosis and shrinkage the
fibroid
Side effect : very painful procedure
 HYALINE DEGENERATION
Hyaline degeneration is the most common type of
fibroids degeneration that can occur in 60% of all fibroids
cases.
The most common change observed in fibroids that are
undergoing this type of degeneration is replacement of
the fibrous and muscle fibroid tissues with the hyaline
tissue (type of connective tissue).
Gradual decrease in the blood supply to the fibroids can
cause this type of fibroids degeneration.
Although, hyaline fibroids degeneration is without
symptoms, it can cause central necrosis (death of the
cells and tissues) and leave cystic spaces at the center.
In this way, cystic fibroids degeneration starts.
Other consequence of the hyaline degeneration is slow
calcification of the fibroids.
 CYSTIC DEGENERATION
Cystic degeneration is not so common type of
fibroids degeneration; it affects only 4% of all fibroids
Usually occurs after menopause.
Hyaline degeneration often precedes cystic
degeneration.
Decreased blood supply to the fibroids may influence
liquefaction of hyalinized areas that are seen as
cystic changes on the ultrasound.
They resemble honeycomb pattern, and sometimes
can be misleading, especially with the submucous
type of fibroids.
They are often misdiagnosed as other gestational
abnormalities, such as missed abortion and
hydatidiform mole.
ROLE of GnRH
 ROLE of GnRH

Use in Advantag Disadvanta Side

preparation for es ges effects
surgery
Cessation of Loss of
Reduce GnRH bone
Inducing risk of oestrogen density if
temporary heavy levels return use more
menopaus bleeding to normal than 6
al state Enable fibroids months
suprapub return to osteoporos
Very ic their previous is
Temporary effective incision size
amenorrhe in rather
a Not
shrinking than
appropriate for
fibroids midline
woman who
abdomin
trying to
al
conceive due
incision
to anovulation
induced and
return of
fibroids with
drug cessation
MYOMECTOMY VS
HYSTERECTOMY
 MYOMECTOMY HYSTERECTOMY
Removal of fibroids only Removal of uterus with the fibroids
May preserve fertility Not preserve fertility
Can recur Cannot recur
Can be performed open or Can be performed laparoscopically,
laparoscopic vaginally or abdominally
More invasive Less invasive than myomectomy
Longer healing time Post-operative recovery much faster
Fibroids that are in the muscle require No incisions that require healing in
an incision in the uterus for removal, the muscle of the uterus
which can be deep in the muscle, and
will require repair
No menopausal symptoms post- Post-operatively, patient will have
operatively menopausal symptoms
Risk of blood loss
Adhesions can form at site of
myomectomy affecting endometrial
cavity or fallopian tubes/ovaries
reduce fertility
FIBROID IN PREGNANCY
 COMPLICATIONS
Premature labour
Malpresentations
Transverse lie
Obstructed labour
Post partum haemorrrhage
Red degeneration
Torsion of subserous pedunculated
fibroids
 MANAGEMENT OF LABOUR
If fibroid obstructs descent and
engagement caesarean section
If fibroid not obstructs vaginal
delivery

*** If caesarean section is done,

myomectomy should not be done at
the same time heavy bleeding
 RED DEGENERATION
Also known as necrobiosis
Most common complications of fibroids in
pregnancy.
As it grows, the fibroid may become
ischaemic, lead to:
Acute pain
Tenderness over the fibroid
Frequent vomiting
Fever
If these symptoms are severe:
Uterine contractions may be precipitated
miscarriage or preterm labour
 Differential diagnosis of red
degeneration:
Acute appendicitis
Pyelonephritis/UTI
Ovarian cyst accident
Placental abruption
Red fibroid degeneration requires
treatment in hospital:
Potent analgesics (opiates and IV fluids)
 ENDOMETRIAL POLYP
Discrete outgrowth of
endometrium attached by a pedicle
, which move with the flow of the
distention medium.
o pedunculated/ sessile
o -single/multiple
o -vary size (0.5-4cm)
Menorrhagia,
Abnormal bleeding
Under 40 y/o

Unlikely to be of significance.
Require tx if symptom persistent > 3/12

40 y/o pre menopausal

Dx by USS or hysteroscopy
Common abnormality is endometrial hyperplasia
which can present in endometrial polyp tissue

Post menopausally

Mandatory to remove endometrial polyps which can

be due to hyperplasia or malignancy
 Investigation
TVS
Hysteroscopy
Endometrial biopsy
Hysterosonogram

Management
Hysterescopic polypectomy
ASHERMANS SYNDROME
Fibrosis and adhesion formation
when the endometrium has been
removed down to the basal layer.
Causes : Endometrial resection,
excessive curettage, & infection
(TB, Schistosomiasis)
Presentation : Amenorrhea,
oligomenorrhea, infertility
 Investigation
Blood: FBC (TWBC) TRO TB, Schistoso.
Urine: nil
Imaging: Hysteroscopy

Management
Hysterocopic lysis of IU adhesion
IUD