1. Chapter 13. Benign Diseases of the Female Reproductive Tract(2) Pelvic Mass
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2. Prepubertal Age Group
Adolescent Age Group
Reproductive Age Group
Postmenopausal Age Group

4. Prepubertal Age Group
Differential Diagnosis
Diagnosis and Management

5. Differential Diagnosis
Prepubertal Age Group
Differential Diagnosis
Malignancy : < 5% in children and adolescents
☞ malignancy (< 9 years of age ) : 80% of the ovarian neoplasm
Ovarian tumor : 1% of all tumors in these age groups
Germ cell tumors : 1/2 ~ 2/3 of ovarian neoplasms
( <20 years of age)
Epithelial neoplasm : rare
Symptoms : abdominal or pelvic pain (initial symptoms)
pelvic mass very quickly enlarge
☞ D/Dx : Appendicitis, Wilms’ tumor or Neuroblastoma
Acute pain : associated with torsion

6. Diagnosis Ultrasonography Imaging studies
Prepubertal Age Group
Diagnosis
Ultrasonography
Imaging studies
: CT scanning, MRI or Doppler flow studies

7. Prepubertal Age Group
Management
Unilocular cysts : always benign and will regress in 3~6months
☞ not require surgical management with oophorectomy or
oophorocystectomy
Recurrence rate after cyst aspiration : 50%
Premature surgical therapy for a functional ovarian mass can result in ovarian and tubal adhesions that can affect future fertility

8. Prepubertal Age Group
Management

9. Adolescent Age Group
Differential Diagnosis
Diagnosis and Management

10. Differential Diagnosis
Ovarian masses
Uterine masses
Inflammatory Masses
Pregnancy

11. Differential Diagnosis (1) Ovarian masses
Adolescent Age Group
Differential Diagnosis (1) Ovarian masses
Malignant neoplasm is lower among adolescents than among younger children
Epithelial neoplasms : ↑
Mature cystic teratoma : most common type
> ½ of ovarian neoplasms in women younger than 20 yerars of age
cf) Germ cell tumor : 1st decade of life
Dysgenetic gonads : malignant tumor in 25%
☞ gonadectomy is recommended for patients with XY gonadal
dysgenesis or its mosaic variations

12. Differential Diagnosis (1) Ovarian masses
Adolescent Age Group
Differential Diagnosis (1) Ovarian masses
Functional ovarian cyst : ↑
- incidental finding on examination or associated with pain
caused by torsion , leakage or rupture
Endometriosis
: less common during adolescence than in adulthood
chronic pain (+) : 50~60% endometriosis
Transverse view of Lt ovarian endometrioma shows a heterogenous appeareance with diffuse low level echoes interspersed with echogenic and anechoic areas

13. Differential Diagnosis (2) Uterine Masses
Adolescent Age Group
Differential Diagnosis (2) Uterine Masses
Uterine leiomyomas : not common
Obstructive uterovagianal anomalies
- imperforate hymen ~ transverse vaginal septa
- vaginal agenesis with a normal uterus and functional
endometrium
- vaginal duplications with obstructing longitudinal septa
and obstructed uterine horns

14. Differential Diagnosis (3) Inflammatory Masses
Adolescent Age Group
Differential Diagnosis (3) Inflammatory Masses
Highest rates of PID of any age group
Consist of tuboovarian complex, tuboovarian abscess,
pyosalpinx or chronically hydrosalpinx

15. Differential Diagnosis (4) Pregnancy
Adolescent Age Group
Differential Diagnosis (4) Pregnancy
Ectopic pregnancy
discovered before rupture
☞ allowing conservative management with laparoscopic
surgery or medical therapy with methotrexate

16. Diagnosis History and pelvic examination Laboratory studies
Adolescent Age Group
Diagnosis
History and pelvic examination
Laboratory studies
- pregnancy test
- CBC
- tumor markers – α-fetoprotein and hCG
Ultrasonography
CT or MRI

17. Adolescent Age Group
Management
Figure 13.11
Asymptomatic unilocular cystic masses : conservatively
If surgical management is required
☞ attention should be paid to minimizing the risks of
subsequent infertility resulting from pelvic adhesion .
☞ conserve ovarian tissue
In the presence of a malignant unilateral ovarian mass
☞ unilateral oophorectomy rather than more radical surgery,
even if the ovarian tumor has metastasized
In general, conservative surgery is appropriate
; further surgery can be performed if necessary, after an adequate
histologic evaluation of the ovarian tumor

18. Management Lparoscopy - management of suspected acute PID
Adolescent Age Group
Management
Lparoscopy
- management of suspected acute PID
- to confirm the diagnosis
- to perform irrigation, lysis of adhesions,
- draninage and irrigation of unilateral or bilateral pyosalpinx
or tuboovarian abscess
- extirpation of significant disease
♣ associated with a risk of major complications
( bowel obstruction and bowel or vessel injury)-

19. Reproductive Age Group
Differential Diagnosis
Diagnosis and Management

20. Differential Diagnosis
Reproductive Age Group
Differential Diagnosis

21. Differential Diagnosis
Reproductive Age Group
Differential Diagnosis
Malignancy : 10% of those younger than 30years of age
Most common tumor
: mature cystic teratoma or dermoid (1/3 of women <30years of age)
endometrioma (1/4of women 31-49years of age)
Uterine masses
Ovarian masses
Others

22. Differential Diagnosis Uterine leiomyoma
Reproductive Age Group
Differential Diagnosis Uterine leiomyoma
m/c benign Uterine tumor

23. Differential Diagnosis Uterine leiomyoma
Epidemiology
- 20% of all women of reproductive age
- asymptomatic fibroids of women >35years : 40%~50%
Symptoms
: abnormal bleeding ~ pelvic pressure (<1/2)
discovered incidentally during routine annual
examination

24. Differential Diagnosis Uterine leiomyoma
Reproductive Age Group
Differential Diagnosis Uterine leiomyoma
Etiology
- unkown
< several studies >
- a single neoplastic cell within the smooth muscle of the
myometrium
- increased familial incidence
- hormonal responsiveness and binding has been demonstrated
in vitro
♠ Fibroid have the potential to enlarge during pregnancy as
well as to regress after menopause

25. Differential Diagnosis Uterine leiomyoma
Reproductive Age Group
Differential Diagnosis Uterine leiomyoma
Characteristics
: hard and stony ~ soft (usually described as firm or rubbery)
Degenerative changes : 2/3 of all specimens
Leiomyomas, with an increased number of mitotic figures , may occur in various forms
- during pregnancy or in women taking progestational
agents
- with necrosis
- a smooth muscle tumor of uncertain malignant potential
(defined as having 5~9mitoses /10HPF that do not
demonstrate nuclear atypia or giant cells, or with a lower
mitotic count (2~4 mitoses/10HPF) that does demonstrate
atypical nuclear features or giant cells)

26. Differential Diagnosis Uterine leiomyoma
Characteristics
malignant degeneration : uncommon <0.5%
♠ Sarcomas that have a malignant behavior have ≥10mitoses/HPF

27. Differential Diagnosis Uterine leiomyoma
Reproductive Age Group
Differential Diagnosis Uterine leiomyoma
Symptom
Menorrhagia
: initial symptom, one that most frequently leads to surgical
intervention
Chronic pelvic pain
: dysmenorrhea, dyspareuria or pelvic pressure
Acute pain
: d/t torsion of pedunculated leiomyoma or infarction and
degeneration

28. Differential Diagnosis Uterine leiomyoma
Symptom
Urinary symptoms
- frequency
- Partial ureteral obstruction
- complete urethral obstruction (rare)
Infertility

29. Differential Diagnosis Uterine leiomyoma
Reproductive Age Group
Differential Diagnosis Uterine leiomyoma
Pregnancy loss or complications
(10% rate of pregnancy complications by one study)
- Although growth of leiomyomas may occur with
pregnancy, no demonstrable change in size (base on serial
ultrasonographic examination) has been noted in 70~80%
of patients
- Risk of pregnancy complication
: influenced by both myoma location and size

30. Differential Diagnosis Uterine leiomyoma
Reproductive Age Group
Differential Diagnosis Uterine leiomyoma
Symptoms (infrequently)
Rectosignoid compression with constipation or intestinal obstruction
Prolapse of a pedunculated submucous tumor through the cervix
→ severe cramping and subsequent ulceration and
infection (uterine inversion has also been reported)
Venous stasis of lower extremities and possible thrombophlebitis 2nd to pelvic compression
Polycythemia
Ascites

31. Differential Diagnosis Ovarian masses
Reproductive Age Group
Differential Diagnosis Ovarian masses
Most ovarian tumors(80~85%) : benign
20~44years : 2/3 of ovarian tumors(benign)
Chance that a primary ovarian tumor is malignant in a patient <45years : < 1/15
Symptom
- Nonspecific
- Abdominal distension, abdominal pain or discomfort , lower
abdominal pressure sensation , urinary or gastrointestinal
symptoms
- Vaginal bleeding (related to estrogen production)
- Acute pain
: adnexal torsion , cyst rupture or bleeding into a cyst

32. Differential Diagnosis Ovarian masses
Reproductive Age Group
Differential Diagnosis Ovarian masses
Pelvic finding
Benign tumor
Malingnant tumor
Unilateral
Bilateral
Cyst
solid
Mobile
smooth
Fixed
Irregular
Ascites
Cul-de-sac nodules
Rapid growth rate

33. Differential Diagnosis Ovarian masses
Reproductive Age Group
Differential Diagnosis Ovarian masses
Nonneoplastic Ovarian Masses
Other Benign Masses
Neoplastic Masses
Other adnexal Masses

34. Differential Diagnosis Non neoplastic ovarian masses
Reproductive Age Group
Differential Diagnosis Non neoplastic ovarian masses
Functional ovarian cysts
: follicular cysts, corpus luteum cysts, theca lutein cysts
Benign , not cause symptoms or require surgical management
Follicular cysts
- most common fuctional cyst
- diameter >8cm(rare)
- defined as cystic follicle dimeter >3cm
- Rupture : resolve in 4~8wks

35. Differential Diagnosis Non neoplastic ovarian masses
Corpus luteum cysts
- Less common than follicular cysts
- Rupture
→ leading to hemoperitoneum & surgical management
- Most ruptures occur on cycle days 20 ~ 26

36. Differential Diagnosis Non neoplastic ovarian masses
Reproductive Age Group
Differential Diagnosis Non neoplastic ovarian masses
Thecal luteum cysts
- The least common
- Bilateral
- occur with pregnancy, including molar pregnancies, associated multiple gestations, molar pregnancies, choriocarcinoma, diabetes, Rh sensitization, Clomiphene citrate use, hMG-hCG ovulation induction , use of GnRH analogs
- Size
: quite large(~30cm), multicystic, regress spontaneoustly

37. Differential Diagnosis Non neoplastic ovarian masses
Reproductive Age Group
Differential Diagnosis Non neoplastic ovarian masses
Combination monophasic oral contraceptive therapy
- markedly reduce the risk of functional ovarian cysts
In comparision with previously available higher-dose pills, the effect of cyst suppression with current low-dose oral contraceptives is attenuated.
Smoker: twofold increased risk of developing ovarian cysts.

38. Differential Diagnosis Non neoplastic ovarian masses
Reproductive Age Group
Differential Diagnosis Non neoplastic ovarian masses
Endometrioma
: 6~8cm size
PCOS

39. Differential Diagnosis neoplastic ovarian masses
Reproductive Age Group
Differential Diagnosis neoplastic ovarian masses
Reproductive years >80% of benign cystic teratomas (dermoid cysts)
Dermoid cysts
: represented 62% of all ovarian neoplasms < 40years women
Malignant transformation <2% of dermoid cysts ( in all ages)
most cases occur in women >40 years of ages
Risk of torsion : 15%(more frequently than with ovarian tumors in general d/t high-fat content → float within the abdominal and pelvic cavity)
Bilateral :10%
Ovarian cystectomy is almost always possible, even if it appears that only a small amount of ovarian tissue remains
Laparoscopic cystectomy is often possible , and intraoperative spill of tumor contents is rarely a cause of complications

40. The risk of epithelial tumors increases with age
Differential Diagnosis neoplastic ovarian masses
The risk of epithelial tumors increases with age
Serous tumor
Mucinous ovarian
characteristics
Psammoma bodies
: fine calcific granulation –
>scattered within the tumor
and visible on radiograph
grow to large
dimensionsdifficult to
distinguish histologically
from metastatic gastroi
ntestinal malignancies
sometimes with papillary components
lobulated smooth surface
multilocular,(serous cystadenoma)
multilocular,
bilateral
10%
malignant
20~25%
5~10% : borderline malignant potential
5~10%

41. Differential Diagnosis neoplastic ovarian masses
Reproductive Age Group
Differential Diagnosis neoplastic ovarian masses
Others
- fibromas(a focus of stromal cells)
- Brenner tumors
- cystadenofibroma (mixed forms of tumors)

42. Differential Diagnosis Other Adnexal Masses
Reproductive Age Group
Differential Diagnosis Other Adnexal Masses
Tuboovarian abscess
Ectopic pregnancies
Parovarian cysts
: noted either on examination or on imaging studies
- Normal ipsilateral ovary can be visualized using
ultrasonography
- frequency of malignancy: quite low (2% of patients)

43. Reproductive Age Group
Diagnosis
Pelvic Examination including rectovaginal examination and pap test
: estimations of the size of a mass should be presented in centimeters rather than in comparison to common objects or fruit (eg. Orange, grapefruit, tennis ball, golf ball)
Other studies
- Endometrial sampling with an endometrial biopsy or D&C
: when both a pelvic mass and abnormal bleeding are present.
- Studies of Urinary tract : cystoscopy, ultrasonography, an intravenous
pyelogram
Laboratory studies
: pregnancy test, cervical cytology, CBC, ESR, testing of stool for
occult blood, tumor markers –CA125
- CA125 ↑: uterine leiomyoma, PID, pregnancy, endometriosis
→ unnecessary surgical intervention

44. Diagnosis Imaging Studies
Reproductive Age Group
Diagnosis
Imaging Studies
- pelvic ultrasonography, transvaginal and transabdominal
ultrasonography
- CT, abdominal flat plate radiograph – seldom indicated as a
primary diagnostic procedure
- MRI : diagnosis of uterine anomalies
Scoring system
- predict benign versus malignant adnexal masses
Ultrasonographic indices
- characterizations of morphology
: septations, solid components, ovarian size
- demographic factors (ig, age)
- color flow imaging and doppler waveform analysis

45. Diagnosis

46. Diagnosis Hysteroscopy
- direct evidence of intrauterine pathology or submucous leiomyomas
Hysterosalpingography
- demonstrate indirectly the contour of the endometrial cavity and any
distortion or obstruction of the uterotubal junction 2nd to leiomyomas
an extrinsic mass or peritubal adhesions

47. Management Nonsurgical management Surgical management
Reproductive Age Group
Management
Management should be based on the primary symptoms and may include observation with close follow-up, temporizing surgical therapies, medical management or definitive surgical procedures
Nonsurgical management
Surgical management

48. Nonsurgical Management
Reproductive Age Group
Management Leiomyoma
Nonsurgical Management
judicious patient observation and follow-up are indicated primarily for uterine leiomyomas : intervention is reserved for specific indications and symptoms
GnRH agonists
- 40~60% decrease in uterine volume
- can be value in some clinical situations
- result in hypoestrogenism
☞ reversible bone loss and symptoms such as hot flashes
- Limited to short-term use although low-dose hormonal
replacement may be effective in minimizing the
hypoestrogenic effects.

49. Indication of GnRH agonists
Reproductive Age Group
Management Leiomyoma
Indication of GnRH agonists
- Preservation of fertility in women with large leiomyomas before attempting conception, or preoperative treatment before myomectomy
- Treatment of anemia to allow recovery of normal hemoglobin levels before surgical management, minimizing the need for transfusion or allowing autologous blood donation
- Treatment of women approaching menopause in an effort to avoid surgery
- Preoperative treatment of large leiomyomas, to make vaginal hysterectomy, hysteroscopic resection or ablation or laparoscopic destruction more feasible
- Treatment of women with medical contraindications to surgery
- Treatment of women with personal or medical indications for delaying surgery

50. Reproductive Age Group
Management Leiomyoma
Newer therapies combining GnRH agonists with estrogen add-back therapy
RU486
- progesterone antagonist
☞ decrease the size of uterine leiomayoma

51. - Abnormal uterine bleeding with resultant anemia, unresponsive to
Reproductive Age Group
Management Leiomyoma
Surgical Therapy
Asymptomatic leiomyomas : not usually require surgery
Indication
- Abnormal uterine bleeding with resultant anemia, unresponsive to
hormonal management
- Chronic pain with severe dysmenorrhea, dyspareunia, or lower
abdominal pressure or pain
- Acute pain, as in torsion of a pedunculated leiomyoma, or prolapsing
submucosal fibroid
- Urinary symptoms or signs such as hydronephrosis after complete evaluation
- infertility, with leiomyomas as the only abnormal finding
- markedly enlarged uterine size with compression symptoms or discomfort

52. - rapid enlargement of the uterus during the premenopausal years
Reproductive Age Group
Management Leiomyoma
Uterine sarcoma
- rapid enlargement of the uterus during the premenopausal years
- any increase in uterine size in a postmenopausal woman
→ indication for surgery
☻ Fibroid uterus → absolute risk of uterine sarcoma : < 2~3/1000

53. Management Leiomyoma Hysterectomy Myomectomy
: definitive management of symptomatic uterine leiomyoma
Myomectomy
: for patient who desire childbearing , who are young, who prefer
that the uterus be retained
* Morbidity of abdominal myomectomy and hysterctomy are similar
(recent studies)
- previous reports had suggested higher risks for myomectomy,
including to risks of hemorrhage and transfusion requirements

54. Laparoscopic myomectomy Vaginal myomectomy
Management Leiomyoma
Laparoscopic myomectomy
Vaginal myomectomy
indicated in the case of a prolapsed pedunculated submucous fibroid
Hysteroscopic resection
: small submucosal leiomyoma
* Recurrence (after myomectomy) : > 50%
→ ~1/3 : requiring repeat surgery
Endometrial ablasion
: decrease bleeding for women with primary intramural fibroids
Preop GnRH agonists
: decreased uterine size

55. Nonextirpative approaches - Myolysis
Reproductive Age Group
Management Leiomyoma
Nonextirpative approaches
- Myolysis
- uterine artery embolization

56. Management Ovarian Masses
Reproductive Age Group
Management Ovarian Masses
functional tumors
: expectant
* oral contraceptions
number of randomized prospective studies have shown no
acceleration of the resolution of functional ovarian cysts
With oral contraceptives are effective in reducting the risk of subsequent ovarian cysts
Symptomatic cysts : evaluated promptly
Mildly symptomatic masses (suspected functional)
→ management with analgesics rather than surgery to avoid the
development of adhesions
(→ impair subsequent fertility)

57. Management Ovarian Masses
Reproductive Age Group
Management Ovarian Masses
Indication of surgery
severe pain
supicion of malignancy
torsion

58. Management Ovarian Masses
Reproductive Age Group
Management Ovarian Masses
large cysts, multiloculations, septa, papillae and increased blood flow(on ultrasonography ) → suspected of neoplasia
Ovarian tumor torsion requires oophorectomy on the basis that the untwisting(detorsion) of the ovarian pedicle would lead to emboli
Recent studies have suggested that the primary management should be detorsion with ovarian cystectomy if a cyst is present
: Normal ovarian function frequently results even in ovaries that do not
initially appear to be viable.
- This management is particularly important in prepubertal and young
women
Oophoropexy may be helpful in preventing recurrent torsion
Ultrasonographic or CT-directed aspiration procedures should not be used in women in whom there is a suspicion of malignancy
Laparoscopic management

59. Management Ovarian Masses
Reproductive Age Group
Management Ovarian Masses
The choice of surgical approach (laparotomy or laparoscopy) based on - the surgical indications
- the patient’s condition
- the surgeon’s expertise and training
- informed patient preference
- the most recent data supporting the chosen
approach

60. Postmenopausal Age Group
Differential Diagnosis
Diagnosis and Management

61. Differential Diagnosis
Postmenopausal Age Group
Differential Diagnosis
Ovarian masses
During the postmenopausal years, the ovaries become smaller
- Before menopuse, the dimension are approximately3.5X2X1.5cm
- In early menopause, the ovaries are approximately 2X1.5X0.5cm
- In late menopause they are even smaller : 1.5X0.75X0.5
PMPO (postmenopausal palpable ovary) syndrome
- Ovary that is palpable on examination beyond the menopuse is abnormal
and deserves evaluation
- Not predictor of malignancy
Ovarian cancer
- predominant
- average patient age : 56~60 years

62. Differential Diagnosis
Indication of surgery
: women with a strong family history of ovary, breast,
endometrial or colon cancer or a mass that appears to be
enlarging
Uterine and other Masses

63. Diagnosis History : personal and family medical Hx Pelvic Examination
Postmenopausal Age Group
Diagnosis
History : personal and family medical Hx
Pelvic Examination
Ultrasonography
Serum CA125

64. Management Benign : nonoperative management Indication of surgery
Postmenopausal Age Group
Management
Benign : nonoperative management
Indication of surgery
- based on characteristics of the mass
- a family or personal medical history
- the patient’s desire for definitive diagnosis
- selection of the appropriate surgical procedure is
critical for effective therapy