CASE: 5 ANG BUGON SA PUSON

1. Review the anatomy and physiology of the female reproductive system

1.1 Vulva
-or pudendum is a collective term for the external genital organs that are visible in
the perineal area.

Consists of the ff:

a. Mons pubis
- a rounded eminence that becomes hairy after puberty
b. Labia majora
- 2 large, longitudinal, cutaneous folds of adipose and fibrous tissue that
extend from the mons pubis anteriorly to become lost in the skin between the
vagina and the anus in the area of the posterior fourchette
- have both sweat and sebaceous glands
- Homologous to the male scrotum
c. Labia minora
- nymphae, small, red cutaneous folds situated between the labia majora and
the vaginal orifice
- Anteriorly-divide at the clitoris to form superiorly the prepuce, inferiorly the
frenulum of the clitoris
- composed of dense connective tissue with erectile tissue and elastic fibers.
No hair follicles or sweat glands
-Homologous to the penile urethra and part of the skin of the penis
d. Hymen
- thin, usually perforated membrane at the entrance of the vagina, covered
by stratified squamous epithelium on both sides and consists of fibrous tissue
with few blood vessels.
- carunculae myrtiformes are the remnants of the hymen identified in adult
females
e. Clitoris
- a short cylindrical, erectile organ at the superior portion of the vestibule.
- width less than 1 cm, length of 1.5 2 cm
- female homologue of glans penis
f. Vestibule
- lowest portion of the embryonic urogenital sinus, this is the cleft between
labia minora that is visualized when the labia are held apart. It extends from
the clitoris to the posterior fourchette.
g. Urethra
- conduit for urine from the urinary bladder to the vestibule
- 5 cm in length
- Mucosa of prox. 2/3 is composed of stratified transitional epithelium where as
the distal 1/3 is stratified squamous epithilium
h. Skenes glands
- paraurethral glands: branched, tubular glands that are adjacent to the
distal urethra
- homologous to the prostate
i. Bartholins glands
- vulvo-vaginal glands located beneath the fascia at about 4 & 8 oclock on
the posterolateral aspect of the vaginal orifice
- homologous to Cowpers glands
j. Vestibular glands
- elongated mass of erectile tissue situated on either side of the orifice
- homologous to the bulb of the penis
1.2 Vagina
- a thin walled, distensible, fibromuscular tube that extends from the vestibule of
the vulva to the uterus
- anterior vaginal length is 6-9 cm, and posterior length is 8-12 cm
- vascular system of the vagina is generously supplied with an extensive
anastomotic network throughout its length.

Vaginal artery originates either

1) directly from the uterine artery
2) branch of the internal iliac artery
- anastomose with the cervical branch of the uterine artery to
form the azygous arteries
- branches of the internal pudendal, inferior vesical, and middle
hemorrhoidal arteries also contribute to the interconnecting network and the
longitudinal azygous arteries.

Venous drainage
- upper - middle vagina via the vaginal, uterine, vesical, rectosigmoid veins
- lower - via the pudendal veins

Nerve supply
- comes from the autonomic nervous systems vaginal plexus and sensory fibers come
from the pudendal nerve.
- pain fibers enter the spinal cord in S2-4
- there is paucity of free nerve endings in the upper 2/3 of the vagina

1.3 Cervix
-is the lower narrow portion of the uterus

Blood supply:
Arterial supply from the descending branch of the uterine artery
- Cervical arteries run on the lateral side of the cervix and from
the coronary artery encircling the cervix
- Azygos arteries run longitudinally in the middle of the anterior
and posterior aspects of the vagina
-Anastomoses with vaginal and middle hemorrhoidal vessels
Nerve supply:
-The stroma of the endocervix is rich in free nerve endings. Pain
fibers accompany the parasympathetic fibers to the S2-4
segments

1.4 Uterus
-a thick-walled, hollow muscular organ located centrally

Blood supply:
- uterine arteries large branches of the hypogastric arteries
- ovarian arteries originate directly from the aorta
- venous from the fundus goes to the ovarian veins and blood from the
corpus exits via the uterine veins into the iliac veins
Innervation:
- afferent nerve fibers from the uterus enter the spinal cord at the T11-12
sympathetic segment
-hypogastric and ovarian plexus parasympathetic- derived from the pelvic
nerve and from the S2-4
 1.5 Fallopian tubes
- extends outward from the superolateral portion of the uterus and end by curling
around the ovaries
- the mesentery of the tubes, the mesosalpinx, contains the bloods supply and nerves.
- 10-14 cm in length
- parts: isthmus, ampulla, infundibulum, fimbriae

Blood supply
Arterial derived from the terminal branches of the uterine and ovarian arteries: the
arteries anastomose in the mesosalpinx. Blood from the uterine artery supplies the
medial 2/3 of each tube.

Venous runs parallel to the arterial supply

Innervation
-both sympathetic and parasympathetic nerves from the uterine and ovarian
plexus
-sensory nerves are related to spinal cord segments T11-12 & L1

1.6 Ovaries
- are light gray and each one is approx. the size and config. of a large almond.
- Weigh 3-6 grams, measures 1.5 x 2.5 x 4 cms

Blood supply:
Arterial each of the ovarian arteries directly from the aorta just below the renal
arteries.
They descend in the retroperitoneal space, cross anterior to the internal iliac
vessels, and enter the infundibulopelvic ligaments, reaching the mesovarium in
the broad ligament.

Venous
- Left ovary drains to the left renal vein
- Right ovary drains to the inferior vena cava

2. Discuss the differential diagnosis of pelvic masses

-pathology in this area may arise from the adnexal organs (ovary and fallopian tube as well
as associated vessels) or from the uterus, bowel, retroperitoneum or even metastatic
disease from the other sites.
-A mass in this area may be symptomatic or discovered incidentally. Some
will regress spontaneously while other require surgery

2.1 Gynecological
2.1.1 Ovarian tumors
-Benign
-Malignant
2.1.2 Fallopian tube
-Ecotopic pregnancy
-Hydrosalphinges
-Abscess
2.1.3 Uterine
-Hematometra
-Tumors (benign, malignant)
 2.2 Non gynecological
2.2.1 Gastrointesinal
-colorectal masses
2.2.2 Genito-urinary
-distended bladder

3. Describe the different hypothesis on its pathogenesis of ovarian tumors

-despite many epidemiologic investigations, a clear cut cause of ovarian tumors has not
been identified

3.1 Incessant Ovulation

- It is thought that malignancies are related to frequent ovulation and therefore
women who ovulate regularly appear to be at higher risk
- Included are those with late menopause, a history of nulliparity or late
childbearing.
- Women who have had several pregnancies or who have used OCPs appear to
have some protection against ovarian cancer
-Ovulation age the number of years during which the patient has ovulated

3.2 Gonadotropin Hypothesis

- It has been suggested that ovulation inducing drugs such as clomiphene (Clomid)
increase the risk of ovarian cancer as noted by Whittemore and collegues.
-Rossing and co workers reported an increase in risk from a population based study
that the risk was associated with prolonged use of clomiphene in so far as no
association was noted with <1 year use
- The frequent presence of hormone receptors in these lesions as well as the
hyperestrogenic microenvironment may support this observation.

4. Identify the pathologic classification, key points in history, physical examination and
laboratory tests leading to the diagnosis, histopathologic characteristics and management of
benign ovarian tumors.

4.1 Functional Cyst

- are not neoplasms but anatomic variations arising from normal ovarian function
- Occasionally present as an incidental finding on routine exams or may be
symptomatic (heaviness, dull ache)

4.1.1. Follicular Cyst

- Most commonly found in young menstruating women
- Frequently multiple and may vary from a few mm to as large as 15cm
- A normal follicle may develop into a physiologic cyst
- Dependent on gonadotropins for growth
- Usually clear, thin walled and solitary
- Are translucent, thin walled and are filled with watery straw colored or clear
fluid
-The initial management of a suspected follicular cyst is conservative
observation
- The majority of follicular cysts disappear spontaneously by either resorption
of the cyst fluid or silent rupture within 4-8 weeks of diagnosis
- In premenopausal women, operative management of non- malignant cysts
is cystectomy not oophorectomy

4.1.2. Corpus Luteum Cyst

- Corpus luteum cysts are less common cysts than follicular cysts but they are
clinically more important
 - Clinically, corpora lutea are not termed corpus luteum cysts unless they are
at least 3cm in diameter
- Corpus luteum cysts may be associated with normal endocrine function of
prolonged secretion of progesterone
- CL cysts develop from mature graafian follicles
- Most CL cysts are small average diameter is 4cm
- Grossly they have a smooth surface and depending on whether the cyst
represents acute or chronic hemorrhage, is purplish red to brown
- When a CL is cut, the convoluted lining is yellowish orange
- CL cysts vary from being asymptomatic masses to those causing
catastrophic and massive intraperitoneal bleeding associated with rupture
- Halban in 1915 describe a syndrome of persistently functioning CL cyst that
has clinical features similar to an unruptured ectopic pregnancy

Halbans Classic Triad

1) delay in menses followed by spotting
2) unilateral pelvic pain
3) small adnexal mass

4.1.3. Theca Lutien Cyst

- The least common of the 3 physiologic cysts
-Almost always bilateral and produce moderate to massive enlargement of
the ovaries
- Individual cysts vary from 1 and 10 cm or more
- Arise from prolonged or excessive stimulation of the ovaries by endogenous
or exogenous gonadotropins or increased sensitivity to gonadotropins

Hyperreacto luteinalis Ovarian enlargement secondary to the

development of multiple luteinized follicular cysts
- Found in approx 50% of molar pregnancies and 10% of
choriocarcinomas.
- Also found in the later months of pregnancies with large placentas
such as twins, diabetes and Rh sensitization
- Occasionally discovered in normal pregnancies
- Rarely found in young girls with juvenile hypothyroidism
- Presence of cysts established through palpation and confirmed by
sonography
- Treatment is conservative because these cysts gradually regress
- Drainage not done due to possibility of bleeding

Luteoma of Pregnancy a specific benign reaction of ovarian theca lutein

cell. They do not arise from CL of pregnancy
- Majority of patients are asymptomatic
- Regress spontaneously following completion of pregnancy

4.2 Neoplastic Cyst

4.2.1 Epithelial
- 2/3 of ovarian neoplasms are epithelial tumors
- Malignant epithelial tumors account for 85% of ovarian cancers probably
arising from inclusion cysts lined with surface(coelomic) epithelium within
the adjacent ovarian stroma
-May be benign (adenoma), malignant (adenocarcinoma) or an
intermediate form (borderline malignant adenocarcinoma or tumors of
low malignant potential)
 4.2.2.1 Serous Cystadenoma
-Most frequent epithelial ovarian tumors
- Benign forms occur primarily in reproductive years, borderline forms
30-50 years, malignant women 40 and above
-Well differentiated serous tumors consist of ciliated cells that resemble
those of the fallopian tube
-Bilateral in 10%

4.2.2.2 Mucinous Cystadenoma

-Consist of epithelial cells filled with mucin cells resemble those of the
endocervix or may mimic intestinal cells
-Found primarily in the reproductive years and mucinous carcinomas
are usually found in the 30-60 age range
-Bilateral in 5%

4.2.2.3 Benign Transitional Cell Tumor (Brenner)

-Benign, borderline and malignant forms make up 2% of ovarian tumors
-Rare, smooth, small, solid fibroepithelial ovarian tumors that are
usually asymptomatic
-Approx 30% are discovered as small solid tumors in association with
concurrent serous cystic neoplasia, such as serous or mucinous
cystadenomas of the ipsilateral ovary
-Majority are less than 5 cm
-Unilateral in 85-95%
-1 to 2 % undergo malignant change
-Slow growing masses

Accepted theory tumors result from metaplasia of coelomic

epithelium into uroepithelium
Gross: smooth, firm, gray-white, solid tumors resembling fibromas. On
sectioning, appears gray with a yellowish tinge with small
cystic spaces
Histologic: 2 principal components
=Solid masses or Nests of epithelial cells
=Surrounding fibrous stroma
-Similar to transitional epithelium of urinary bladder
-Pale epithelial cells have a Coffee bean appearing nucleus
which is also described as a longitudinal groove in the cells
nucleus
Management : Surgical
-Simple excision is procedure of choice
-TAHBSO may be performed due to age

4.2.2 Sex Cord-Stromal Tumors

- SCST are a heterogenous group of rare neoplasms that originate from the
ovarian matrix
- Cells within this matrix have the potential for hormone production

4.2.2.1 Thecoma
-Relatively common SCSTs that develop in postmenopausal women in
their 60s and develop infrequently before age 30
-Most hormonally active of the SCSts producing estrogen
-Primary symptoms are vaginal bleeding and/or pelvic mass
-Many women present with concurrent endometrial hyperplasia or
adenocarcinoma
- Composed of lipid-laden stromal cells that are occasionally luteinized
 -Half are either hormonally inactive or androgenic with the potential
for masculinisation
-Appears solid on ultrasound
Treatment: surgery is curative since condition is benign

4.2.2.2 Fibroma
-Most common benign solid lesions of the ovary
-Hormonally inactive SCST variant
-Malignant potential is less than 1%
-Comprise 5% of benign neoplasms and 20% of solid ovarian tumors
-Vary greatly in size average diameter is 6 cm but may increase up to
30 cm
-90% Unilateral
-Extremely slow growing tumors
-Often misdiagnosed as leiomyomas prior to surgery
Gross: heavy, solid, well encapsulated and grayish white. Cut surface
is homogenous white or yellowish white solid tissue with a
trabeculated or whorled appearance similar to myomas
Histologic: composed of connective tissue, stromal cells and varying
pelvic symptoms pressure and abdominal enlargement (may
be due to ascites)

MEIGS SYNDROME
Ovarian fibroma
Ascites caused by the transudation of fluid from fibroma
Hydrothorax secondary to the flow of ascitic fluid into the
pleural space via the lymphatics of the diaphragm
- 75% in the right, the left 10%, both sides 15%

Management- follow simple excision of tumor there is resolution of all

symptoms including the ascites
-TAHBSO often performed since this is frequently found in
menopausal women

4.2.3 Germ Cell Tumor

4.2.3.1 Mature Cystic Teratoma
- are usually cystic structures that on histologic examination contain
elements from all 3 germ layers
- The word teratoma literally means monstrous growth
- Teratomas may be benign or malignant
- Dermoid is a descriptive term in that it emphasizes the
preponderance of ectodermal tissue with some mesodermal and
rare endodermal derivatives
- Mature teratomas are malignant with immature or embryonic
appearing tissue
- Account for 90% of germ cell tumors of the ovary
- Occur from infancy to reproductive years
- Dermoids are the most common ovarian neoplasm in prepubertal
females and are also common in teenagers
- More than 50% of dermoids are found in women 25-50 years old
- Vary from a few mm to 25 cm in diameter. However, 80% are less than
10 cm
- Bilaterally is 10 to 15%
- Cysts are usually unilocular with smooth, shiny, opaque cyst walls
with a doughy consistency
- Benign teratomas are believed to arise from a single germ cell after
 st
the 1 meiotic division. They develop from totipotential stem cells
and they are neoplastic sequelae from a transformed germ cell
- Chromosomal makeup is 46 XX
Histologically: Composed of mature cells from all 3 germ layers. A
combination of skin appendages, increase sebaceous and
sweat glands, hair follicles, muscle fibers, cartilage, bone,
teeth, glial cells and epithelium of the respi and GIT may be
visualized
- 50-60% of cysts are asymptomatic and are discovered during routine
pelvic exam, Ultrasound or laparotomy
Symptoms: Pain and pelvic pressure
Complications: torsion, rupture, infection, hemorrhage, malignant
degeneration
=Rupture is more common in pregnancy
=Torsion is more the MOST frequent complication

-Associated with 3 medical diseases:

=Thyrotoxicosis
=Carcinoid Syndrome
=Autoimmune Hemolytic Anemia
-Adult thyroid tissue found in 12% of benign teratomas
-Struma ovarii teratoma in which thyroid tissue has overgrown other
elements and is the predominant tissue

Treatment: Cystectomy with preservation of as much ovarian tissue as

possible
=Laparoscopic cystectomy is an accepted approach with
rates of spillage comparable with laparotomy
=10 cm cut-off for laparoscopic approach
nd
=if diagnosed in pregnancy removal in 2 trimester

4.2.4 Others
4.2.4.1 Endometioma
- Usually associated with endometriosis in other areas of the pelvic cavity.
2/3 of women with endometriosis have ovarian involvement
- Size varies from small, superficial, blue-black implants that are 1-5 mm in
diameter to large, multiloculated hemorrhagic cysts of up to 5-10 cm
- Large ovarian endometriomas of 20 cm are extremely rare
- Larger cysts are frequently bilateral
- Most common symptoms: Pelvic pain, dyspareunia, infertility
-On P.E. ovaries are often tender and immobile secondary to inflammation
and adhesions
Histologically: endometrial glands and stromal and Large phagocytic cells
containing hemosiderin
Treatment
=Medical rarely successful
=Surgery complicated by formation of de novo and recurrent
adhesions

4.2.4.2 Polycystic Ovary

 Recommended Management of Ovarian Masses Found with Imaging

TYPE OF MASS RECOMMENDATION

1. Simple Cyst with or without hemorrhage

Perimenopausal woman

<3 cm diameter Invariably functional; No additional treatment

<3 cm diameter The majority are functional ; TVS repeated

in 6-8 weeks. Remove if persistent

Postmenopausal woman

<5 cm diameter The majority are benign ; CA 125 And repeat

TVS, may observe if normal
>5 cm diameter Ovary may be removed if persistent or
symptomatic

2. Complex Mass
Displays any of the ff features:
Septation
Mural nodule Malignancy is difficult to rule out
unless typical features of cystic
Irregular wall thickening
teratoma or endometrioma is
Shadowing echodensity identified.
Regional, diffuse, bright echoes Postmenopausal remove
Hyperchoic lines and dots complex masses
Premenopausal remove
persistent complex masses

3. Solid or predominantly solid mass Recommended removal