Benign Gynecologic

Lesions
Eileen M. Manalo, M.D., FPOGS, FPSREI
Associate Professor IV
UP- Philippine General Hospital
Obstetrics and Gynecology
 Benign Lesions
of the Genital
Tract
• lesions of the vulva, vagina, cervix, uterine corpus,
ovaries and fallopian tubes

Benign Characteristics:
1. slow-growing
2. well-circumscribed
3. not associated with hemorrhage, necrosis or evidence of
widespread dissemination (metastasis)
4. no constitutional signs and symptoms of weight loss and
anorexia

• a tissue biopsy is needed to make a specific diagnosis.

 Topic Objectives

1. To describe and discuss the more

common lesions and conditions of the
female genital tract
2. To discuss their pathophysiology, as well
as their corresponding treatment
 Benign
Lesions of the
Vulva
 Urethral Caruncle

• fleshy outgrowth of the distal edge of the urethra

• frequently in postmenopausal women
• must be differentiated from urethral carcinomas
• generally small, single and sessile but may be
pedunculated and grow to be 1 to 2 cm in
diameter
• tissue is soft, smooth, friable and bright red and
initially appears as an eversion of the urethra
 Urethral Caruncle

• believed to arise from an ectropion of the

posterior urethral wall associated with
retraction and atrophy of the
postmenopausal vagina
• histologically composed of transitional and
stratified squamous epithelium with loose
connective tissue
 Urethral Caruncle

• Growth is secondary to chronic irritation or

infection

• Symptoms may be variable

– mostly asymptomatic
– dysuria frequency, and urgency
 Urethral Caruncle

• differential diagnosis
• primary carcinoma of the urethra
• prolapse of the urethral mucosa

• not a precursor for urethral carcinoma

• diagnosis is established by biopsy under
local anesthesia
 Urethral Caruncle

Treatment
– Initially
1. oral or topical estrogen
2. avoidance of irritation
– cryosurgery, laser therapy, fulguration, or operative
excision

– following operative destruction - a foley catheter

should be left in place for 48 to 72 hours
– follow-up is necessary to ensure that the patient
does not develop urethral stenosis
 Urethral Prolapse

• predominantly in premenarchal
females

• Grossly
– does not have the bright-red color of
a caruncle
– is not as circumscribed in gross
configuration
– it may be ulcerated with necrosis or
grossly edematous

• Majority are asymptomatic but

some may have dysuria
 Urethral Prolapse

Therapy
2. hot sitz baths
3. antibiotics
4. topical estrogen cream
5. excision of the redundant mucosa –
rarely done but may be necessary
 Vulvar Cysts

• Bartholin’s duct cyst is the

most common of the large
vulvar cysts
• treatment is not necessary
in women younger than 40
unless the cyst becomes
infected or enlarges enough
to produce symptoms
 Vulvar Cysts

• the most common small vulvar cysts are

epidermal inclusion cysts or sebaceous
cysts
 Sebaceous Cysts

• located immediately beneath the epidermis

• mostly discovered on the anterior half of the
labia majora
• multiple, freely movable, round, slow growing,
and nontender with firm consistency
• grossly appear white or yellow with caseous
contents on cut section
• local scarring of the adjacent skin sometimes
occurs when rupture of the contents of the cyst
produces inflammatory reaction in the
subcutaneous tissue.
 Inclusion Cysts

• develops when an infolding of squamous

epithelium has occurred beneath the
epidermis in the site of an episiotomy or
obstetric laceration
• When found in the vagina – most likely
related to previous trauma
 Inclusion Cysts

• alternative theories of histogenesis

– include embryonic remnants
– occlusion of pilosebaceous ducts of sweat
glands

• Treatment
– usually none
– If infected – local heat as well as incision and
drainage
– Recurrent cysts require excision.
 Nevus

• commonly referred to as a mole

• a localized nest or cluster of melanocytes
• arise from the embryonic neural crest and
are present from birth
• one of the most common benign
neoplasms in females
• generally asymptomatic
 Nevus

• Histologic groups:
– junctional
– compound
– intradermal nevi

• 5% to 10% of all malignant melanomas in

women arise from the vulva
• 50% of malignant melanomas arise from a
preexisting nevus
 Nevus

• symptoms of an early malignancy include

1. asymmetry
2.border irregularity
3.color variegation
4. diameter usually greater than 6 mm (ABCD)
 Nevus

• all flat vulvar nevi should be excised and

examined histologically
• flat junctional nevus and dysplastic nevus have
high malignant potential
• proper excisional biopsy should be three
dimensional and adequate in width and depth
– Approximately 5 -10 mm of normal skin surrounding
the nevus should be included,
– the biopsy should include the underlying dermis as
well
 Hemangioma

• are rare malformations of

blood vessels rather than
true neoplasms.
• frequently discovered
initially during childhood
• approximately 60% of
vulvar hemangiomas
spontaneously regress in
size by the time the child
goes to school
 Hemangioma

• appear histologically as predominantly

thin-walled capillaries arranged randomly
and separated by thin connective tissue
septa.
• most are asymptomatic
• may occasionally become ulcerated and
bleed
 Fibroma

• most common benign solid tumor of the vulva

• commonly found in the labia majora
• occur in all age groups
• have smooth surface and distinct contour
• with low grade potential for becoming malignant
• smaller fibromas are asymptomatic
• large tumors may produce chronic pressure
symptoms or acute pain
• treatment - operative removal if the fibromas
are symptomatic and/or continue to grow
 Lipoma

• benign, slow growing, circumscribed

tumors of fat cells arising from the
subcutaneous tissue of the vulva.
• second most frequent benign vulvar
mesenchymal tumor
• most lipomas are discovered in the labia
majora and are superficial in location
• malignant potential is extremely low
 Hidradenoma

• benign vulvar tumor that originates from

apocrine sweat glands of the inner
surface of the labia majora and nearby
perineum.
• found in white women between 30 and 70
years of age.
• asymptomatic but may cause pruritus or
bleeding if the tumor undergoes necrosis
• excisional biopsy is the treatment of
choice
 Endometriosis

• Rare in the vulva

• firm, small nodule or nodules
• varies from a few millimeters to several centimeters in
diameter
• found at the site of an old, healed obstetric laceration,
episiotomy site, an area of operative removal of a
Bartholin’s cyst, or along the canal of Nuck

• Pathophysiology
– secondary to metaplasia
– retrograde lymphatic spread, or
– potential implantation of endometrial tissue during operation
 Endometriosis

• commonly present with introital pain and

dyspareunia
• classic history - cyclic discomfort and
enlargement of the mass during menses
• Treatment
– wide excision or laser vaporization depending
on the size of the mass
• Recurrence after treatment are common
 Hematoma

• usually secondary to
blunt trauma - (straddle
injury)
• spontaneous hematomas
are rare and usually
occur from rupture of a
varicose vein during
pregnancy or the
postpartum period
 Hematoma

• Management
– usually conservative unless the hematoma is
greater than 10 cm in diameter or is rapidly
expanding
– direct pressure may be applied to control the
bleeding
– compression and application of an ice pack to
the area
– Identification and ligation of bleeders if the
hematoma continues to expand
 Dermatologic Lesions

• skin of the vulva is susceptible to any

generalized skin disease or involvement by
systemic disease.
• most common skin diseases include
– contact dermatitis
– neurodermatitis
– Psoriasis
– seborrheic dermatitis
– cutaneuos candidiasis
– lichen planus
 Dermatologic Lesions

• majority are scalelike rashes and usually

presents with pruritus
• diagnosis and treatment are often
obscured or modified by the environment
of the vulva
 Vulvar Edema

• may be a symptom of either local or

generalized disease
• Most common causes:
– secondary reaction to inflammation
– lymphatic blockage
 Benign
Lesions of the
Vagina
 Urethral Diverticulum

• a saclike projection arising from the posterior urethra

• often present as a mass of the anterior vaginal wall
• symptoms are identical to lower genital tract infection

• Diagnosis:
• voiding cystourethrograph
• cystourethroscopy.
• Other diagnostic tests: urethral pressure profile recordings, vaginal
ultrasound, positive-pressure urethrography and MRI

• Treatment:
– Excisional surgery in acute infection
 Inclusion Cyst

• most common cystic structures of the vagina

• usually discovered in the posterior or lateral
walls of the lower third of the vagina
• common in parous women
• often results from birth trauma or gynecologic
surgery
• majority are asymptomatic
• if symptomatic, excisional biopsy is indicated
 Tampon Problems

• risks with its usage:

– vaginal ulcers
– toxic shock syndrome from toxins produced by
Staphylococcus aureus

• associated with microscopic epithelial changes

• the classic “forgotten” tampon presents with a
foul vaginal discharge and occasional spotting
• Treatment: antibiotic vaginal cream for the next
5 to 7 days
 Local Trauma

• Coitus is the most frequent etiology

• most common injury is a transverse tear
of the posterior fornix
• Manifests with profuse or prolonged
vaginal bleeding
• Management:
– prompt suturing under adequate anesthesia
 Benign
Lesions of the
Cervix
 Endocervical and
Cervical Polyp

• most common benign

neoplastic growth of the cervix
• Seen in multiparous women in
their 40s and 50s
• usually secondary to
inflammation or due to
abnormal focal responsiveness
to hormonal stimulation
 Endocervical and
Cervical Polyp

• Symptoms
– classic symptom is intermenstrual bleeding
– many are asymptomatic
– recognized for the first time during a routine
speculum examination
 Endocervical and
Cervical Polyp

• Management
– Polypectomy may be an office procedure
– most can be managed by grasping the base of the
polyp with an appropriately sized clamp.
– The polyp is avulsed with a twisting motion and sent
to the pathology for microscopic evaluation.
– if bleeding ensues, the base may be treated with
chemical cautery, electrocautery, or cryocautery
 Nabothian Cysts

• so common that they are

considered a normal feature of
the adult cervix
• retention cysts of endocervical
columnar cells occurring where
a tunnel or cleft has been
covered by squamous
metaplasia.
• produced by the spontaneous
healing process of the cervix
• asymptomatic
• treatment is not necessary
 Cervical Lacerations

• frequently occur with both normal and abnormal deliveries

• vary from minor superficial lacerations to extensive full-
thickness lacerations

Management
• Acutely bleeding cervical lacerations should be sutured
• should be palpated to determine the extent of cephalad
extension of the tear

Complications
• extensive cervical lacerations especially those involving the
endocervical stroma may lead to incompetence of the cervix
during a subsequent pregnancy
 Cervical Myomas

• smooth, firm masses similar to myomas of the fundus

• most are small and asymptomatic
• may become pedunculated and protrude through the
external os of the cervix
• diagnosis is by inspection and palpation

management
– similar to uterine myomas
– observation/ expectant management
– medical therapy with GnRH agonists
– myomectomy or hysterectomy
 Cervical Stenosis

• most often occurs in the region of the internal os

• may be divided into congenital or acquired
• causes of acquired cervical stenosis:
– Operative (i.e. cone biopsy, cautery)
– Radiation
– Infection
– Neoplasia
– atrophic changes
 Cervical Stenosis

Symptoms
– in premenopausal women: dysmenorhea,
pelvic pain, abnormal bleeding, amenorrhea
and infertility
– postmenopausal women are usually
asymptomatic
– diagnosis is established by inability to
introduce a 1 to 2 mm dilator into the uterine
cavity
 Cervical Stenosis
Management
– dilation of the cervix with dilators
– if stenosis recurs, monthly
laminaria tents may be used
– after a cervical dilation - a stent is
left in the cervical canal for a few
days to maintain patency.
– Treatment success depends on
the proper use of the laser and the
quality and quantity of residual
columnar epithelium remaining in
the endocervix.
 Benign
Lesions of the
Uterus
 Endometrial Polyp

• localized overgrowths of
endometrial glands and stroma
that project beyond the surface of
the endometrium
• most arise from the fundus of the
uterus
• may vary from a few millimeters to
several centimeters in diameter
• may have a broad base or be
attached by a slender pedicle.
 Endometrial Polyp

• peak incidence between ages 40 and 49

• etiology is unknown
• often associated with endometrial hyperplasia
– unopposed estrogen may be the cause
– May be associated with chronic administration of
tamoxifen
• majority are asymptomatic
• those that are symptomatic are associated with
a wide range of abnormal bleeding patterns.
Endometrial Polyp

Components
1. endometrial glands
2. endometrial stroma
3. central vascular
channels
 Endometrial Polyp

• malignant transformation
has been estimated to be as
high as 0.5%
• Diagnosis:
– Hydrosonography
– hysteroscopy and/or
hysterosalpingography
• management - removal by
curettage or via the
hysteroscope.
 Leiomyoma
• benign tumors of muscle cell
origin
• often referred to as fibroids or
myomas
• most frequent tumors of the
pelvis
• highest prevalence occurring
during the fifth decade of a
woman’s life
• majority are found in the
corpus of the uterus
 Leiomyoma

• classified into subgroups

by their relative anatomic
relationship and position
to the layers of the uterus.

• 3 most common types

a.intramural
b.subserous
c.submucous
 Leiomyoma

• submucosal tumors
– associated with abnormal vaginal bleeding or
distortion of the uterine cavity that may produce
infertility or abortion
• subserosal myomas give the uterus its knobby
contour during pelvic examination
• parasitic myoma - myoma that outgrows its
blood supply and obtains a secondary blood
supply from another organ
• broad ligament myoma – results from lateral
growth of myoma
 Leiomyoma

Etiology
• each tumor results from an original single
muscle cell (monoclonal theory)
• somatic mutation of normal myometrium
to leiomyomas influenced by estrogen and
progesterone and local growth factors
 Leiomyoma

• rare before menarche

• most diminish in size following menopause with
the reduction of a significant amount of
circulating estrogen.
• often enlarge during pregnancy and occasionally
enlarge secondary to oral contraceptive therapy
• lower incidence among smokers
• -however, the relationship between estrogen and
progesterone levels and myoma growth is
complex
 Leiomyoma

pathology
• grossly, has a lighter color than the
normal myometrium
• on cut surface it has a glistening, pearl-
white appearance, with the smooth
muscle arranged in a trabeculated or
whorled configuration
• histologically there is a proliferation of
mature smooth muscle cells; the
nonstriated muscle fibers are arranged
interlacing bundles.
 Leiomyoma

Types of Degeneration
2. Hyaline
3. Myxomatous
4. Calcific
5. Cystic
6. Fatty
7. Red degeneration
• occurs in pregnancy in 5% to 10% of
gravid women with myomas
– medically treated during pregnancy,
otherwise, myomectomy is done
• Necrosis
• Malignant - 0.3% and 0.7%
 Leiomyoma

symptoms
• most common are pressure from an enlarging
pelvic mass, pain and abnormal uterine bleeding
• severity of symptoms is usually related to the
number, location, and size of the myomas
• majority are asymptomatic
• rapid growth after menopause is a disturbing
symptom
 Leiomyoma

diagnosis
1. pelvic examination
2. Ultrasound

management
• if small, symptomatic, judicious observation is made
• at first discovery, a pelvic examination at 6 month
intervals to determine the rate of growth should be done
• women with abnormal bleeding and leiomyomas should
be investigated thoroughly for concurrent problems
such as endomterial hyperplasia
• surgery when persistently symptomatic
 Leiomyoma

Medical Management
• Medical treatment involves reduction in the size of the myoma by reducing the
level of estrogen and progesterone
• e.g.GnRh agonists

Advantages
• Facilitate easier surgery
• induction of amenorrhea

Disadvantages
10. delay in final tissue diagnosis
11. degeneration of some leiomyomas, necessitating piece-meal enucleation at
myomectomy
12. hypoestrogenic side effects (e.g. trabecular bone loss, vasomotor flushes)
13. cost
14. need to self-administer or receive injections in many cases
 Leiomyoma

Surgical Management

Indications for Surgery

4. rapidly expanding pelvic mass
5. persistent abnormal bleeding
6. pain or pressure
7. enlargement of an asymptomatic myoma
to more than 8 cm in a woman who has
not yet completed child bearing

Contraindications to Surgery
10. pregnancy
11. advanced adnexal disease
12. malignancy
 Leiomyoma

Transcatheter uterine artery embolization

• newest modality in managing uterine myomas
• multiple embolic materials have been used including
gelatin sponge, silicon spheres, metal coils, and
polyvinyl alcohol particles of various diamters
• postprocedural abdominal and pelvic pain is common for
the first 24 hours
• success rates in regard to decreasing menorrhagia and
reduction in uterine size are promising
 Adenomyosis
• growth of glands and
stroma into the uterine
myometrium to a depth
of at least 2.5 mm from
the basalis layer
• sometimes known as
internal endometriosis
• pathogenesis remains
unknown.
 Adenomyosis

Pathology
2. diffuse involvement of the anterior and
the posterior alls of the uterus, with
the posterior being more often
involved
3. there is a focal area of the lesion -
adenomyoma.
• results in a asymmetric uterus
where there is usually a
pseudocapsule.

Criteria for diagnosis

– a finding of inactive or proliferative
glands, more than one low power
field (2.5 mm) from the basalis
layer of the endometrium.
 Adenomyosis

Diagnosis
• majority of women are asymptomatic
• May present with secondary dysmennorhea and
menorrhagia. severity of symptoms increases
proportionally with depth of invasion and
penetration.
• Usually presents with uterine enlargement
palpated through pelvic examination
• Ultrasound and MRI are helpful in diagnosis.
Adenomyosis

Treatment
• no satisfactory
proven medical
treatment for
adenomyosis.
• Hysterectomy is the
definitive treatment
 Benign
Lesions of the
Fallopian
Tubes
 Adenomatoid
Tumors

• most prevalent benign tumor of the

oviduct
• small,gray-white, circumbscribed nodules,
1 to 2 cm in diameter
• usually unilateral
• asymptomatic
• do not become malignant but may be
mistaken for low-grade neoplasm
 Paratubal Cysts

• Diagnosis is incidental
• often multiple and may vary from
0.5 cm to more than 20 cm in
diameter
• when pedunculated and near the
fimbrial end of the oviduct -
hydatid cysts of Morgagni
• treatment is simple excision
• Complications: torsion
 Torsion

• rare event however has been reported with both normal

and pathologic fallopian tubes
• pregnancy predisposes to this problem
• usually accompanies torsion of the ovary in 50-60% of
cases
• right tube more frequently involved than the left
• presents with acute lower abdominal and pelvic pain

Management
• exploratory operation
• with a minor degree of torsion, it is possible to restore
normal circulation to the tube and salvage it
 Benign
Lesions of the
Ovaries
 Follicular Cysts

• most frequent cystic structure

in normal ovaries
• arises from temporary
variation of a normal
physiologic process
• may result from either
– the dominant mature follicle’s
failing to rupture (persistent
follicle) or
– an immature follicle’s failing to
undergo the normal process of
atresia.
• most commonly found in
young, menstruating women
 Follicular Cysts

• majority are asymptomatic

• May be discovered during ultrasound imaging of the pelvis or a
routine pelvic examination
• May also present with signs and symptoms of ovarian enlargement
and therefore must be differentiated from a true ovarian neoplasm

Management
• Conservative observation
• majority disappear spontaneously by either reabsorption of the cyst
fluid or silent rupture within 4 to 8 weeks on initial diagnosis
• persistent ovarian mass necessitates operative intervention to
differentiate it from a true neoplasm of the ovary
• cystectomy and oophorectomy
Corpus Luteum Cyst
• less common than follicular cysts,
but clinically more important
• minimum of 3 cm in diameter
• may be associated with either
normal endocrine function or
prolonged secretion of
progesterone.
• associated menstrual pattern may
be normal, delayed menstruation
or amenorrhea
• vary from being asymptomatic to
those causing catastrophic and
massive intraperitoneal bleeding
with rupture.
 Corpus Luteum Cyst

Differential Diagnosis
1. ectopic pregnancy
2. ruptured endometrioma
3. adnexal torsion

Management
• Conservative if unruptured
• With persistent bleeding - treatment is
cystectomy.
 Theca Lutein Cysts

• least common of the three types of physiologic ovarian

cysts
• almost always bilateral and produce moderate to
massive enlargement of the ovaries
• arise from either prolonged or excessive stimulation of
the ovaries by endogenous or exogenous
gonadotrophins
• Seen in 50% of molar pregnancies and 10% of
choriocarcinoma
• also discovered in the latter months of pregnancies often
with conditions that produce a large placenta, such as
twins, diabetes and Rh sensitization
 Theca Lutein Cysts

• hyperreactio luteinalis
– is the condition of ovarian enlargement
secondary to the development of multiple
luteinized follicular cysts.
• Luteoma of pregnancy
– not a true neoplasm but rather a specific,
benign, hyperplastic reaction of ovarian theca
lutein cells
 Theca Lutein Cysts

• produce vague symptoms, such as

pressure in the pelvis
• presence is established by palpation and
often confirmed by ultrasound examination
• treatment is conservative
 Dermoid Cyst

• Benign cystic teratoma

• most common ovarian neoplasm
in prepubertal females and in
teenagers
• vary from a few millimeters to 25
cm in diameter, may be single or
multiple
• usually discovered either in the
cul-de-sac or anterior to the
broad ligament
 Dermoid Cyst

• composed of mature
cells, usually, from all
three germ layers
• most solid elements
arise are contained in a
protrusion or nipple
(mamila) in the cyst
wall termed the
prominence or tubercle
of Rokitansky
 Dermoid Cyst

• adult thyroid tissue is discovered

microscopically in approximately 12% of
benign teratomas
• Struma ovarii
– teratoma in which the thyroid tissue has
overgrown other elements and is the
predominant tissue
 Dermoid Cyst

• presenting symptoms include pain, sensation of pelvic pressure

• 50% to 60% are asymptomatic
• Some are discovered during a routine pelvic examination,
coincidentally visualized by an abdominal x-ray or ultrasound
examination

management
• cystectomy with preservation of as much normal ovarian tissue as
possible

Complications
1. Torsion
2. Rupture
3. Infection
4. Hemorrhage
5. malignant degeneration
 Endometrioma

• areas of ovarian
endometriosis that become
cystic
• usually associated with
endometriosis in other areas
of the pelvic cavity
• large chocolate cysts of the
ovary may reach 15 to 20 cm
 Endometrioma

• the most common symptoms

associated
1. pelvic pain
2. Dyspareunia
3. infertility
• Tender and immobile ovaries
on pelvic examination
– dense adhesions on surrounding
structures is a common finding
 Endometrioma

management
• the choice of management depends on:
1. patient’s age
2. future reproductive plans
3. severity of symptoms
• medical therapy is rarely successful in treating
ovarian endometriosis
• surgical therapy is complicated by formation of
de novo and recurrent adhesions
 Fibroma

• the most common benign,

solid neoplasm of the ovary
• comprise approximately 5%
of benign ovarian neoplasms
and approximately 20% of all
solid tumors of the ovary
• arises from undifferentiated
fibrous stroma of the ovary
• commonly presents in
postmenopausal women
• malignant potential is low,
less than 1%
 Fibroma

• Manifest with pressure symptoms and abdominal

enlargement
• Meigs’ syndrome
– the association of an ovarian fibroma, ascites and hydrothorax
– both resolve after the removal of an ovarian tumor

management
• Exploratory operation
• in postmenopausal women, often a bilateral salpingo-
oophorectomy and total abdominal hysterectomy are
performed
 Cystadenoma

• the epithelial element is

most commonly serous,
but histologically may be
mucinous and
endometrioid or clear cell
• are usually small tumors
that arise from the
surface of the ovary
• bilateral in 20% to 25% of
women
• usually occur in
postmenopausal women
 Cystadenoma

• smaller tumors are asymptomatic or pelvic operations.

• large tumors may cause pressure symptoms, rarely
adnexal torsion.

Management
• postmenopausal women: bilateral salpingo-
oophorectomy and total abdominal hysterectomy
• in younger women: simple excision of the tumor and
inspection of the contralateral ovary is appropriate
 Torsion

• a complication of benign ovarian tumors in the

postmenopausal woman
• important cause of acute lower abdominal and pelvic
pain
• commonly affects both fallopian tube and ovaries
• pregnancy appears to predispose women to adnexal
torsion

Symptoms
• Acute abdominal and pelvic pain
• nausea and vomiting
• fever
 Torsion

management
• conservative operation for young women
– laparoscope or via laparotomy
• with severe vascular compromise -
unilateral salpingo-oophorectomy
 Endometriosis
• a benign disease but a
progressive one
• the presence or growth of the
glands and stroma of the lining
of the uterus in an aberrant or
heterotopic location
– Aberrant endometrial tissue
grows under the cyclic
influence of ovarian
hormones

• mid 30s, nulliparous and

involuntarily infertile with
symptoms of secondary
dysmenorrhea and pelvic pain
 Etiology of
Endometriosis

• RETROGRADE MENSTRUATION
– pelvic endometriosis is secondary to implantation of endometrial cells
shed during menstruation
• METAPLASIA
– arises from the metaplasia of coelomic epithelium or proliferation of
embryonic rests.
4. LYMPHATIC AND VASCULAR METASTASIS
– endometrial tissue is transplanted via lymphatic pathways and the
vascular system.
• IATROGENIC DISSEMINATION
• IMMUNOLOGIC CHANGES
– the altered function of the immune-related cells are directly involved on
the pathogenesis of endometriosis
• GENETIC PREDISPOSITION
 Endometriosis

PATHOLOGY
• ovaries are the most common
site
• grossly exhibit wide variation in
color, shape, size and
associated inflammatory and
fibrotic changes.

• cardinal histological features

1. ectopic endometrial glands
2. ectopic endometrial stroma
3. hemorrhage into the adjacent
tissue.
 Endometriosis

Signs and Symptoms

– Classic symptoms include cyclic pelvic pain and infertility.
– Pelvic pain is often inversely proportional to the amount of
endometriosis.
– cyclic pelvic pain is related to the sequential swelling and the
extravasations of blood and menstrual debris in to the
surrounding tissue and mediated by prostaglandins and
cytokines
– Dyspareunia
– GI and urinary symptoms
– catamenial hemothorax and massive ascites - rare
– classic pelvic findings of a retroverted uterus with scarring and
tenderness posterior to the uterus
 Endometriosis

Diagnosis
2. Ultrasound
3. Laparoscopy
 Endometriosis

Goals of Management
2. relief of pain
3. promotion of fertility

• Primary long term goal in management is

to prevent progression of the disease
process
 Endometriosis

Medical Management
– primary goal of hormonal treatment is
induction of amenorhea.
– DOES NOT provide a long lasting cure of the
disease
 Endometriosis

Medications for Endometriosis

• Danazol
• GnRH Agonists*
• Oral contraceptives
• Medroxyprogesterone acetate (DMPA)
 Endometriosis

SURGICAL THERAPY

• Often occurs concurrently during laparoscopy to establish diagnosis

• only option after failed medical treatment
• for women who have moderate to severe endometriosis
• Conservative surgery has as its goal the removal of macroscopic
visible areas of endometriosis with preservation of fertility.

Types of Surgical Therapy Used

9. laparoscopy
10.laser
11.Total hysterectomy with ovarian preservation
12.total abdominal hysterectomy with bilateral salpingo
oophorectomy
.
Thank you!