Benign Diseases of

Cervix, Uterus &

Ovary

Benign Disease of
Cervix

Cervical Ectropion

Formation
Squamocolumnar
junction is located at the
external os before
puberty

As estrogen levels rise

during puberty, the
cervical os opens,
exposing the
endocervical columnar
epithelium onto the
ectocervix

It is then exposed to the

acidic environment of
the vagina and, through
a process of squamous
metaplasia, transforms
into stratified squamous
epithelium

This area of columnar

cells on the ectocervix
forms an area that is red
and raw in appearance
called an ectropion
(cervical erosion).

Causes
Puberty
During pregnancy
Oral contraceptive pill
Congenital
Sexual intercourse

Signs and Symptoms

Excessive but non-purulent vaginal
discharge
Post-coital bleeding

Treatment
No treatment for asymptomatic
Hormonal therapy
Discontinuing oral contraceptives
Ablation treatment

Cervical Stenosis

Definition
The endocervical canal is more narrow
than is typical. In some cases, the
endocervical canal may be completely
closed.

Symptoms
Before menopause
Menstrual abnormalities
Amenorrhea, dysmenorrhea and abnormal
bleeding.

Infertility

After menopause
Not cause symptoms
A hematometra or pyometra can cause
pain or cause the uterus to bulge

Causes
congenital cervical stenosis
chronic infection (chronic cervicitis)
trauma
from previous instrumentation
cone biopsy/loop electrosurgical excision procedures (LEEP)
cryotherapy
laser treatment

stenosis secondary to a tumour/mass:

cervical polyp
carcinoma of the cervix

post radiation therapy

cervical endometriosis

Investigation
Hysterosalpingogram
narrowing of the endocervical canal (normal
diameter: 0.5-3.0 cm)
complete obliteration of the cervical os,
preventing insertion of the
hysterosalpingographic catheter.

Pelvic ultrasound
visualisation of an underlying mass if its
complicated by proximal dilatation of the
female genital tract (e.g. hematometra)

Treatment
Vaginal delivery of a baby
Insertion of dilators with ultrasound
guidance
Laser treatment if caused by scar tissue
Hysteroscopic shaving of cervical tissue

Cervical Intraepithelial
Neoplasia
Potentially premalignant transformation
and abnormal growth (dysplasia) of
squamous cells on the surface of the
cervix.
May progress to become cervical cancer,
usually cervical squamous cell carcinoma
(SCC)
Major cause - human papillomavirus
(HPV) 16, 18

Risk Factors
Infected by a high risk type of HPV, such
as 16, 18, 31, or 33
Immunodeficient
Women who give birth before age 17
Poor diet
Multiple sexual partners
Lack of condom use
Cigarette smoking.

Classification

Sign and Symptoms

Usually causes no symptoms, and is most
often discovered by a routine Pap test.
The prognosis is excellent for who receive
appropriate follow-up and treatment.
But women who go undiagnosed or who
don't receive appropriate care are at
higher risk of developing cervical cancer.

Pap Smear
Cells are collected from the cervical surface
and examined under microscope to look for
the signs of abnormal and cancerous cells
In Malaysia, all women who are, or who have
been sexually active, between the ages of
20 and 65 years, are recommended to
undergo Pap smear testing.
If the first two consecutive Pap results are
negative, screening every three years is
recommended.

Management
CIN 1 Conservative
CIN 2, 3 & persistent CIN 1 (more than 1
year)
Surgical
Loop electrosurgical excision procedure (LEEP)
Cold knife conization
Laser vaporization and cryotherapy

Prevention - Vaccine (13 year-old girls)

Gardasil (HPV 16, 18)
Cervarix (HPV 16, 18, 6, 11)

Endometrial Polyps
&
Asherman syndrome

Endometrial Polyps
Discrete outgrowth of endometrium, attached by a
pedicle which move with the flow of the distension
medium.
It may be pedunculated or sessile, single or multiple
and vary in size. (0.5-4 cm)
Women under 40 years old unlikely to have this.
May cause intermenstrual bleeding and treatment is
by removal if the symptoms persistent at least 3
months or more.

 Women more than 40 years old & pre-menaupausal

and have endometrial polyps that diagnosed by
ultrasound or hysteroscopy. Should consider removal of
the polyps.
Increasing in age, most common abnormality is
endometrial hyperplasia which can present in just the
endometrial polyps tissue.
Post-menopausally, mandatory to remove endometrial
polyps which can be due hyperplasia or malignancy.
Polyps can also caused by tamoxfen (drug) to treat
breast cancer.
Most cases, polyps are benign but removal is necessary
to prevent possibility of malignancy.

Signs of uterine polyps

include:

Irregular menstrual bleeding for

example, having frequent, unpredictable
periods of variable length and heaviness
Bleeding between menstrual periods
Excessively heavy menstrual periods
Vaginal bleeding after menopause

Investigation:
Transvaginal ultrasoud
Hysteroscopy
Curretage

Treatments
Watchful waiting.Small polyps without
symptoms (asymptomatic) may resolve on their
own. Treatment is unnecessary unless you're at
risk of uterine cancer.
Medication.Certain hormonal medications,
including progestins and gonadotropin-releasing
hormone agonists, may shrink a uterine polyp
and lessen symptoms.
Curettage

Asherman Syndrome
An irreversible damage of the single layer thick
basal endometrium does not allow normal
regeneration of endometrium.
It undergoes fibrosis and adhesion formation
termed Asherman Syndrome
Result is reduced or absent menstrual shedding.
Can happen because of overzealous curettage of
the uterine cavity during evacuation of retained
product of conception after miscarriage

Causes:
DNC
Tuberculosis & schistosomiasis

Symptoms:
The adhesions may cause amenorrhea
(lack of menstrual periods), repeated
miscarriages, and infertility.
However, such symptoms could be
related to several conditions. They are
more likely to indicate Asherman
syndrome if they occur suddenly after a
D&C or other uterine surgery.

Investigation:
A pelvic exam is usually normal.
Tests may include:
Blood tests to detect tuberculosis or
schistosomiasis
Hysteroscopy
Hysterosonogram
Infertility evaluation
Transvaginal ultrasound examination

Management:
Hysteroscopic technique to manually
breakdown or lyse the intrauterine adhession.
After scar tissue is removed, the uterine
cavity must be kept open while it heals to
prevent adhesions from returning.
Your health care provider may place a small
balloon inside the uterus for several days and
prescribe estrogen therapy while the uterine
lining heals.

 Antibiotic treatment may be necessary if

there is an infection.

Uterine Fibroids

 Noncancerous growths of the uterus that often

appear during childbearing years. Also called
leiomyomas or myomas, uterine fibroids aren't
associated with an increased risk of uterine cancer
and almost never develop into cancer.
Uterine fibroids develop from the smooth muscular
tissue of the uterus (myometrium). A single cell
divides repeatedly, eventually creating a firm,
rubbery mass distinct from nearby tissue.
Fibroids range in size from seedlings, undetectable
by the human eye, to bulky masses that can distort
and enlarge the uterus. They can be single or
multiple.
As many as 3 out of 4 women have uterine fibroids
sometime during their lives, but most are unaware

Sites:
Submucosal
Fibroids grow into the uterine cavity.
Intramural
Fibroids grow within the wall of the uterus.
Subserosal
Fibroids grow on the outside of the uterus.
Pedunculated fibroids
Some fibroids grow on stalks that grow out from
the surface of the uterus or into the cavity of the
uterus.

Symptoms:
Heavy menstrual bleeding
Prolonged menstrual periods seven
days or more of menstrual bleeding
Pelvic pressure or pain
Frequent urination
Difficulty emptying bladder
Constipation

Causes:
Genetic changes.
Changes in genes that differ from those in normal uterine
muscle cells. Fibroids also run in families and that identical
twins are more likely to both have fibroids than non identical
twins.
Hormones.
Fibroids contain more estrogen and progesterone receptors
than normal uterine muscle cells do. Fibroids tend to shrink
after menopause due to a decrease in hormone production.
Other growth factors.
Substances that help the body maintain tissues, such as
insulin-like growth factor, may affect fibroid growth.

Risk factors:
Nulliparity
Obesity
Heredity.
If your mother or sister had fibroids, you're at increased risk of
developing them.
Race.
Black women are more likely to have fibroids than women of other racial
groups.
Other factors:
Onset of menstruation at an early age, having a diet higher in red meat
and lower in green vegetables and fruit, and drinking alcohol and beer.
Factors that lower the risk of fibroids:
Pregnancy (the risk decreases with increasing number of pregnancies)
Long-term use of progestin-only birth control pills or oral contraceptives
Use of the birth control shot (depot medroxyprogesterone acetate or
Depo-Provera)

Investigations:
Blood:
FBC to determine if the patient
has anemia duet to chronic blood
loss and other blood tests to rule
out bleeding disorders or thyroid
problems.
Imaging:
Pelvic USS
MRI
Show the size and location of
fibroids, identify different types of
tumours and help determine
appropriate treatment options.
CT SCAN

Special tests:
Hysterosalpingogram
X-ray test that looks at the inside
of the uterus and fallopian tubes
and the area around them.
Hysterosonography.
(Saline
infusion sonography)
Injection of salt solution into the
uterus
to
help
create
the
ultrasound image.
Laparoscopy
Look and locate fibroids on the
outer surface of the uterus.

Treatments:
Conservative Medical:
:

Surgical:

Emotional
support
Bed rest
Practice
healthy and
balanced
diet

Endometrial Ablation
Destroys the lining of the
uterus. It is used to treat
small fibroids inside the
uterus.
Myomectomy
This procedure removes
only the fibroids and leaves
the healthy areas of the
uterus intact. Preserve the
ability to get pregnant.
Hysterectomy
Cure uterine fibroids
completely. Recommended
if fibroids are large, very
heavy bleeding, near or
past menopause.
Uterine Artery
Embolization
cuts off the blood supply to

Pain medication
Birth control pills &
hormonal birth
control pills.
These medications
control heavy bleeding
and painful periods.
Progestin-releasing
intrauterine device
(IUD)
Reduces heavy and
painful bleeding but
does not treat the
fibroids themselves.
Gonadotropinreleasing hormone
agonists.
Stop ovulation, helps
in reducing the size of
fibroids.

Complications:
Iron-deficiency anaemia.
Bladder frequency, constipation (due to increased pelvic
pressure).
Torsion of pedunculated fibroid.
Ureteral obstruction causing hydronephrosis.
Infertility: as a result of narrowing of the isthmic portion of
the Fallopian tube or as a consequence of interference with
implantation (submucosal fibroids).
In pregnancy:
Recurrent miscarriage.
Fetal malpresentation.
Intrauterine growth restriction.
Premature labour.
Postpartum haemorrhage.

History Taking

Age: Reproductive age

Pregnancy: Nulliparity?
Menstrual History:
Early menarche?
Length of bleeding
(usually prolonged)
Intermenstrual bleeding
Bleeding after
intercourse
Nature of periods:
Heavy/Clot/Flooding?
Menorrhagia,
metrorrhagia
Associated symptoms:
dysmenorrhea,
dyspareunia, urinary
frequency/constipation
Pelvic pain?
Diet? (high in red
meat,soy)
Family history of fibroids

Enlarged uterus extending above

the symphysis pubis
Fibroid typically has an irregular
contour.
Fibroids are muscular in origin and
have a solid consistency.
They feel firmer than the uterine
fundus.
During a bimanual pelvic exam,
irregularities can be palpated near
the adnexa or even posterior on
the uterus.
The majority of fibroids can be
palpated near the midlines, which
are usually mobile.

Physical Examination

In cases of large tumours, a

central irregular mass can be
palpated on transabdominal
examination.
Enlarged uterus (>8 weeks)

Benign diseases of the

ovary
Functional ovarian cysts
Inflammatory ovarian cysts
Germ cell tumours
Epithelial tumours
Sex cord stromal tumours

Causes of benign
ovarian tumours

Types

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
Fibroma
Thecoma

Sex cord stromal

Functional ovarian cysts

Follicular

Corpus luteal

Theca luteal

Dx when cyst >3cm

Rarely grow >10cm
USS-simple unilocular cyst
Asymptomatic- observation/ sequential
repeat USS
Symptomatic- laparoscopic cystectomy
Following ovulation
May have pain rupture/haemorrhage
Mx- analgesia/ ovarian cystectomy
a/w pregnancy (particularly multiple
pregnancy)
Often dx incidentally at routine USS
Most resolve spontaneously

Inflammatory ovarian cysts

Usually a/w PID
Most common in young women
Noted as mass/ abscess
May involve ovary, tube & bowel
Occasionally can develop from other
infective causes (appendicitis, diverticulitis)
Dx : PID-based, inflammatory markers
Mx: antibiotics, surgical drainage or excision
May present with endometriomas

Germ cell tumours

Most common ovarian tumours in young
women
The most common form is mature dermoid cyst
(cystic teratoma)-80%

**combination of all tissue types

Can be bilateral -10%
Risk of malignant transformation is rare- <2%
Dx: usually incidental, 15% with torsion, MRI is
helpful
Mx: surgical excision (cystectomy)/ complete
oophorectomy-if present with torsion

Epithelial tumours
Increase with age, most common in perimenopausal women
Serous
cystadenomas

Mucinous
cystadenomas
Brenner tumours

Most common
20-30% of benign tumours in
women under 40
Unilocular, rarely involve opposite
ovary
Large multiloculated
Bilateral in 10% of cases
Often small, found incidentally
Secrete estrogen

Sex cord stromal tumours

Fibroma
s

Most common form

Solid tumours composed of stromal cells
Older women
Often with torsion d/t heaviness of ovary
Meig syndrome (pleural effusion, ascites,
ovarian fibroma)
Mx- removal of fibroma

Thecom
as

Oestrogen-secreting tumours
Often in post-menopause, with
manifestations of excess oestrogen
production (post-menopausal bleeding)
May induce endometrial Ca

History
Pain
Pelvic/ abdominal swelling (DDx??)
Pressure on bowel or bladder
Acute, intermittent pain torsion of cyst,
rupture or haemorrhage
Age-causes vary with age

Physical Examination
Pelvic/abdominal mass (separate from
the uterus) **sometimes incidentally
found in USS
Tenderness

Investigation

Management

FBC infection,
haemorrhage
UPT
Inflammatory markers (CRP,
WCC)
Tumour markers
Imaging- USS/ CT scans/ MRI
Diagnostic laparoscopy
Fine-needle aspiration and
cytology
alpha-fetoprotein (AFP) and
human chorionic
gonadotrophin (hCG)

Follow-up
Analgesic
Antibiotics
Surgical excision/
drainage