Benign tumours

Question 1

What is the definition of a fibroid?

Answer 1

Benign smooth muscle and connective tissue tumour of the uterus
-Most common neoplasm of the pelvic region (20% of white and 50% of afro-caribbean women)
-Develop in response to oestrogen so most common in REPRODUCTIVE YEARS

Question 2

What can cause fibroids to increase in size?

Answer 2

-Oestrogen therapy (regress after menopause)
-Progestins, clomifene and pregnancy
–Result in haemorrhagic degeneration and pain

Question 3

How are fibroids classified?

Answer 3

NB all fibroids begin in the myometrium, and are ultimately classified by direction of growth
-SUBSEROSAL = >50% of fibroid extends outside uterine contours
-INTRAMURAL = located within myometrium
-SUBMUCOSAL = >50% projection into endometrial cavity
-PARASITIC = detached from uterus and attached to other structures
(-PEDUNCULATED = on a stalk (submucosal or subserosal)

Question 4

How do fibroids present?

Answer 4

-Most are asymptomatic
-AUB - often menorrhagia
-Pelvic pressure, bloating
-Urinary symptoms
-Lower abdo pain, often during menstruation
-Subfertility

Question 5

What is typically noted on examination of fibroids?

Answer 5

-Able to palpate on bimanual examination
–Enlarged
–Hard, irregular uterine mass, ‘bulky’
-Confirmed on USS

Question 6

What patients will require intervention to manage their fibroids?

Answer 6

Those who have:
-Bulky symptoms
-Excessive bleeding
-Rapid growth
-?Sarcoma
-Resulting significant hydronephrosis
-Distortion of the uterus in those who would like to conceive or are experiencing recurrent miscarriage

Question 7

What medical management is offered to treat fibroids?

Answer 7

-To reduce excessive bleeding, and if fibroid <3cm:
–Mirena IUS (1st line)
–OCP
–Progestogens
-In anticipation of surgery / short term treatment:
–GnRH agonists (induce amenorrhoea also)

Question 8

What surgical techniques are used in the management of fibroids?

Answer 8

NON-INVASIVE
-Uterine artery embolisation - decreases blood flow to fibroids
MINIMALLY INVASIVE
-Hysteroscopic myomectomy (if up to 4cm, retains fertility)
-Laparoscopy
-Laparotomy
-Hysterectomy

Question 9

What complications can arise from fibroids?

Answer 9

‘Red degeneration’
-Occurs in larger fibroids (>5cm)
-Increase in size in pregnancy, compromising its own blood supply
-Causes pain and eventual necrosis
-Usually occurs in 2nd and 3rd trimesters
Endometrial polyps
-Overgrowth of endometrium, can be resected

Question 10

How are ovarian cysts diagnosed?

Answer 10

-USS
-Following features would raise suspicions of malignancy:
–Irregular borders
–Ascites
–Populations
–Separations within ovarian cyst

Question 11

How does management of ovarian cysts vary between premenopausal and postmenopausal women?

Answer 11

PREMENOPAUSAL
-If <5cm, simple, mobile, unilateral, no ascites:
–Observe for 4-6 weeks, likely benign
–If mass persists / increases in size it is unlikely to be a functional cyst
-If 5-7cm
–Annual USS
-If >7cm
–Consider MRI or surgical intervention
-If >10cm, solid or complex, fixed, bilateral, ascites
–Laparoscopic cystectomy removal in endobag
POSTMENOPAUSAL
-Refer to gynae regardless of nature / size as may be suspicious

Question 12

How do ovarian cysts present?

Answer 12

-Pelvic pain
-Bloating, feeling of fullness
-Acute pain in presence of torsion or haemorrhage
-If patient is experiencing weight loss, early satiety, loss of appetite, ascites, lymphadenopathy –> gynae referral for ?malignancy

Question 13

What are the types and features of functional cysts?

Answer 13

FOLLICULAR CYST
-Most common
-Occur during reproductive years, regress after 2-3 menstrual cycles
-Arise due to non-rupture of dominant follicle or failure of atresia in non-dominant follicle
CORPUS LUTEUM CYST
-Arise if corpus luteum doesn’t break down - may fill with blood / fluid and form a cyst
-More likely to have intraperitoneal bleeding than follicular cysts
-Most resolve spontaneously within 4-6 weeks

Question 14

What is the most common benign germ cell tumour?

Answer 14

DERMOID CYST
-Mature cystic teratoma, may contain skin, hair, teeth
-Can measure from 1mm-25cm
-Median age = 30y, can be bilateral
-Usually asymptomatic but may have torsion

Question 15

What types of benign epithelial tumours are there?

Answer 15

SEROUS CYSTADENOMAS
-Most common, 10-20% are bilateral
MUCINOUS CYSTADENOMAS
-Multilocular, lobulated and smooth-surfaced
-Bilateral lesions are rare
-Can become very big, sometimes weighing >50kg
-Can cause pseudomyxoma peritonea if ruptures

Question 16

What are the features of ovarian endometriosis?

Answer 16

-‘Chocolate cysts’
-Cystic areas of endometriosis that can reach 10-25cm in size

Question 17

What are fibromas and what syndrome are they commonly associated with?

Answer 17

-Small, solid, benign fibrous tumours
-Associated with Meigs’ syndrome
–Pleural effusion, benign ovarian fibroma and ascites