Benign Tumours

Question 1

Definition of fibroids?

Answer 1

leiomyomata – benign tumours of the myometrium. 25% of women

Question 2

Risk factors and protective factors for fibroids?

Answer 2

Risk Factors = Peri-menopause, Afro-Caribbean women, family history.

Protective = parous women, COCP or injectable progestogens.

Question 3

History in fibroids?

Answer 3

Symptoms related to site rather than size
• Asymptomatic (50%)
• Menorrhagia and dysmenorrhoea (30%)
• Pressure effects (pressing on bladder and ureters)
• Subfertility (blocking ostia)
• Rarely cause pain unless torsion

Question 4

Examination in fibroids?

Answer 4

Solid mass may be palpable on pelvic or abdominal examination. Will arise from the pelvis and be continuous with the uterus.

• Multiple small fibroids cause irregular ‘knobbly’ enlargement of the uterus.

Question 5

Complications of fibroids?

Answer 5

Torsion of Pedunculated Fibroid –> pain

Degenerations - Inadequate blood supply (i.e. red, hyaline, cystic) –> pain and uterine tenderness

Malignancy - 0.1% are leiomyosarcomata

Pregnancy - Premature labour, malpresentations, transverse lie, obstructed labour, post-partum haemorrhage.

Question 6

Investigations in fibroids?

Answer 6

USS
MRI/laparoscopy – to distinguish from ovarian mass
Hysteroscopy

Question 7

Management of fibroids not causing problems?

Answer 7

Asymptomatic with small/slow-growing fibroids – no treatment.

Large ones not removed should be serially measured because of remote risk of malignancy.

Question 8

Medical management of fibroids?

Answer 8

Tranexamic acid, NSAIDs, progestogens – often ineffective but worth trying as 1st line.

GnRH agonists – temporary amenorrhoea and fibroid shrinkage (only 6 months use, to make surgery easier) – will return to normal size if drug stopped.

Question 9

Surgical management of fibroids?

Answer 9

Hysteroscopic – fibroid polyp or small (3-4cm) submucous polyp can be resected.

Hysterectomy - laparoscopic, vaginal or abdominal

Myomectomy – if preservation of fertility needed.

Uterine Artery Embolization – 80% success rate, effects on fertility unclear.

Question 10

Two main types of ovarian cyst?

Answer 10

Primary neoplasms

Tumour-like conditions

Question 11

Types of primary neoplasm?

Answer 11

Epithelial tumours - serous/mucinous cystadenoma

Germ cell tumours - dermoid cyst (teratoma)

Sex cord tumours (rare) - granulosa cell tumours (malignant/benign), thecomas, fibromas (both benign)

Question 12

Types of tumour-like conditions?

Answer 12

• Endometriotic Cyst
o Endometriosis causes altered blood to accumulate  rupture is very painful.

• Functional Cysts = Follicular cysts and lutein cysts

Question 13

What are the types of functional cysts?

Answer 13

o Follicular cysts
 Persistently enlarged follicles.
 Only found in pre-menopausal women.
 Combined pill protects against by preventing ovulation.

o Lutein cysts
 Persistently enlarged corpora lutea
 Only found in pre-menopasual women
Tend to cause more symptoms

Question 14

Clinical features of ovarian cyst rupture?

Answer 14

History
Severe, sudden onset lower abdominal pain, iliac fossa pain radiating to right flank, nausea, vomiting, fever.

Examination
Abdo – tenderness
PV – adnexal tenderness

Question 15

Risk factors for ovarian cysts?

Answer 15

Developmental abnormalities, early pregnancy, women undergoing hormonal stimulation for IVF.

Question 16

Complications of ovarian cysts

Answer 16

Rupture
• Rupture of contents into peritoneal cavity causes intense pain

Haemorrhage
• Into a cyst or into peritoneal cavity causes pain. Can cause hypovolaemic shock.

Torsion
• Of pedicle (bulky due to cyst) causes infarction of ovary +/- tube and severe pain.
• Urgent surgery and detorsion to save ovary.

Question 17

Management of ovarian cysts?

Answer 17

If asymptomatic
• Treatment not required, observed using USS.

If functional cyst >5cm for over 2 months
• CA125 level measured and consider laparoscopy – removal and/or drainage.

Question 18

In whom are epithelial tumours most common

Answer 18

Post-menopausal women

Question 19

In whom are teratomas most common?

Answer 19

Pre-menopausal women

Question 20

In whom are functional cysts found?

Answer 20

Pre-menopausal women only