Subject: Gynecology

Topic: 5.01b – Benign Neoplasms of the Oviducts and Ovaries

Lecturer: Dr. Co-Hidalgo
Date: December 17, 2015

OUTLINE  Do not become malignant, but can be mistaken as a low-grade

I. Oviducts d. Benign Cystic Teratoma neoplasm
a. Leiomyoma e. Endometriosis
b. Angiomyoma f. Ovarian Fibroma
c. Paratubal Cyst g. Epithelial Cystic Tumors C. PARATUBAL CYSTS
d. Hydatid Cysts of Morgagni h. Brenner Tumor
 Often multiple from 0.5 to more than 20 cm in diameter
e. Adenofibroma i. PCOS
II. Ovaries j. Ovarian Remnant Syndrome  Located within the broad ligament between the tube and the
a. Follicular Cysts k. Papillomatosis ovary
b. Corpus Luteum Cysts
 Translucent containing clear or pale yellow fluid
c. Theca Lutein Cysts
 Small, asymptomatic, slow growing and are discovered during the
REFERENCES third and fourth decades of life
2016 B Trans, recordings, PPT, notes from dra.  Anechoic, well-delineated, thin-walled, soft and contain clear
fluid which can rupture during manipulation.
I. OVIDUCTS/FALLOPIAN TUBE
 Leiomyomas
 Adenomyotoid Tumor*
 Adenofibromas*
 Paratubal Cysts*
 Cystic Mesothelioma
 Serous Cystadenoma

A. LEIOMYOMAS (not discussed, discussed along with
leiomyoma of the uterus)
 Underreported, majority are asymptomatic
 Usually coexist with the more common uterine leiomyomas
 May be single or multiple and usually are discovered in the
interstitial portion of the tubes
o May originate from muscle cells in the walls of the tube or
blood vessels or from smooth muscle in the broad ligament
 May be subserosal, interstitial or submucosal
 Present as smooth, firm, mobile, usually non-tender masses that
may be palpated during the bimanual examination
 Appear as a spherical mass that protrudes from beneath the
peritoneal surface, varying from a few mm to 15 cm diameter
 Rarely, they may undergo acute degeneration or be associated with
unilateral tubal obstruction or torsion
 If symptomatic: surgical excision
B. ADENOMATOID TUMORS/ ANGIOMYOMAS
Figure 2. 2cm Non-neoplastic cyst with broad ligaments abuts the normal
ovary. To identify, look for the ovary then if it is normal and there is a cyst
beside it, that can be a paratubal cyst
MANIFESTATIONS
 Usually asymptomatic and appears as an incidental finding during
gynecologic/lower abdominal surgeries, but presents with dull pain
if symptomatic
 There are no symptoms unless they are stretched or if there is
torsion, like in cases of a large paratubal cyst, the oviduct should
not be removed because it will return to normal size after excision
of the cyst
 They can grow rapidly during pregnancy and puerperium
producing TORSION
o Tubal torsion is usually accompanied by torsion of the ovaries
o This is secondary to an ovarian mass in 50-60% of patients and
common among women of reproductive age
o Right tube is more frequently involved
o Symptoms: Acute lower abdominal and pelvic pain, sudden or
gradual, 48 hours duration. Pain may be located in the iliac
fossa, radiating to the thigh and flank.
o Management: For minor torsion, restore normal circulation
and save the tube by manually untwisting

TREATMENT: Simple Excision, or Aspiration of fluid inside.

D. HYDATID CYSTS OF MORGAGNI

Figure 1. Adenomatoid Tumor  Pedunculated
 Found near the fimbrial end of the fallopian tube
 MOST COMMON BENIGN TUMOR OF THE FALLOPIAN TUBE
 MESOTHELIAL in origin though some authors say that it is an
endothelial origin in rare tumors
 Small, well-circumscribed nodule, whitish to gray-white, 1-2 cm
 Usually located on the SEROSAL SURFACE
 Usually unilateral and present as small nodules just under the
tubal serosa
 Do not produce pelvic symptoms or signs, and also found below Figure 3. Hydatid Cyst of Morgagni. Broad Ligament Cyst. This parovarian,
the serosa of the fundus paratubal cyst is thin-walled and contains clear watery fluid.

Trans Group: Tuguinay, Ty, Uy, Valderrama Page 1 of 7

Edited by: Alanna
 E. ADENOFIBROMA
 Occasionally reported but more a recent study revealed that
adenofibromas are common in the tubes
 Almost exclusively located in the distal (fimbrial) portion
 More solid in consistency
II. OVARIES
 Functional cysts, hence no treatment is needed, will resolve in 3-6
months
 At 3 months, a follicular or physiologic cyst should already
disappear and at days 5 to day 7 of menses, this should disappear.
A. FOLLICULAR CYSTS
 MOST FREQUENT CYST IN NORMAL HEALTHY OVARIES, from
temporary pathologic variation of a normal physiologic process
 Result from either failure of a dominant follicle to rupture
(persistent follicle) or failure of an immature follicle to undergo
the normal process of atresia (failure to resorb follicular fluid)
 Lined with inner layer of granulosa cells and an outer layer of the
theca interna cells
 Occurs during all stages of life: fetal to postmenopausal period
 Translucent, thin walled, unilocular filled with a watery, clear to
straw colored fluid, no solid component, just clear liquid inside
 Situated in the ovarian cortex, and sometimes appear as
translucent domes on the surface of the ovary.
 Multiple, varies from few mm to 15 cm diameter
 May be found as early as 20 weeks gestation in female fetuses and
throughout a woman’s reproductive life. Found most commonly in
young, menstruating women.
 Not neoplastic, dependent on gonadotropins for growth
MANIFESTATIONS
 Mostly asymptomatic, do not do anything unless it is very big but
usually it will resolve spontaneously
 May present with signs and symptoms of ovarian enlargement,
rule out an ovarian neoplasm
 May rupture during examination, because of their thin walls.
 May present with tenesmus, transient pelvic tenderness, deep
dyspareunia
DIAGNOSIS
 Routine Gynecologic Exam
 Ultrasound (anechoic or black structure full of fluid, no solid
component inside)
 Routine Gynecologic Exam
 Vaginal Ultrasound: anechoic mass, increased Peritoneal fluid in the
TREATMENT
 Conservative observation, because majority of follicular cysts
disappear spontaneously by either reabsorption of the cyst fluid or
silent rupture within 4 to 8 weeks of initial diagnosis.
 Observe for 3-6 months (up to 8 weeks), then let the patient come
back for ultrasound on day 5-7(3-5 according to lecturer) of menses
and check if it is still there
 Oral contraceptives may be prescribed for 4 to 6 weeks
 Persistent ovarian mass necessitates operative intervention to
differentiate it from a true neoplasm of the ovary; differentiate it
with mucous or serous cystadenoma.
B. CORPUS LUTEIN CYST
Figure 4. Corpus Luteum Cyst on Ultrasound (left). Hemorrhagic corpus luteum
with an outer yellow rim and central hemorrhage (right). Sometimes this could
look like an ectopic pregnancy, so correlate it clinically then observe for a fetus
and HCG levels. (corpus luteum is threadlike)
 Less common than follicular cysts, but more clinically important
 Mainly result from intracycstic hemorrhage, minimum of 3 cm
diameter
 All corpora lutea are cystic with gradual reabsorption of a limited
amount of hemorrhage, which may form a cavity.
 They may be associated with normal endocrine function or
prolonged secretion of progesterone
 Menstrual pattern may be normal, delayed menstruation or
amenorrhea
 2-4 days post-ovulation, during the stage of vascularization, thin-
walled capillaries invade the granulosa cells from the theca interna.
Spontaneous but limited bleeding fills the central cavity of the
maturing corpus luteum with blood.
 If the hemorrhage into the central cavity is brisk, intracystic
pressure increases and rupture is possible.
 If cystic central cavity persists, blood is replaced by clear fluid, and
the result is a hormonally inactive corpus albicans cyst.
MANIFESTATIONS
 Asymptomatic to severe abdominal pain because of
intraperitoneal bleeding associated with rupture
 Classic triad
o Delayed menses + spotting
o unilateral pelvic pain
o small, tender, adnexal mass (similar to ectopic pregnancy)
 Most ruptures occur on day 20-26 of menstrual cycle, so always
correlate this with the menstrual cycle of patients
 Produce dull, unilateral, lower abdominal and pelvic pain,
hemorrhage
DIAGNOSIS
posterior cul-de-sac accompanied with tenderness (immediate
cystectomy)
DIFFERENTIALS: Ectopic Pregnancy (differentiate with serum or
urinary HCG), Ruptured Endometrioma, Adnexal Torsion
TREATMENT
 Observation for mild pain or minimal peritoneal fluid – will
resolve
 Cystectomy is the operative treatment of choice since it is
conservative
C. THECA LUTEIN CYSTS
 LEAST COMMON OF THE PHYSIOLOGIC OVARIAN CYSTS
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 Almost always bilateral
 Secondary to hundreds of thin-walled lobules or cysts, producing a
honeycombed appearance
 Produce moderate to massive enlargement of the ovaries
 Vary in size from 1 cm to 10cm or more in diameter
 Arise from other prolonged or excessive stimulation of the ovaries
by endogenous or exogenous gonadotropins or increased ovarian
sensitivity to gonadotropins
 Produces an enlarged ovary, larger than corpus, usually seen in
hydatiform mole
 50% molar pregnancies and 10% choriocarcinomas have associated
bilateral theca lutein cysts. HCG from trophoblast produces
luteinization of the cells in immature, mature, and atretic follicles
 External surface of the ovary appears lobulated
 Small cysts contain a clear to straw-colored or hemorrhagic fluid
CLINICAL MANIFESTATIONS
 Majority of women with smaller cysts are asymptomatic
 Generally only the larger cysts produce vague symptoms, such as a
sense of pressure in the pelvis
 Ascites and increasing abdominal girth have been reported with
hyperstimulation from exogenous gonadotropins.
DIAGNOSIS
 Palpation followed by transvaginal ultrasound for confirmation
 Presence of theca lutein cysts is established by palpation and
confirmed by ultrasound
TREATMENT
 Conservative because they usually regress spontaneously
 Bleeding is difficult to control in these cases because of the thin
walls that constitute the cysts. No attempts should be made to
drain or puncture them.
Figure 5. Bilateral Theca Lutein Cysts. Note its lobulated appearance
RELATED CONDITIONS TO THECA LUTEIN CYSTS
1. HYPERREACTO LUTEINALIS
 Ovarian enlargement secondary to the development of multiple
luteinized follicular cysts
2. LUTEOMA OF PREGNANCY
 Rare, specific, benign hyperplastic reaction of ovarian theca lutein
cells
 Asymptomatic, NOT A TRUE NEOPLASM
 Discovered during caesarian section or postpartum ligation
 Regress spontaneously following completion of pregnancy
 Nodules do NOT arise from the corpus luteum of pregnancy
 50% are multiple, and 30% have bilateral nodules
 Incidental findings during surgery of solid, fleshy often
hemorrhagic nodules
 Masculinization of the mother in 30% and sometimes the female
fetus
Figure 6. Luteoma of pregnancy with numerous solid brown nodules.
Figure 7. 3cm Luteoma with multiple reddish nodules.
D. BENIGN CYSTIC TERATOMA
 MOST COMMON OVARIAN NEOPLASMS
 MOST COMMON OVARIAN NEOPLASM IN PREPUBERTAL AND
TEENAGERS
 Dermoid Cyst, Mature teratoma
 Teratoma: “monstrous growth”
 Teratomas of the ovary may be benign or malignant. Although
dermoid is a misnomer, it is the most common term used to
describe the benign cystic tumor, composed of mature cells,
whereas the malignant variety is composed of immature cells
(immature teratoma)
 Dermoid: Emphasizes the preponderance of ectodermal tissue
with some mesodermal and rare endodermal derivatives
 Believed to arise from a single germ cell after the 1st meiotic
division. They develop from totipotential stem cells and are
neoplastic sequelae from a transformed germ cell.
 Account for more than 90% of germ cell tumors of the ovary
 Certain elements from all three germ cell layers
 May contain a malignant component usually in >40 years old:
Found in 1% of cases and usually a squamous carcinoma
 Occurs from infancy to postmenopausal years
 Bilaterality is 10 to 15%
 Grow from few mm to 25cm in diameter
 Doughy consistency upon palpation and usually unilocular
 50-60% are asymptomatic, but others may present with pain and
sensation of pelvic pressure
 Torsion: Most frequent complication of a dermoid
 Associated medical conditions are thyrotoxicosis, carcinoid
syndrome, autoimmune hemolytic anemia
DIAGNOSIS
 Diagnosis is often established when a semisolid mass is palpated
anterior to the broad ligament
 50% have pelvic calcifications on radiographic exam
 Ultrasound: These characteristics include a dense echogenic area
within a larger cystic area, a cyst filled with bands of mixed echoes,
and an echoic dense cyst
TREATMENT
 Cystectomy: For young patients (35-45 y/o), pre-menopausal,
especially the nulligravid (remove the cyst and retain ovarian
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 tissue)
 Salphingo-oophorectomy: For older patient with a complete family
(remove the fallopian tubes and ovaries)
OTHERS
1. TUBERCLE OF ROKITANSKY
 Protrusion or Mamilla in the cyst wall containing mostly solid
elements.
 Most solid elements arise and are contained in a protrusion or
nipple (mamilla) in the cyst wall, termed the prominence or
tubercle of Rokitansky.
 May be visualized by ultrasound as an echodense region.
 If malignancy occurs, it is most always found in this nest of cells.
 The wall of the cyst will often contain granulation tissue, giant
cells, and pseudoxanthoma cells
 Do not leave tumor when excising
2. STRUMA OVARII
 A teratoma/complex mass in which the thyroid tissue has
overgrown other elements and is the predominant tissue.
o Viable endometrium can land on a favorable site and, if
tolerated by the patient’s immune system, can establish
enough of a blood supply to live and respond to the cyclic
ovarian hormones
2. COELOMIC METAPLASIA THEORY
o The peritoneal cavity contains some cells that have retained
their undifferentiated nature and, given the proper stimulus,
may grow and differentiate into endometrial cells.
INCIDENCE
 Exact incidence of endometriosis in the general population is not
known.
 Endometriosis is found in
o 6% to 43% of women undergoing sterilization
o 12% to 32% of women undergoing laparoscopy for pelvic
pain
o 21% to 48% of women undergoing laparoscopy for infertility
o 50% of teenagers undergoing laparoscopy for chronic pelvic
pain and dysmenorrheal
Usually associated with endometriosis in other areas of the pelvic

 Usually unilateral and measure less than 10 cm in diameter. cavity

 Less than 5% develop thyrotoxicosis, which may be secondary to
the production of increased thyroid hormone by either the ovarian CLINICAL PRESENTATION
or the thyroid gland. Most are asymptomatic, but most common symptoms are pelvic
pain, dyspareunia and infertility (around 25-50% of infertile
women have some degree of endometriosis)
 About half of the women who are demonstrated to have
endometriosis have no symptoms at all
 Classically, women with symptomatic endometriosis present with
a chronic steadily worsening pelvic pain. It is worse with menses
and sometimes worse with ovulation. It may be focal or diffuse
Figure 8. Mature cystic teratoma (dermoid cyst) filled with hair but its location is usually constant.
and keratinous debris with one solid nodular area (Rokitansky  A second classical symptom is painful intercourse on deep
protuberance). penetration.
 Less common is painful bowel movements. If implants are
E. ENDOMETRIOSIS
located on the rectosigmoid or close to it (uterosacral ligaments),
 Patches of “normal” endometrium located outside of the uterus then she may experience pain while actually passing her stool.
 MOST COMMON LOCATIONS for these implants are on the
o Ovary
CLINICAL PRESENTATION
o Anterior and posterior cul-de-sac
o Posterior broad ligament  Unusual tenderness and thickness (a dough-like consistency) in
o Uterosacral ligament the adnexal areas.
o Uterus  Tender nodules along the uterosacral ligament, usually
o Fallopian tube appreciated best on combined recto-vaginal bimanual exam.
o Sigmoid Colon  Tender nodules at the junction of the bladder and the uterus.
o Appendix  Tender nodules over the uterine corpus.
o Round ligament  Many women (particularly those with asymptomatic
Size varies from small superficial, blue-black implants that are 1 to endometriosis) have no positive physical findings.
5 mm diameter to large, monoculated hemorrhagic cysts 5 to 10 On pelvic exam, ovaries are often tender and immobile,

cm secondary to associated inflammation and adhesions

Endometriomas are areas of ovarian endometriosis that become
cystic
Ovarian surface is often pocked, irregular and scarred
ETIOLOGY
 The specific cause of endometriosis is not known
 Several theories can, in part, explain the existence of
endometriosis
1. IMPLANTATION THEORY
o During menses, some reflux of menstrual products back
through the fallopian tubes occurs.
DIAGNOSIS
 Clinical diagnosis is through HISTORY of the classical description
 Surgical diagnosis is made by visualizing typical endometriosis
implants in the typical places endometriosis tends to flow in.
o LAPAROSCOPY – method of choice for direct visualization
 Histologic diagnosis
 There are no laboratory tests that are specific for endometriosis.
- ultrasound must be done
o Medium level echoes are noted on ultrasound
o Always document if viable or normal tissue was noted on

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 ultrasound to guide surgeons in performing invasive
procedures
 Some women with endometriosis have a persistent complex or
solid adnexal mass on ultrasound, CT or MRI.
o These endometriomas can assume a passable resemblance to
almost any adnexal neoplasm.
o This means that the differential diagnosis for virtually any
adnexal mass would include endometriosis.
 Most women with endometriosis will have an elevated serum CA-
125, however this is not specific.
o This chemical is released any time when there is peritoneal
irritation from any source
NATURAL HISTORY
 Untreated
 Endometriosis can worsen
 Regress or stay the same
 More often is progressive
 Pregnancy and breast-feeding SUPPRESS endometriosis.
 Birth control pills, even if taken cyclically, usually SUPPRESS
endometriosis, particularly if the endometriosis is minimal (mild
or moderate).
 At menopause, endometriosis usually REGRESSES.
PRINICIPAL MANAGEMENT
 There is no single best management for all women with
endometriosis
 Treatment must be individualized.
 There are PRIMARY FACTORS to be considered namely:
o The need for preserving childbearing capacity
o The severity of her symptoms
o Presence or absence of infertility as a clinical concern for her.
o Age
For example:
 A 35 year old woman with severe symptoms and no desire for any further
childbearing might be best managed by a hysterectomy.
 The same woman at age 50 might prefer to go with medical therapy until
menopause, when the symptoms will go away.
 The same woman at age 40, but with mild symptoms might do well on
birth control pills.
 ALWAYS INFORM PATIENTS OF RISKS AND BENEFITS OF PROCEDURES.
A. MEDICAL MANAGEMENT
1. BIRTH CONTROL PILLS
 For mild or moderate endometriosis.
 Reduce the heaviness of the menstrual flow and its duration
 Provide a powerful decidualizing effect on the implants by virtue
of their strong progestin. This discourages further growth of pre-
existing implants.
 When taken continuously, stops the episodic hormonal
withdrawal bleed that occurs both with normal endometrium
and with endometrial implants.
 It usually takes 3-6 months of continuous OCPs or oral
contraceptive pills, and up to 12 months to achieve maximum
benefit.
 OCPs are relatively inexpensive, making this treatment choice
very affordable for most patients.
2. GnRH AGONISTS
a. Leuprolide
b. Goserelin
 Numerous drawbacks include temporary menopausal side
effects
 Moderately expensive; may be as expensive as surgery
 Consider the patient’s age. If she is an elderly female who is a
good surgical candidate, opt for surgery over medical
management
 Given for about 6 months
3. DANAZOL
 This is a cousin of testosterone and has both direct and indirect
effects on endometriosis
 Directly inhibits endometriotic implant growth through its
powerful decidualization properties
 Suppresses the secretion of pituitary gonadotropins, resulting in
inhibition of ovarian function and lower estrogen levels.
 Blocks steroidogenic enzymes.
 DRAWBACKS:
o High cost
o Significant side-effects (weight gain, masculinizing side-effects
and depression)
o It is normally taken for about a year before stopping it.
4. PROGESTINs
 Progestins seem to be about as effective in treating
endometriosis as OCPs
 Somewhat less well tolerated
 Weight gain and breakthrough bleeding are the biggest
problems
 It is not particularly expensive, and is a reasonable choice for
someone wishing to avoid surgery and OCPs, but intolerant of
Danazol or Leuprolide
B. SURGICAL MANAGEMENT
 Conservative surgical management:
o Removal of endometriosis and retain normal tissue as much
as possible to preserve child bearing capacity
 Definitive Surgical management
o Hysterectomy with or without removal of the tubes, ovaries
and other sites of endometriosis.
o Hysterectomy with bilateral salpingo-oophorectomy.
o Hard to perform surgery due to possible puncturing of
chocolate cysts or adherence to rectum
F. OVARIAN FIBROMA
 MOST COMMON BENIGN SOLID OVARIAN NEOPLASMS
 Occurs most commonly in postmenopausal women.
 Unilateral and often at least 3cm in size
Low malignant potential and extremely slow growing tumors
 Fibromas are connective-tissue tumors that arise from the
ovarian cortical stroma (undifferentiated ovarian stroma)
 If the stroma is estrogenic or leutenized, the tumors are actually
THECOMAS.
Incidence of ascites is directly proportional to the size of the
tumor
Pelvic pressure and abdominal enlargement may develop
Smaller tumors are asymptomatic since they do not elaborate
hormones
 MEIG’S SYNDROME- Association of ovarian fibroma, ascites and
hydrothorax
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 MANAGEMENT
 Surgery: the approach and extent depend on the age of the MANAGEMENT
patient  CT scan demonstrates a finding of extensive amorphous
Simple Excision brings about resolution of symptoms calcification within the solid components of the ovarian mass
Bilateral salpingo-oophorectomy and total abdominal  Surgery – simple excision or ablation; depends on patient’s age
hysterectomy done since the condition is common among post-
menopausal women

G. EPITHELIAL CYSTIC TUMORS

 Epithelial cystic tumors account for about 60% of all true ovarian
neoplasms.
 2 types: Serous Cystadenoma and Mucinous Cystadenoma

SEROUS CYSTADENOMA
 Typically unilocular but sometimes multilocular with papillary
Figure 10 Brenner Tumor
components (*that is, it’s walls are not smooth)

MUCINOUS CYSTADENOMA
 Account for approximately 10-15% of all epithelial ovarian
neoplasms.
 70% are benign and found in women 30-50 years old
 Smooth-walled compared to serous variety, they rarely are
associated with true papillae.
 Often multilocular
 Mucinous tumors consist of epithelial cells filled with mucin.
These cells resemble cells of the endocervix or may mimic
intestinal cells, which can pose a problem in the differential Figure 11 Benign Brenner tumor. A cyst in the Brenner tumor is lined by an
diagnosis of tumors that appear to originate from the ovary or inner layer of endocervical-type mucinous cells and an outer layer of stratified
intestine transitional cells, a few of which have grooved nuclei.

INCIDENCES OF OVARIAN NEOPLASMS

Table 1. Incidences of Ovarian Neoplasms

Cystic Teratoma 58%
Serous Cystadenoma 25%
Mucinous Cystadenoma 12%
Benign Stroma 4%
Brenner tumor 1%

I. POLYCYSTIC OVARIAN SYNDROME (PCOS)

Figure 9. Multiloculated mucinous cystadenoma  The diagnosis of PCOS has been simplified from the previously
tedious method.
H. BRENNER TUMOR/TRANSITIONAL CELL TUMOR  Currently, 2 of 3 criteria are required for diagnosis:
 Rare, small, smooth, solid, fibroepithelial ovarian tumors that are 1. Polycystic ovaries (multiple small cysts, often around the
generally asymptomatic. periphery of the ovary, the classic “string of pearls”
 Relatively rare and most common in the fourth to sixth decades appearance)
of life 2. Signs of androgen excess (acne, hirsutism, temporal balding,
 Small, firm, and gray white solid, slow growing, with occasional male pattern hair loss, clitoromegaly, etc)
yellow tinge with small cystic spaces 3. Menstrual irregularities (oligomenorrhea or polymenorrhea).
 1 to 2% chance of malignant transformation
 Found incidentally at pathologic evaluation, often in conjunction Note: A diagnosis of PCOS does not require multiple ovarian cysts or
with a serous or mucinous cystadenoma or dermoid cyst polycystic ovaries.
 Two principal components are solid masses or nests of epithelial
cells and a surrounding fibrous stroma
 30% discovered as small, solid tumors in association with a
concurrent serous cystic neoplasia, such as serous or mucinous
cystadenomas of the ipsilateral ovary.
 Presently, most authorities accept the theory that most of these
tumors result from metaplasia of coelomic epithelium into
uroepithelium (“transitional cell tumor”)
 Postmenopausal bleeding is sometimes seen as endometrial
hyperplasia is a coexisting abnormality in 10-16% cases

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 Figure 12 PCOS on UTZ. Note the multiple unechoic areas indicating the
presence of cysts

J. OVARIAN REMNANT SYNDROME

 Chronic pelvic pain secondary to small area of functioning ovarian
tissue after intended removal of both ovaries
 Most women who develop this had endometriosis or chronic
pelvic inflammatory disease and extensive pelvic adhesions
discovered during previous surgical procedures
 Another risk factor is laparoscopic oophorectomy
 50% present with chronic pelvic pain is cyclic, exacerbated
following coitus
 50% present with pelvic masses that are small, 3 cm, most
commonly located in the retroperitoneal space immediately
adjacent to either ureter

MANAGEMENT
 Diagnosed through palpation during pelvic exam, vaginal
ultrasound or MRI
 Surgical removal of remaining ovarian tissue via laparoscopy or
laparotomy with wide excision of the mass using meticulous
techniques to protect integrity of ureter

K. PAPILLOMATOSIS
 Must be differentiated from condyloma (warty and rough, hard,
itchy, covers like a cauliflower)
 Papillomatosis is very soft, smooth

OB-GYN joke: An obstetric resident was requested to explain

and check for signs of labor. The senior resident then
checked in and asked, “Fully delighted?” The patient said
“Fully delighted!”

And we know that in all things God works for the good of
those who love him, who have been called according to his
purpose.

Romans 8:28

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