Benign tumors of women’s reproductive system PLAN OF LECTURE

1. Benign tumors of the uterus • Etiopathogenesis • Classification • Clinical symptoms • Diagnostics • Management 2. Benign ovarian tumors • Etiopathogenesis • Classification • Clinical symptoms • Diagnostics • Management

Leiomyoma smooth muscule + fibrous connective tissue Frequency of uterine myoma makes 15-25% among women after 35-40 years Etiopathogenesis

myoma - mesenchymal tumor (region of active growth formation around the vessels growing of tumor) + hyperoestrogenism Myomas are rarely found before puberty, and after menopause. The association of fibroids in women with hyperoestrogenism is evidenced by endometrial hyperplasia, abnormal uterine bleeding and endometrial carcinoma. Myomas increase in size: during pregnancy, with oral contraceptives, after delivery.

Accoding to Location of uterus myomas

Hysteromyoma classification:

• А. By the node localization: 1. subserous – growth in the direction of the perimetrium; 2. intramural (interstitial) – growth into the thickness of the uterine wall; 3. submucous – node growth into the uterine cavity; 4. atypical – retrocervical, retroperitoneal, antecervical, subperitoneal, perecervical, intraligamentous.

• В. By the node size (small, medium, and large)

• C. By the growth form • (false – conditioned by blood supply disturbance and edema, and true – caused by the processes of smooth muscle cells proliferation).

• D. By the speeding of the growth (fast and slowly)

The symptoms of uterine fibroids Fibroids can also cause a number of symptoms depending on their size, location within the uterus, and how close they are to adjacent pelvic organs.

• Pelvic pain

• Abnormal uterine bleeding

• Pressure on the bladder with frequent or even obstructed urination, and pressure on the rectum with pain during defecation

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Pelvic ultrasonography

• Submucosal tumor

Hysterosalpingography (Submucosal tumor) Hysteroscopy (Submucous macronodular fibroid) Laparoscopy Interstitial-Submucosal myoma

Hysteromyoma complications

• “birth”, • necrosis, • myomatous node suppuration, • node pedicle torsion, • rupture of the node capsule and vessels, • malignant change of the fibromyoma. • Infertility Pedunculated leiomyoma

“Birth”-node Necrosis node

Uterine Fibroid Embolization (UFE) or Uterine Artery Embolization (UAE)

- a nonsurgical procedure that blocks blood flow to fibroids in the uterus. Embolization is done with local anesthesia, and there are no incisions or cuts in the skin. A thin flexible tube is threaded into the blood vessels that supply blood to the fibroid; a solution is then injected into the blood vessels. This blocks the blood supply to the fibroid, causing it to shrink. Fibroids treated with embolization shrink by half or more. Normal uterine tissue usually remains unharmed, because it is supplied by other arteries. Women who are considered the best candidates for embolization are women who:

• Have fibroids that are causing heavy bleeding • Have fibroids that are causing pain or pressing on the bladder or rectum • Don't want to have a hysterectomy • Don't want to have children in the future

Complications of embolization are not common, but can occur. They are:

• Infection - the most serious, potentially life- threatening complication of embolization. See your doctor immediately if you have a high fever and feel ill or notice pus in your vaginal discharge. In rare cases, emergency hysterectomy is needed to treat an infected uterus. • Loss of menstrual periods • Premature menopause • Scar tissue formation Myolysis Myolysis is the destruction of muscle tissue. Myolysis is generally recommended for smaller fibroids. It is not recommended for women who hope to have children. These treatments can cause serious pregnancy complications, such as uterine scarring and infection; these can be dangerous to both mother and fetus.

• Laser (myolysis) - usually done by laparoscopy. A laser is used to remove the fibroid or clot the blood supply to the fibroid, causing the fibroid to shrink and eventually die. • Cold (cryomyolysis) - usually done by laparoscopy. Liquid nitrogen is used to freeze the fibroid. • Electric current - Myoma coagulation (myolysis) - usually done by laparoscopy. An electrical needle is passed directly into the fibroid delivering high-temperature energy to destroy both the fibroid and the blood vessels feeding it. • High-frequency focused ultrasound - Using a high-intensity ultrasound beam, the Magnetic Resonance Imaging (MRI) scanner helps the doctor locate the fibroid, and the ultrasound sends out very hot sound waves to destroy it. tumor of a woman’s uterus (womb). uterine fibroids

A submucous myoma

Interstitial fibroid uterus.

Benign ovarian tumors The risk factors with ovarian tumors

• Women with ovarian dysfunction • Women with postmenopausal bleeding • Women with chronic inflammatory processes of uterine adnexa • Women after surgical intervention (or resection ovaries) Benign ovarian tumors • Cyst– tumor-like (non- • Cystoma – true blastomatous) tumor (blastomatous), formation of mainly which grows due to retention nature from a proliferation of cells natural cavity Benign ovarian tumors are divided into three main types, based on where the abnormal cell growths originated:

• Surface epithelial tumors – these tumors begin in the cells lining the surface of the ovary. It is the most common type of ovarian tumor. • Stromal tumors – these benign and malignant tumors begin in the part of the ovary that manufactures female reproductive hormones. It is very rare and when cancerous is considered a low-grade cancer. • Germ cell tumors – these tumors begin in the cells that develop into eggs. The majority of germ cell tumors are benign, but sometimes can develop into cancer. These are most common in younger women and, if treated early, fertility can be preserved. Varieties of cystic/neoplastic enlargements of the ovaries

» 1. Functional cysts • Follicular cysts » • Lutein cysts » • Multiple functional cysts » • Corpus luteal cyst (PCOS)

» 2. Inflammatory • Salpingo-oophoritis » • Puerperal, abortal, IUCD related » » 3. Metaplastic • Endometrioma » 4. Neoplastic benign and malignant » • Premenarchal years: 10% are malignant—mostly dysgerminoma teratoma » • Reproductive period—15% malignant » • Premenopausal—50% malignant Histological Classification of Ovarian Tumors

• І. Epithelial tumors. • А. Serous, mucinous, endometrioid, mesonefroid, and mixed: • а) benign: cystadenoma, adenofibroma, superficial papilloma; • b) related: intermediate forms of cystic adenomas and adenofibromas; • c) malignant: adenocarcinoma, cystadenocarcinoma, papillary carcinoma. • B. Brenner’s tumor: • а) benign; • b) related; • c) malignant. • ІІ. Sex cord-stromal tumors. • А. Granulosa theca cell tumors: granulosa cell tumors, tumors of the thecoma- fibroma group, generalized tumors. • B. Androblastomas, Sertoli-Leydig cell tumors (differentiated, intermediate, low- diferentiated). • ІІІ. Lipid cell tumors. • ІV. Germinogenous tumors. • А. Dysgerminoma. • B. Teratoid tumors (homologous, heterologous). • V. Tumor-like neoplasms and pretumor processes: luteoma of pregnancy, hyperthecosis, follicular cysts, corpus luteum cyst, endometriosis, inflammatory cysts, paraovarian cyst. Clinical norma

Ovariorum (norma) Follicles dominant

Functional cysts form from the fluid-filled cavities (follicles) in the ovaries.

Functional follicle cyst Functional luteal cyst with septa

Endometriod tumors

Cyctadenoma Cyctadenoma Mucinous cystoma / thecoma Benign cyctic teratoma (dermoid cyct) Benign cystic teratomas (dermoid cysts): These tumors usually develop from all three layers of tissue in the embryo (called germ cell layers). All organs form from these tissues. Thus, teratomas may contain tissues from structures, such as nerves, glands and skin. Cystadenocarcinoma Ovarian Cyst - Symptoms

• sharp pains in the lower abdomen; • severity in the hip; • heavy bleeding during menstruation, irregular menstruation; • weakness, nausea, sometimes vomiting after sexual intercourse or intense physical education; • pressure in the abdomen during urination; • constant body temperature above 38 ° C; • sudden weight loss with normal nutrition.

•It begins to put pressure on neighboring organs Anatomical and surgical pedicle

The pedicle of an ovarian cyst showing the relations of the ovarian vessels, the ovarian ligament and the fallopian tube, together with the anastomosing branch of the uterine artery.

Investigations

• Ultrasound. Transabdominal transducer is employed if the tumour is abdominal. Otherwise transvaginal ultrasound (TVS) gives more detailed features of the tumour. » Radiograph of abdomen/pelvis which may demonstrate a soft tissue shadow, or teeth in a dermoid (molar tooth). » Diagnostic laparoscopic examination may be needed in a few cases. » Intravenous pyelography will exclude a hydronephrosis. Ultrasound can also diagnose it. » In all suspected metastatic ovarian cancers, a barium meal should be performed to exclude gastrointestinal primary carcinoma. » Radiograph of chest will rule out pulmonary metastasis and also hydrothorax in case of Meigs syndrome. » Breast examination will rule out pregnancy as well as detect a metastatic growth. Tissue markers : CA-125, NB/70k, HE4 Treatment Cystectomy Key Points

1 The tumours are often asymptomatic to begin with, and are often far advanced by the time they are diagnosed.

2 Sex cord tumours have a potential to secrete hormones which may manifest clinical symptoms like precocious puberty, menstrual disturbances and postmenopausal bleeding. Virilizing effects may be observed in masculinizing tumours.

3 Bilateral tumours, rapidly growing tumours and presence of ascites are suggestive of malignancy and require investigations.

4 Tumour markers like CA-125, HE 4 are particularly useful in postmenopausal women suspected of having a malignant epithelial cell tumour.

5 Benign ovarian tumour is surgically dealt with by ovarian cystectomy, ovariotomy, laparoscopic dissection of the cyst in a young woman and hysterectomy ith bil t l l f d i ld