24.2 Benign Upper Genital Tract Disorders: Leiomyoma, Adenomyosis & Endometriosis, Endometrial Polyps and Hyperplasia, Functional Cysts and Benign Ovarian Tumors, Adnexal Torsion and Tubal Disease

Why this area matters

TOS area M asks you to:

• classify disorders and tumors of the uterus, fallopian tubes and ovaries and their premalignant potential;
• correlate symptoms with risk factors;
• plan treatment with appropriate anesthesia and perioperative care;
• choose diagnostic tests;
• prevent, monitor and control these disorders, including their effects on fertility and pregnancy.

Fibroids, endometriosis and ovarian cysts are among the most common reasons for gynecologic surgery in the Philippines. They cause heavy bleeding, anemia, pelvic pain and infertility.

Uterine leiomyoma (fibroids)

• Biology: fibroids are benign monoclonal smooth muscle tumors, the most common pelvic tumor in women. They grow under estrogen and progesterone and shrink after menopause.
• Location (FIGO types 0 to 8):
  • submucosal fibroids distort the cavity; they cause the most bleeding and infertility and may prolapse through the cervix;
  • intramural fibroids are the most common;
  • subserosal and pedunculated fibroids may cause pressure symptoms or twist;
  • cervical and broad ligament fibroids can obstruct labor or the ureter.
• Symptoms:
  • heavy menstrual bleeding with iron deficiency anemia;
  • pelvic pressure, urinary frequency and constipation;
  • an enlarged, irregular, firm uterus;
  • infertility and miscarriage.
• Degeneration:
  • hyaline degeneration is the most common;
  • cystic degeneration;
  • calcific degeneration, typical after menopause;
  • red (carneous) degeneration in pregnancy, with acute pain and low-grade fever, managed with analgesia.
  • Malignant change to leiomyosarcoma is very rare. A rapidly growing mass after menopause needs evaluation.
• Treatment:
  • asymptomatic fibroids need no treatment;
  • for bleeding: NSAIDs, tranexamic acid, LNG-IUS and combined hormonal contraceptives;
  • GnRH agonists shrink fibroids and correct anemia before surgery, but cause menopausal symptoms and bone loss with long use;
  • myomectomy (hysteroscopic, laparoscopic or open) preserves fertility;
  • hysterectomy is definitive;
  • uterine artery embolization suits women not planning pregnancy.

Endometriosis versus Adenomyosis

Endometriosis and infertility:

• Endometriosis impairs fertility through adhesions, distorted tubes and ovaries, and inflammation.
• Endometriomas ("chocolate cysts") damage ovarian reserve, so surgery is weighed against preserving eggs.
• Medical suppression relieves pain but does not improve fertility. Women who wish to conceive may need surgery or assisted reproduction.

Endometrial polyps and hyperplasia

• Endometrial polyps:
  • cause intermenstrual and postmenopausal bleeding;
  • more common with tamoxifen and obesity;
  • seen on saline sonohysterography and removed by hysteroscopic polypectomy;
  • a small proportion, especially in postmenopausal women, contain hyperplasia or cancer.
• Endometrial hyperplasia:
  • results from unopposed estrogen (obesity, PCOS, anovulation, estrogen-only therapy, granulosa cell tumor);
  • the 2014 WHO classification separates hyperplasia without atypia (low cancer risk, treated with progestins such as the LNG-IUS or oral progestins, plus follow-up biopsy) from atypical hyperplasia/endometrial intraepithelial neoplasia (EIN);
  • EIN carries a high risk of coexisting carcinoma and is treated with total hysterectomy, or high-dose progestin in women who want fertility.

Ovarian cysts and benign ovarian tumors

• Evaluating an adnexal mass:
  • ultrasound features (size, solid parts, septations, papillary projections, blood flow, ascites) separate benign from suspicious masses (IOTA rules);
  • CA-125 helps in postmenopausal women but is often raised by endometriosis, fibroids, PID and pregnancy in younger women;
  • a simple cyst under about 5 cm in a woman of reproductive age is usually functional and is rescanned after 6 to 8 weeks;
  • suspicious masses, and any new mass before menarche or after menopause, are referred for surgical evaluation;
  • AFP, hCG and LDH are checked in girls and young women with solid masses, looking for germ cell tumors.

Adnexal torsion and tubal disorders

• Ovarian torsion:
  • happens when an enlarged ovary, often 5 cm or more and often a dermoid or cyst, twists on its pedicle;
  • causes sudden severe unilateral pelvic pain with nausea and vomiting;
  • Doppler flow may still be present, so normal flow does not exclude torsion;
  • treatment is urgent laparoscopy with detorsion, preserving the ovary even if it looks dark, with cystectomy.
• Hydrosalpinx:
  • a distal tubal blockage, usually after PID or genital TB, filled with fluid;
  • causes infertility and lowers IVF success, so the tube is removed or clipped before IVF.
• Paratubal cysts (remnants of the mesonephric duct) are usually harmless but can twist.