BENIGN GYNECOLOGIC LESIONS

Case 1
A 25 year old comes to your clinic for a well woman examination. She is asymptomatic. On
physical examination, you find a 7 cm adnexal mass.

Questions
1. What are your initial considerations and why?
● Age : The patient's age is a crucial factor in determining the probable etiology of an
adnexal mass and certain types of adnexal masses are more common in different age
groups such as ,
- In premenopausal women, physiologic follicular cysts and corpus luteum cysts
are the most common adnexal masses
- Malignant neoplasms are uncommon in younger women but become more
frequent with increasing age.
- In postmenopausal women with adnexal masses, both primary and secondary
neoplasms must be considered, along with leiomyomas and ovarian fibromas
● Past Medical History: history of endometriosis or pelvic inflammatory disease (PID)
may increase the likelihood of certain types of adnexal masses. Any previous
gynecological surgeries or conditions can be potential risk factors.
● Obstetric History: Information about the patient's obstetric history to find out if there
was any ectopic pregnancy or other complications during pregnancy.
● Family History: Positive family history of gynecological conditions such as ovarian or
breast cancer may indicate a higher risk for ovarian malignancies.
● Menstrual History: irregular menstrual cycles, abnormal bleeding patterns, or any
recent changes in menstrual characteristics, which can be relevant to the underlying
cause of the adnexal mass.
2. How will you proceed in evaluating and managing this patient?
Evaluation:
-
- Imaging Studies : Transvaginal Sonography and Pelvic MRI can be done to evaluate the
mass and determine whether the mass is cystic or solid and to know its location
- Tumor Markers: Blood tests, including CA-125 can be done . Elevated CA-125 levels can
be associated with ovarian cancer, and can also be elevated in various other conditions
as well. Other tumor markers such as carcinoembryonic antigen (CEA) and cancer
antigen 19-9 (CA19-9) can also be done to check if there is any elevation that can be
caused by secretions of mucinous epithelial ovarian carcinomas.
- Consultation with a Gynecologist or Gynecologic Oncologist: Due to the size of the mass and
the potential seriousness of the findings, a referral to a specialist is crucial for proper
evaluation and management.
Management :
 - Observation: Most ovarian cysts regress within 6 months of identification so regular follow
and observation would be the initial management . Regular follow up can be done based
on the findings of the tumor markers and imaging to monitor any changes in the mass.
- Surgery : Depending on the size and location of the cyst or mass surgery can be done as
in many cases cyst excision serves as the definitive diagnostic tool.

3. What are your differentials?

● Functional Ovarian Cyst: A functional ovarian cyst is a common and benign fluid-filled
sac that develops on or within the ovaries during the menstrual cycle. It is usually related
to the normal hormonal fluctuations that occur during the menstrual cycle. Functional
cysts are often small, asymptomatic, and resolve on their own without treatment. They
are simple, fluid-filled structures with clear fluid on ultrasound. They are usually less than
5 cm in diameter. In some cases, they can grow larger and may cause mild discomfort or
pelvic pain.
● Ovarian Teratoma (Dermoid Cyst): Ovarian teratomas, also known as dermoid cysts,
are benign ovarian tumors that arise from germ cells. They are composed of different
types of tissues, including skin, hair, teeth, and sometimes other organs or tissues. They
can be filled with sebum, a yellowish oily material. On ultrasound, dermoid cysts often
appear as complex cystic masses with internal echoes, representing the different types
of tissues within the tumor. They may have a characteristic "tip-of-the-iceberg"
appearance, showing a solid component with hair or fat floating in the cystic portion.
● Endometrioma: An endometrioma, also known as a chocolate cyst, is a cystic mass
formed by endometrial tissue that implants and grows outside the uterus. Endometriosis
is a condition where endometrial tissue grows in abnormal locations, leading to
inflammation and pain during the menstrual cycle.On ultrasound, endometriomas often
appear as well-defined, cystic masses with homogeneous low-level echoes. They may
be associated with "ground-glass" or "homogeneous" appearance on imaging.
● Fibroma: A fibroma is a benign tumor of fibrous tissue that can arise from the ovary. It is
typically solid and composed of fibrous connective tissue. On ultrasound, fibromas
usually appear as solid, hypoechoic masses without any cystic components.

Case 2
A 40 year patient comes to you due to a vulvar mass, left labia, slowly enlarging, non painful.
On examination, you noted a 3 x 3 cm mass at the left vulvar area,firm, non tender.

Questions:
1. What questions would you ask your patient that will help you come up with your
diagnosis?
● When did you first notice the mass or from how long has it been present?
● Do you experience any other symptoms such as irritation or discomfort?
● Do you experience any other symptoms not related to the mass such as weight loss ,
fatigue ?
● Have you tried any medication or self treatment to reduce the mass?
● Any past medical conditions or gynecological issues or previous surgeries
 ● Any family history of gynecological conditions such as vulvar or ovarian cancer ?
● Can you tell me about your menstrual cycle, like how many days does it last ?
● Have you noticed any changes in your menstrual cycles recently ?
● Do you smoke or consume alcohol

2. How will you proceed in evaluating and managing this patient?

- Biopsy: A biopsy can be recommended to obtain a tissue sample from the vulvar mass
for histopathological examination. This will help confirm the diagnosis and rule out any
potential malignancy.
- Imaging Studies: imaging studies such as ultrasound or MRI can be ordered to further
evaluate the mass and assess its relationship to nearby structures.
- Tumor markers can also be ordered such as mous cell carcinoma (SCC) antigen and
carcinoembryonic antigen (CEA).

● If the mass is painless and not causing any discomfort or functional problems,
observation and regular monitoring can be the initial management approach.
● Surgical excision can also be the choice of treatment to prevent recurrence.
● Patient should be advised not to attempt self-treatment, such as trying to drain or
remove the lipoma at home, as this can lead to infection or other complications.

3. What are your differentials?

● Vulvar Lipoma: A vulvar lipoma is a benign tumor composed of mature fat cells.
Lipomas are typically painless, soft to the touch, and slowly growing. They can develop
in various locations where there is adipose tissue, including the vulvar area. Lipomas are
usually harmless and do not require immediate treatment unless they cause discomfort
or functional issues.

● Vulvar Cyst: Bartholin's cyst and Skene's duct cyst are two common types of vulvar
cysts. Bartholin's cysts form when the Bartholin's gland becomes blocked, leading to the
accumulation of fluid and the formation of a cyst. Skene's duct cysts develop when the
Skene's duct becomes blocked. These cysts can cause pain and discomfort, especially if
they become infected. Treatment may involve warm compresses, drainage, or, in some
cases, surgical intervention.

● Vulvar Abscess: A vulvar abscess is an infected mass that may result from the infection
of a hair follicle, sebaceous gland, or Bartholin's gland. It is typically tender, red, swollen,
and painful. Abscesses require drainage and may need antibiotic treatment to resolve
the infection.

● Vulvar Fibroma: A vulvar fibroma is a benign tumor composed of fibrous tissue. It may
present as a firm, non-tender mass in the vulvar area. Fibromas are generally non-
 cancerous and may not require treatment unless they cause discomfort or functional
problems.

Case 3
A 35 year old patient comes to you due to episodes vaginal spotting, brownish to reddish in
color, non foul smelling, not related to menstrual cycle, lasting for 3-5 days, consuming 1-2
panty liners per day, lighty soaked.

Questions:
1. What questions would you ask your patient that will help you come up with your
diagnosis?
● When did you first notice the spotting?
● Do you notice any other substances, such as mucus or clots, in the spotting?
● Is the spotting intermittent or continuous?
● Do you experience any pain, discomfort, or itching along with the spotting?
● Do you have any known medical conditions, such as thyroid disorders or bleeding
disorders?
● Have you undergone any recent gynecological procedures or surgeries?
● Are you taking any medications or supplements
● Do you have a family history of gynecological conditions or bleeding disorders?
● When was your last menstrual period and have you experienced any changes in your
menstrual pattern recently?
● Are you currently using any form of contraception, such as hormonal contraceptives or
intrauterine devices (IUDs)?
● Have there been any recent changes in your lifestyle, stress levels, or significant life
events?

2. List down at least 3 benign conditions that can cause vaginal spotting, and how to
proceed with evaluation and management for each condition.
Bening Conditions:
- Cervical Erosion: Cervical ectropion occurs when the glandular cells from the cervical
canal extend to the outer surface of the cervix. These cells are more fragile and may
bleed easily, leading to spotting. Cervical ectropion is common in young women, women
taking hormonal contraceptives, and during pregnancy.
Evaluation and management :
- Pelvic exam and colposcopy to visualize the cervix and assess for any abnormalities and
to rule out other conditions.
- In many cases, cervical ectropion does not require specific treatment as it is a normal
variation. It may resolve on its own over time.
- If the patient experiences bothersome symptoms, such as persistent spotting, we can
recommend hormonal contraceptives to regulate bleeding or cauterization of the affected
area.
 - Cervical Polyps: Cervical polyps are benign growths on the cervix that can cause
intermittent bleeding, including spotting. They are usually harmless and may resolve on
their own, but larger or symptomatic polyps may require removal.
Evaluation and management :
- A pelvic examination to identify the presence of cervical polyps and assess their
characteristics.
- Transvaginal ultrasound or hysteroscopy may be performed to further evaluate
the polyp and rule out other abnormalities.
- Small asymptomatic polyps may resolve spontaneously, and observation may be
sufficient.
- If symptomatic or causing persistent spotting, the polyps can be removed during
a simple office procedure called polypectomy.

- Vaginal Infections: Certain vaginal infections, such as yeast infections or bacterial

vaginosis, can cause irritation and inflammation of the vaginal tissues, leading to
spotting or light bleeding.
Evaluation and management :
- A pelvic examination to assess the vaginal and cervical tissues for signs of
infection, such as redness, swelling, or discharge.
- A sample of vaginal discharge may be collected for laboratory testing to identify
the specific infectious agent.
- For yeast infections, antifungal medications, such as topical creams or oral
tablets, are commonly used.
- Bacterial vaginosis is typically treated with antibiotics, either orally or as topical
vaginal preparations.

3. What are your differentials?

● Atrophic Vaginitis (Vaginal Atrophy):Atrophic vaginitis is characterized by thinning,

dryness, and inflammation of the vaginal tissues due to decreased estrogen levels, often
seen in menopausal or perimenopausal women. It can cause symptoms like vaginal
dryness, itching, and pain during intercourse, and mild spotting may occur.
● Uterine Fibroids (Submucosal): Uterine fibroids are non-cancerous growths that can
develop in or around the uterus. Submucosal fibroids grow within the uterine cavity and
may cause abnormal bleeding or spotting, especially if they irritate the uterine lining.
● Cervical Ectropion (Cervical Erosion):Cervical ectropion refers to the presence of
glandular cells from the cervical canal on the outer surface of the cervix. These cells are
more fragile and may bleed easily, leading to spotting.
● Cervical Polyps:Cervical polyps are small, benign growths that can develop on the
cervix. They may cause intermittent bleeding or spotting, especially after sexual
intercourse or a pelvic examination.