Ginecologia

Surg Clin N Am 88 (2008) 245–264

Benign Gynecologic Conditions
Kevin J. Boyle, MD*, Saioa Torrealday, MD
Department of Obstetrics and Gynecology, Tripler Army Medical Center, 1 Jarrett White Road, Honolulu, HI 96859-5000, USA

Benign adnexal masses Benign adnexal tumors are masses involving the ovary, fallopian tube, or surrounding uterine ligaments. Adnexal masses are a common andchallenging problem faced by gynecologists. Although most adnexal masses are benign, their potential for malignancy drives the need for accurate diagnosis and treatment. Etiology Functional ovarian cysts Follicular cysts are the most common cystic structures seen on the normal ovary. Normal follicles typically are multiple and range in size from a few millimeters to several cm. Follicles become cysticonce they reach a diameter greater than 3 cm. Follicular cysts are believed to grow in response to gonadotropins. It remains unknown whether follicular cysts form when dominant follicles fail to rupture and release their ova, or if they form when nondominant follicles fail to undergo the normal process of atresia. Follicular cysts usually are thin walled, contain clear fluid, and have maximumdiameters of up to 15 cm [1]. Corpus luteum cysts develop from mature postovulatory Graafian follicles. Like follicular cysts, corpus luteum are not termed ‘‘cysts’’ until they reach a minimum size of 3 cm in diameter [1]. Most corpus luteum cysts remain asymptomatic and small with an average diameter of only 4 cm. Two to 3 days after ovulation, thin-walled capillaries normally invade the granulosa cell,and spontaneous bleeding fills the central cavity of the maturing

The views expressed in this article are those of the authors and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the US Government. * Corresponding author. E-mail address: kevin.j.boyle@us.army.mil (K.J. Boyle). 0039-6109/08/$ - see front matter. Published by Elsevier Inc.doi:10.1016/j.suc.2007.12.001

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corpus luteum with blood. Usually this blood is absorbed from the central cavity to form a cystic space. When the hemorrhage is excessive, it overcomes the body’s ability to absorb the blood, and the cystic space continues to grow. These cysts can become significantly large and cause discomfort as they enlarge.Eventually, if the intra-cystic pressure exceeds the capacity of the cyst’s thin walls to contain the blood, these cysts rupture, potentially causing significant intraperitoneal hemorrhage. Because corpus luteum cysts secrete progesterone, menstrual bleeding may be normal or delayed, depending on how long the cysts’ progesterone production stabilizes the endometrial lining. Halban’s triad ofspotting, unilateral pain, and a pelvic mass often is used to describe the presence of corpus luteum cysts [1]. Theca lutein cysts are the least common functional ovarian cysts. They almost always are bilateral and cause moderate to massive enlargement of the ovaries. These cysts arise from excessive or prolonged luteinization of the ovary by human chorionic gonadotropin (hCG). Multiple cysts can formon the ovary, each ranging in size from 1 to 10 cm. Iatrogenic stimulation of the ovaries with assisted reproductive regimens may initiate the formation of theca lutein cysts; conception tends to prolong and maintain their growth secondary to persistent hCG stimulation. In fact, any condition that causes sustained hCG production can lead to development of theca lutein cysts. Thus, it is common todiscover these cysts during the later months of singleton gestations, in the earlier months of twin or higher multiple pregnancies, and occasionally concomitant with molar pregnancies, choriocarcinomas, and other hCG-secreting tumors [2]. Endometriomas Endometrial implants can form throughout the pelvis and quite frequently are found on the ovary (see section on endometriosis). Endometriosis of...