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Pelvic Masses

Pelvic masses are common in women of all ages.  Before embarking on unpleasant or expensive investigations, it is important to exclude some common “physiological” masses.
If the patient has no complaint and a mass is felt in the left iliac fossa, a vaginal examination may reveal a soft mass which is easily deformed by the examining finger.  This is probably a sigmoid colon loaded with stool.  A laxative should be administered and the examination repeated after an interval.
A symmetrical mass rising above the pubic bone and dull to percussion could be bladder.  (This is sometimes quite asymmetrical due to scarring from a previous caesarean section).  Passing a catheter can prevent some very red faces. 
Some women, though pregnant, have no history of amenorrhoea (periods stopping).  It is important to consider this possibility in all women of child bearing age, even if taking active measures to prevent pregnancy.  Even with a history of a short interval since the last period, a uterus may be unexpectedly large if there is a multiple pregnancy or hydatidiform mole.
An inflammatory mass of the appendix in the right or diverticulitis on the left should be considered as should a tubo-ovarian mass.  Endometriosis can produce masses as an ovarian cyst or elsewhere.
The commonest gynaecological masses in the pelvis are fibroids (leio-myo-fibromas) and ovarian cysts. 

Fibroids

What Are Fibroids?

They are non-malignant growths occurring in the uterus (womb), usually growing very slowly over a number of years, although they may grow intermittently. They can be present for some time without causing any trouble and can be left untreated but should be regularly monitored by your doctor.

Are Fibroids Common?

Yes, they are very common. One estimate is that 30% of all women have fibroids to some extent and sometimes if they are so small as not to cause symptoms, are only found when an examination or investigation is being performed for another reason, such as sub-fertility.   They are not usually the main reason for failure to become pregnant.

What Problems Do They Cause?

They will tend to either cause heavy periods or cause problems by being a space occupying lesion in the pelvis, putting pressure upon other organs. Small fibroids within the uterus may affect periods adversely whereas large fibroids on the outside may make no difference. As the pelvis is filled, one may have little room for the bladder to fill up and pass water quite frequently. On rare occasions, the urethra can be blocked by the pressure, causing acute urinary retention. Sometimes the fibroid uterus can produce pain, either a colicky abdominal pain from bowel pressure or perhaps a low back ache.  Leiomyosarcomas can occur in these tumours but these are very rare (<0.1%), usually presenting at age 50-55. 

How Did I Get Them?

No-one knows why they develop, despite the fact that they are the most common tumour in women. All fibroids stop growing and actually shrink after the menopause and increase in size during pregnancy, which implies that the presence of oestrogen is involved. There may also be a hereditary factor as they are more likely to develop if there is a family history. They cannot be "caught" nor prevented from developing.


How Can They Be Treated?

There are 2 ways to treat fibroids - with drugs, or with surgery (or with drugs prior to surgery).
Drug treatment
If development of fibroids is influenced by hormone changes in the woman's body, they will tend to shrink at the time of the menopause. However, this depends upon having no hormone replacement therapy and thereby suffering the damage to all the other systems in the body that this might cause. A temporary menopause can be produced by gonadotrophin-releasing hormone agonist (GnRH) injections on a monthly basis in an attempt to shrink fibroids before surgery.  That might facilitate a laparoscopic operation rather than a large incision. GnRH agonists may be used prior to myomectomy to reduce the amount of bleeding. Side effects such as hot flushes and night sweats can make them quite unpleasant to use without some form of add-back therapy and they certainly should not be used for long periods of time without add-back therapy. When the GnRH therapy is stopped, the fibroids tend to rapidly achieve their original size.
Surgical treatments
Surgery is used either to remove the uterus or to remove the fibroid itself. Fibroids can be removed individually by myomectomy and this is especially suitable for young women wishing to have more children in the future.

Myomectomy

Removing a small fibroid laparoscopically


Hysterectomy - removal of the uterus and cervix whilst preserving the ovaries - is the most common way of surgically treating fibroids in
women who have completed their families and may be resorted to if other surgery fails.
Other Therapies
Arterial embolization has been the subject of much recent publicity about this new technique involving the injection of little particles into the uterine arteries to block the vessels that feed the fibroids, thereby causing the fibroids to die. There have been reports of spectacular success and also of complete failure. This procedure is, I believe, still in the experimental phase and there are several questions to be answered before it can be generally recommended. 

Ovarian Cysts

Many women are unnecessarily distressed when a cyst is mentioned at an ultrasound examination. It is normal, in a healthy menstrual cycle, to produce a follicle in the ovary which grows to approximately 25mm (an inch) in diameter before it bursts to release the egg. It is spherical and contains a watery fluid and so is often termed a cyst. Some cysts are follicles which have not burst but have continued to expand.

What is an Ovarian Cyst?

Any spherical hollow structure seen on ultrasound tends to be called a cyst. It is normal for a woman who is not preventing ovulation by taking the oral contraceptive pill to produce a follicle each month. The egg develops in this. It reaches about 25 mm before it bursts to release the egg. Bleeding from endometriosis may form an ovarian cyst.  These contain dark altered blood and are termed “chocolate cysts” or endometriomas.

Ovarian

An ovarian cyst caused by endometriosis

Dermoid cysts are not uncommon. Ovarian cancer can produce cysts but there are other features that enable us to differentiate this from simple cysts.

How might an Ovarian Cyst cause problems?

A follicle is normal but when it bursts to release the egg when about 25mm in diameter, there may be a twinge of pain (called mittelschmerz). If it does not burst, there is seldom any trouble until it reaches about 50mm diameter. At this size, the weight of fluid in the cyst causes it to sag down. The pedicle, through which blood reaches the ovary can then twist. Rather like wringing out a towel, this causes pressure in the pedicle. Veins are at lower pressure than arteries and so this twisting (or torsion) can crush the veins, stopping blood leaving the ovary whilst still allowing arterial flow into it. This can cause bleeding into the cyst or rupture with concomitant pain.  Torsion of an ovary is an emergency requiring rapid untwisting and drainage (at least) of the cyst.  Otherwise the ovary will die.
An endometrioma will tend to hurt at each period as it is stretched with new bleeding.


How is a cyst diagnosed?

Abdominal swelling or pain might suggest a cyst. If it is big enough to cause trouble, it may well be felt at a bimanual examination. Confirmation is usually by ultrasound scanning. The scan may show features that suggest that the cyst is benign or malignant or that there has been bleeding into the cyst. We will often arrange a blood test for the chemical CA-125.

What is a Dermoid Cyst?

These cysts are so called because they are very like skin (or dermis). They contain hair and sebum (the lubrication for hair). Sebum is fatty and lighter than water so they do not normally behave like simple cysts.

How are they formed?

There is some discussion about this. We think that they arise from an unfertilised egg which tries to develop.

Are there other tissues?

Yes. It is common to find rudimentary teeth. Also, other tissues such as thyroid may be found.

How is an ovarian cyst treated?

  • Drainage: A simple cyst that is not too large can be needled at laparoscopy and the fluid drawn out. The cyst then shrivels up.
  • Laparoscopic Ovarian Cystectomy: A laparoscopy is performed. The cyst is drained then one can cut out the cyst wall using two tiny incisions in the abdomen to insert instruments.
  • Laparotomy and Ovarian Cystectomy: Sometimes an open operation is needed.
  • Malignant Pelvic Masses

    Ovarian cancer is rare before age 40. The risk of ovarian cancer increases with age: 

    •4:100,000 age 25-29
    •15.7:100,000 age 40-44 
    •54:100,000 age 75-79 
    •Risk increases if one first-degree relative has ovarian cancer (risk increases from 1.4% to 5%. Women who have 2 or more first degree relatives with ovarian cancer have a 7% lifetime risk of developing ovarian cancer.
    •Unfortunately, most women are diagnosed at an advanced stage. 75% of women with stages I or II disease can be cured but this falls to 5-15% for women with more advanced disease. 
    •Cancers in other organs should be considered as well. Colon cancer causes 30,000 deaths annually in the USA, more than twice the number of deaths due to ovarian cancer. Change in bowel habits, rectal bleeding, and/or abdominal/pelvic pain and constitutional symptoms should trigger evaluation with colonoscopy.
    •Breast cancer can metastasize to the ovary as can uterine and colon cancer. A careful breast exam and rectal exam, faecal occult blood, and mammography are helpful in detecting these cancers. Family history is helpful as well as all of these cancers tend to run in families. 


    How are these masses treated?
    As the treatment is individualised for each woman’s best result by the Multi-Disciplinary Team (MDT), and is constantly changing as our knowledge improves, I do not propose to describe this here.  It is best discussed with your doctors if and when necessary.  

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