APGO Educational Objectives:

The uterine myoma is the most common gynecologic neoplasm and is often asymptomatic. Physicians are often called upon to distinguish myomas from other pelvic masses which may need more immediate management. The student will demonstrate a knowledge of the:

1. Symptoms and physical findings
2. Methods to confirm the diagnosis
3. Indications for surgical treatment.

Recommended Reading Assignment:

1. Uterine Leiomyoma and Neoplasia, Chapter 43, pp 499-511, Ovarian and Adnexal Disease, Chapter 47, pp 556-567, in Obstetrics and Gynecology, 3rd Edition, Beckmann, et al.

Questions:

1. What other questions would you ask this patient?
2. What laboratory tests would you order?
3. What radiographic or sonographic tests would you order?
4. What procedures would you consider to complete evaluation of this patient?
5. What medical therapies and surgical therapies are available to treat this patient? Are there any drawbacks or consequences?

1. Differential Diagnosis Listing
The actual approach to the evaluation begins with an understanding of the differential diagnosis of a pelvic mass. In the female, pelvic masses may arise from: Uterus, Ovary, Tube, Mesosalpinx, Bowel, Abdomen, Miscellaneous

1. Uterine Masses (including enlargement due to pregnancy)

   1. Pregnancy
      (1) Normal IUP
      (2) Hydatidiform mole
   2. Fibroids (leiomyoma)
   3. Leiomyosarcoma
   4. Endometrial CA
   5. Anomalies of incomplete midline fusion

2. Ovarian Masses (could be)

   1. Functional cysts
        (1) Follicular
        (2) Luteal
   2. Theca Lutein Cysts
   3. Luteoma of Pregnancy
   4. PCO
   5. Endometriomas
   6. Neoplasms
         (1)  Benign
         (2)  Malignant

3. Tubal Masses (include)

   1. TOA/TOC
   2. Ectopic pregnancy

4. Mesosalpingeal Masses

   1. Mesonephric (Wolffian)
   2. Paramesonephric (Muellerian)

5. Bowel

   1. Stool
   2. Appendiceal abscess
   3. Diverticular abscess
   4. Colon CA

6. Retroperitoneal

   1. Pelvic Kidney
   2. Teratoma
   3. Anterior meningocoele
   4. Lipo-/fibro- sarcoma
   5. Neurofibroma

7. Miscellaneous

   1. Full bladder
   2. Peritoneal cyst
   3. Urachal cyst

2. History

1. Age - Very important clue as to the likely nature of the mass
2. Menstrual Hx - Cues consideration of pregnancy, ovarian cyst or PCO; dysmenorrhea suggest endometriosis
3. Sexual Hx - Cues consideration of PID, pregnancy, ectopic; dyspareunia suggests endometriosis
4. Contraceptive Hx - Cues the likelihood of PID (with IUD), of pregnancy (with less reliable methods), or of ovarian cysts (unlikely on OC's)
5. Symptoms of pregnancy - More likely with normal IUP or mole than with ectopic
6. Pelvic pressure/fullness
7. Bowel habits - Cues consideration of GI etiology
8. Urinary habits

3. Physical Exam

1. Abdomen

2. Pelvic

   1. Speculum
         (1)  Pap/cultures
   2. Bimanual
   3. Rectovaginal

3. Rectal

4. Characterize the mass by (to derive clues as to benign vs. malignant):

   1. Size
   2. Shape
   3. Mobility
   4. Contour

4.  Basic Labs

1. UA
2. CBC
3. Pregnancy test
4. Pap
5. Cultures
6. Stool for occult blood

5.  X-rays

1. Abdominal film
2. IVP
3. BE
4. Pelvic Ultrasound
5. CT/MRI

6. Special Tests

1. Laparoscopy
2. Hysteroscopy
3. Endometrial sampling
4. Colonoscopy
5. Hysteroscopy

*Management of a 6 cm cystic, smooth mobile mass in a 32 year old - viable options include:

1. Observation and follow-up
2. Laparoscopic Bx/drainage
3. Image-guided Bx/drainage
4. Laparotomy and resection