Benign Gynecologic Lesions

Benign Gynecologic Lesions Eileen M. Manalo, M.D., FPOGS, FPSREI Associate Professor IV UP- Philippine General Hospital Obstetrics and Gynecology

Benign Lesions of the Genital Tract •

lesions of the vulva, vagina, cervix, uterine corpus, ovaries and fallopian tubes

Benign Characteristics: 1. 2. 3. 4.

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slow-growing well-circumscribed not associated with hemorrhage, necrosis or evidence of widespread dissemination (metastasis) no constitutional signs and symptoms of weight loss and anorexia

a tissue biopsy is needed to make a specific diagnosis.

Topic Objectives 1. To describe and discuss the more common lesions and conditions of the female genital tract 2. To discuss their pathophysiology, as well as their corresponding treatment

Benign Lesions of the Vulva

Urethral Caruncle • • • •

fleshy outgrowth of the distal edge of the urethra frequently in postmenopausal women must be differentiated from urethral carcinomas generally small, single and sessile but may be pedunculated and grow to be 1 to 2 cm in diameter • tissue is soft, smooth, friable and bright red and initially appears as an eversion of the urethra

Urethral Caruncle • believed to arise from an ectropion of the posterior urethral wall associated with retraction and atrophy of the postmenopausal vagina • histologically composed of transitional and stratified squamous epithelium with loose connective tissue

Urethral Caruncle • Growth is secondary to chronic irritation or infection • Symptoms may be variable – mostly asymptomatic – dysuria frequency, and urgency

Urethral Caruncle •

differential diagnosis • •

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primary carcinoma of the urethra prolapse of the urethral mucosa

not a precursor for urethral carcinoma diagnosis is established by biopsy under local anesthesia

Urethral Caruncle Treatment – Initially 1. oral or topical estrogen 2. avoidance of irritation

– cryosurgery, laser therapy, fulguration, or operative excision – following operative destruction - a foley catheter should be left in place for 48 to 72 hours – follow-up is necessary to ensure that the patient does not develop urethral stenosis

Urethral Prolapse • predominantly in premenarchal females • Grossly – does not have the bright-red color of a caruncle – is not as circumscribed in gross configuration – it may be ulcerated with necrosis or grossly edematous

• Majority are asymptomatic but some may have dysuria

Urethral Prolapse Therapy 2. hot sitz baths 3. antibiotics 4. topical estrogen cream 5. excision of the redundant mucosa – rarely done but may be necessary

Vulvar Cysts • Bartholin’s duct cyst is the most common of the large vulvar cysts • treatment is not necessary in women younger than 40 unless the cyst becomes infected or enlarges enough to produce symptoms

Vulvar Cysts • the most common small vulvar cysts are epidermal inclusion cysts or sebaceous cysts

Sebaceous Cysts • located immediately beneath the epidermis • mostly discovered on the anterior half of the labia majora • multiple, freely movable, round, slow growing, and nontender with firm consistency • grossly appear white or yellow with caseous contents on cut section • local scarring of the adjacent skin sometimes occurs when rupture of the contents of the cyst produces inflammatory reaction in the subcutaneous tissue.

Inclusion Cysts • develops when an infolding of squamous epithelium has occurred beneath the epidermis in the site of an episiotomy or obstetric laceration • When found in the vagina – most likely related to previous trauma

Inclusion Cysts • alternative theories of histogenesis – include embryonic remnants – occlusion of pilosebaceous ducts of sweat glands

• Treatment – usually none – If infected – local heat as well as incision and drainage – Recurrent cysts require excision.

Nevus • commonly referred to as a mole • a localized nest or cluster of melanocytes • arise from the embryonic neural crest and are present from birth • one of the most common benign neoplasms in females • generally asymptomatic

Nevus •

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Histologic groups: – junctional – compound – intradermal nevi 5% to 10% of all malignant melanomas in women arise from the vulva 50% of malignant melanomas arise from a preexisting nevus

Nevus • symptoms of an early malignancy include 1. asymmetry 2.border irregularity 3.color variegation 4. diameter usually greater than 6 mm (ABCD)

Nevus • • •

all flat vulvar nevi should be excised and examined histologically flat junctional nevus and dysplastic nevus have high malignant potential proper excisional biopsy should be three dimensional and adequate in width and depth – –

Approximately 5 -10 mm of normal skin surrounding the nevus should be included, the biopsy should include the underlying dermis as well

Hemangioma • • •

are rare malformations of blood vessels rather than true neoplasms. frequently discovered initially during childhood approximately 60% of vulvar hemangiomas spontaneously regress in size by the time the child goes to school

Hemangioma •

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appear histologically as predominantly thin-walled capillaries arranged randomly and separated by thin connective tissue septa. most are asymptomatic may occasionally become ulcerated and bleed

Fibroma • • • • • • •

most common benign solid tumor of the vulva commonly found in the labia majora occur in all age groups have smooth surface and distinct contour with low grade potential for becoming malignant smaller fibromas are asymptomatic large tumors may produce chronic pressure symptoms or acute pain • treatment - operative removal if the fibromas are symptomatic and/or continue to grow

Lipoma • benign, slow growing, circumscribed tumors of fat cells arising from the subcutaneous tissue of the vulva. • second most frequent benign vulvar mesenchymal tumor • most lipomas are discovered in the labia majora and are superficial in location • malignant potential is extremely low

Hidradenoma • benign vulvar tumor that originates from apocrine sweat glands of the inner surface of the labia majora and nearby perineum. • found in white women between 30 and 70 years of age. • asymptomatic but may cause pruritus or bleeding if the tumor undergoes necrosis • excisional biopsy is the treatment of choice

Endometriosis • • • •

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Rare in the vulva firm, small nodule or nodules varies from a few millimeters to several centimeters in diameter found at the site of an old, healed obstetric laceration, episiotomy site, an area of operative removal of a Bartholin’s cyst, or along the canal of Nuck Pathophysiology – secondary to metaplasia – retrograde lymphatic spread, or – potential implantation of endometrial tissue during operation

Endometriosis • commonly present with introital pain and dyspareunia • classic history - cyclic discomfort and enlargement of the mass during menses • Treatment – wide excision or laser vaporization depending on the size of the mass

• Recurrence after treatment are common

Hematoma

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usually secondary to blunt trauma - (straddle injury) spontaneous hematomas are rare and usually occur from rupture of a varicose vein during pregnancy or the postpartum period

Hematoma • Management – usually conservative unless the hematoma is greater than 10 cm in diameter or is rapidly expanding – direct pressure may be applied to control the bleeding – compression and application of an ice pack to the area – Identification and ligation of bleeders if the hematoma continues to expand

Dermatologic Lesions • skin of the vulva is susceptible to any generalized skin disease or involvement by systemic disease. • most common skin diseases include – – – – – –

contact dermatitis neurodermatitis Psoriasis seborrheic dermatitis cutaneuos candidiasis lichen planus

Dermatologic Lesions

• majority are scalelike rashes and usually presents with pruritus • diagnosis and treatment are often obscured or modified by the environment of the vulva

Vulvar Edema • may be a symptom of either local or generalized disease • Most common causes: – secondary reaction to inflammation – lymphatic blockage

Benign Lesions of the Vagina

Urethral Diverticulum • • •

a saclike projection arising from the posterior urethra often present as a mass of the anterior vaginal wall symptoms are identical to lower genital tract infection

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Diagnosis: voiding cystourethrograph cystourethroscopy. Other diagnostic tests: urethral pressure profile recordings, vaginal ultrasound, positive-pressure urethrography and MRI

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Treatment: –

Excisional surgery in acute infection

Inclusion Cyst • most common cystic structures of the vagina • usually discovered in the posterior or lateral walls of the lower third of the vagina • common in parous women • often results from birth trauma or gynecologic surgery • majority are asymptomatic • if symptomatic, excisional biopsy is indicated

Tampon Problems • risks with its usage: – vaginal ulcers – toxic shock syndrome from toxins produced by Staphylococcus aureus

• associated with microscopic epithelial changes • the classic “forgotten” tampon presents with a foul vaginal discharge and occasional spotting • Treatment: antibiotic vaginal cream for the next 5 to 7 days

Local Trauma • Coitus is the most frequent etiology • most common injury is a transverse tear of the posterior fornix • Manifests with profuse or prolonged vaginal bleeding • Management: – prompt suturing under adequate anesthesia

Benign Lesions of the Cervix

Endocervical and Cervical Polyp • most common benign neoplastic growth of the cervix • Seen in multiparous women in their 40s and 50s • usually secondary to inflammation or due to abnormal focal responsiveness to hormonal stimulation

Endocervical and Cervical Polyp • Symptoms – classic symptom is intermenstrual bleeding – many are asymptomatic – recognized for the first time during a routine speculum examination

Endocervical and Cervical Polyp • Management – Polypectomy may be an office procedure – most can be managed by grasping the base of the polyp with an appropriately sized clamp. – The polyp is avulsed with a twisting motion and sent to the pathology for microscopic evaluation. – if bleeding ensues, the base may be treated with chemical cautery, electrocautery, or cryocautery

Nabothian Cysts • •

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so common that they are considered a normal feature of the adult cervix retention cysts of endocervical columnar cells occurring where a tunnel or cleft has been covered by squamous metaplasia. produced by the spontaneous healing process of the cervix asymptomatic treatment is not necessary

Cervical Lacerations • •

frequently occur with both normal and abnormal deliveries vary from minor superficial lacerations to extensive fullthickness lacerations

Management • Acutely bleeding cervical lacerations should be sutured • should be palpated to determine the extent of cephalad extension of the tear Complications • extensive cervical lacerations especially those involving the endocervical stroma may lead to incompetence of the cervix during a subsequent pregnancy

Cervical Myomas • smooth, firm masses similar to myomas of the fundus • most are small and asymptomatic • may become pedunculated and protrude through the external os of the cervix • diagnosis is by inspection and palpation management – – – –

similar to uterine myomas observation/ expectant management medical therapy with GnRH agonists myomectomy or hysterectomy

Cervical Stenosis • most often occurs in the region of the internal os • may be divided into congenital or acquired • causes of acquired cervical stenosis: – – – – –

Operative (i.e. cone biopsy, cautery) Radiation Infection Neoplasia atrophic changes

Cervical Stenosis Symptoms – in premenopausal women: dysmenorhea, pelvic pain, abnormal bleeding, amenorrhea and infertility – postmenopausal women are usually asymptomatic – diagnosis is established by inability to introduce a 1 to 2 mm dilator into the uterine cavity

Cervical Stenosis Management – dilation of the cervix with dilators – if stenosis recurs, monthly laminaria tents may be used – after a cervical dilation - a stent is left in the cervical canal for a few days to maintain patency. – Treatment success depends on the proper use of the laser and the quality and quantity of residual columnar epithelium remaining in the endocervix.

Benign Lesions of the Uterus

Endometrial Polyp

• localized overgrowths of endometrial glands and stroma that project beyond the surface of the endometrium • most arise from the fundus of the uterus • may vary from a few millimeters to several centimeters in diameter • may have a broad base or be attached by a slender pedicle.

Endometrial Polyp • peak incidence between ages 40 and 49 • etiology is unknown • often associated with endometrial hyperplasia – unopposed estrogen may be the cause – May be associated with chronic administration of tamoxifen

• majority are asymptomatic • those that are symptomatic are associated with a wide range of abnormal bleeding patterns.

Endometrial Polyp Components 1. endometrial glands 2. endometrial stroma 3. central vascular channels

Endometrial Polyp • malignant transformation has been estimated to be as high as 0.5% • Diagnosis: – Hydrosonography – hysteroscopy and/or hysterosalpingography

• management - removal by curettage or via the hysteroscope.

Leiomyoma • benign tumors of muscle cell origin • often referred to as fibroids or myomas • most frequent tumors of the pelvis • highest prevalence occurring during the fifth decade of a woman’s life • majority are found in the corpus of the uterus

Leiomyoma • classified into subgroups by their relative anatomic relationship and position to the layers of the uterus. • 3 most common types a.intramural b.subserous c.submucous

Leiomyoma • submucosal tumors – associated with abnormal vaginal bleeding or distortion of the uterine cavity that may produce infertility or abortion

• subserosal myomas give the uterus its knobby contour during pelvic examination • parasitic myoma - myoma that outgrows its blood supply and obtains a secondary blood supply from another organ • broad ligament myoma – results from lateral growth of myoma

Leiomyoma Etiology • each tumor results from an original single muscle cell (monoclonal theory) • somatic mutation of normal myometrium to leiomyomas influenced by estrogen and progesterone and local growth factors

Leiomyoma • rare before menarche • most diminish in size following menopause with the reduction of a significant amount of circulating estrogen. • often enlarge during pregnancy and occasionally enlarge secondary to oral contraceptive therapy • lower incidence among smokers • -however, the relationship between estrogen and progesterone levels and myoma growth is complex

Leiomyoma pathology • grossly, has a lighter color than the normal myometrium • on cut surface it has a glistening, pearlwhite appearance, with the smooth muscle arranged in a trabeculated or whorled configuration • histologically there is a proliferation of mature smooth muscle cells; the nonstriated muscle fibers are arranged interlacing bundles.

Leiomyoma Types of Degeneration 2. Hyaline 3. Myxomatous 4. Calcific 5. Cystic 6. Fatty 7. Red degeneration •

occurs in pregnancy in 5% to 10% of gravid women with myomas – medically treated during pregnancy, otherwise, myomectomy is done

• •

Necrosis Malignant - 0.3% and 0.7%

Leiomyoma symptoms • most common are pressure from an enlarging pelvic mass, pain and abnormal uterine bleeding • severity of symptoms is usually related to the number, location, and size of the myomas • majority are asymptomatic • rapid growth after menopause is a disturbing symptom

Leiomyoma diagnosis 1. pelvic examination 2. Ultrasound

management • if small, symptomatic, judicious observation is made • at first discovery, a pelvic examination at 6 month intervals to determine the rate of growth should be done • women with abnormal bleeding and leiomyomas should be investigated thoroughly for concurrent problems such as endomterial hyperplasia • surgery when persistently symptomatic

Leiomyoma Medical Management • Medical treatment involves reduction in the size of the myoma by reducing the level of estrogen and progesterone • e.g.GnRh agonists Advantages • Facilitate easier surgery • induction of amenorrhea Disadvantages 10. delay in final tissue diagnosis 11. degeneration of some leiomyomas, necessitating piece-meal enucleation at myomectomy 12. hypoestrogenic side effects (e.g. trabecular bone loss, vasomotor flushes) 13. cost 14. need to self-administer or receive injections in many cases

Leiomyoma Surgical Management Indications for Surgery 4. rapidly expanding pelvic mass 5. persistent abnormal bleeding 6. pain or pressure 7. enlargement of an asymptomatic myoma to more than 8 cm in a woman who has not yet completed child bearing Contraindications to Surgery 10. pregnancy 11. advanced adnexal disease 12. malignancy

Leiomyoma Transcatheter uterine artery embolization • newest modality in managing uterine myomas • multiple embolic materials have been used including gelatin sponge, silicon spheres, metal coils, and polyvinyl alcohol particles of various diamters • postprocedural abdominal and pelvic pain is common for the first 24 hours • success rates in regard to decreasing menorrhagia and reduction in uterine size are promising

Adenomyosis • growth of glands and stroma into the uterine myometrium to a depth of at least 2.5 mm from the basalis layer • sometimes known as internal endometriosis • pathogenesis remains unknown.

Adenomyosis Pathology 2. diffuse involvement of the anterior and the posterior alls of the uterus, with the posterior being more often involved 3. there is a focal area of the lesion adenomyoma. • results in a asymmetric uterus where there is usually a pseudocapsule. Criteria for diagnosis – a finding of inactive or proliferative glands, more than one low power field (2.5 mm) from the basalis layer of the endometrium.

Adenomyosis Diagnosis • majority of women are asymptomatic • May present with secondary dysmennorhea and menorrhagia. severity of symptoms increases proportionally with depth of invasion and penetration. • Usually presents with uterine enlargement palpated through pelvic examination • Ultrasound and MRI are helpful in diagnosis.

Adenomyosis Treatment • no satisfactory proven medical treatment for adenomyosis. • Hysterectomy is the definitive treatment

Benign Lesions of the Fallopian Tubes

Adenomatoid Tumors • most prevalent benign tumor of the oviduct • small,gray-white, circumbscribed nodules, 1 to 2 cm in diameter • usually unilateral • asymptomatic • do not become malignant but may be mistaken for low-grade neoplasm

Paratubal Cysts

• Diagnosis is incidental • often multiple and may vary from 0.5 cm to more than 20 cm in diameter • when pedunculated and near the fimbrial end of the oviduct hydatid cysts of Morgagni • treatment is simple excision • Complications: torsion

Torsion • rare event however has been reported with both normal and pathologic fallopian tubes • pregnancy predisposes to this problem • usually accompanies torsion of the ovary in 50-60% of cases • right tube more frequently involved than the left • presents with acute lower abdominal and pelvic pain Management • exploratory operation • with a minor degree of torsion, it is possible to restore normal circulation to the tube and salvage it

Benign Lesions of the Ovaries

Follicular Cysts •

most frequent cystic structure in normal ovaries arises from temporary variation of a normal physiologic process may result from either

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the dominant mature follicle’s failing to rupture (persistent follicle) or an immature follicle’s failing to undergo the normal process of atresia.

most commonly found in young, menstruating women

Follicular Cysts • • •

majority are asymptomatic May be discovered during ultrasound imaging of the pelvis or a routine pelvic examination May also present with signs and symptoms of ovarian enlargement and therefore must be differentiated from a true ovarian neoplasm

Management • Conservative observation • majority disappear spontaneously by either reabsorption of the cyst fluid or silent rupture within 4 to 8 weeks on initial diagnosis • persistent ovarian mass necessitates operative intervention to differentiate it from a true neoplasm of the ovary • cystectomy and oophorectomy

Corpus Luteum Cyst • • •

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less common than follicular cysts, but clinically more important minimum of 3 cm in diameter may be associated with either normal endocrine function or prolonged secretion of progesterone. associated menstrual pattern may be normal, delayed menstruation or amenorrhea vary from being asymptomatic to those causing catastrophic and massive intraperitoneal bleeding with rupture.

Corpus Luteum Cyst Differential Diagnosis 1. ectopic pregnancy 2. ruptured endometrioma 3. adnexal torsion

Management • Conservative if unruptured • With persistent bleeding - treatment is cystectomy.

Theca Lutein Cysts • least common of the three types of physiologic ovarian cysts • almost always bilateral and produce moderate to massive enlargement of the ovaries • arise from either prolonged or excessive stimulation of the ovaries by endogenous or exogenous gonadotrophins • Seen in 50% of molar pregnancies and 10% of choriocarcinoma • also discovered in the latter months of pregnancies often with conditions that produce a large placenta, such as twins, diabetes and Rh sensitization

Theca Lutein Cysts • hyperreactio luteinalis – is the condition of ovarian enlargement secondary to the development of multiple luteinized follicular cysts.

• Luteoma of pregnancy – not a true neoplasm but rather a specific, benign, hyperplastic reaction of ovarian theca lutein cells

Theca Lutein Cysts

• produce vague symptoms, such as pressure in the pelvis • presence is established by palpation and often confirmed by ultrasound examination • treatment is conservative

Dermoid Cyst • Benign cystic teratoma • most common ovarian neoplasm in prepubertal females and in teenagers • vary from a few millimeters to 25 cm in diameter, may be single or multiple • usually discovered either in the cul-de-sac or anterior to the broad ligament

Dermoid Cyst

• composed of mature cells, usually, from all three germ layers • most solid elements arise are contained in a protrusion or nipple (mamila) in the cyst wall termed the prominence or tubercle of Rokitansky

Dermoid Cyst • adult thyroid tissue is discovered microscopically in approximately 12% of benign teratomas • Struma ovarii – teratoma in which the thyroid tissue has overgrown other elements and is the predominant tissue

Dermoid Cyst • • •

presenting symptoms include pain, sensation of pelvic pressure 50% to 60% are asymptomatic Some are discovered during a routine pelvic examination, coincidentally visualized by an abdominal x-ray or ultrasound examination

management • cystectomy with preservation of as much normal ovarian tissue as possible Complications 1. Torsion 2. Rupture 3. Infection 4. Hemorrhage 5. malignant degeneration

Endometrioma • areas of ovarian endometriosis that become cystic • usually associated with endometriosis in other areas of the pelvic cavity • large chocolate cysts of the ovary may reach 15 to 20 cm

Endometrioma • the most common symptoms associated 1. pelvic pain 2. Dyspareunia 3. infertility

• Tender and immobile ovaries on pelvic examination – dense adhesions on surrounding structures is a common finding

Endometrioma management • the choice of management depends on: 1. patient’s age 2. future reproductive plans 3. severity of symptoms

• medical therapy is rarely successful in treating ovarian endometriosis • surgical therapy is complicated by formation of de novo and recurrent adhesions

Fibroma • •

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the most common benign, solid neoplasm of the ovary comprise approximately 5% of benign ovarian neoplasms and approximately 20% of all solid tumors of the ovary arises from undifferentiated fibrous stroma of the ovary commonly presents in postmenopausal women malignant potential is low, less than 1%

Fibroma • •

Manifest with pressure symptoms and abdominal enlargement Meigs’ syndrome – the association of an ovarian fibroma, ascites and hydrothorax – both resolve after the removal of an ovarian tumor

management • Exploratory operation • in postmenopausal women, often a bilateral salpingooophorectomy and total abdominal hysterectomy are performed

Cystadenoma •

• • •

the epithelial element is most commonly serous, but histologically may be mucinous and endometrioid or clear cell are usually small tumors that arise from the surface of the ovary bilateral in 20% to 25% of women usually occur in postmenopausal women

Cystadenoma • •

smaller tumors are asymptomatic or pelvic operations. large tumors may cause pressure symptoms, rarely adnexal torsion.

Management • postmenopausal women: bilateral salpingooophorectomy and total abdominal hysterectomy • in younger women: simple excision of the tumor and inspection of the contralateral ovary is appropriate

Torsion • • • •

a complication of benign ovarian tumors in the postmenopausal woman important cause of acute lower abdominal and pelvic pain commonly affects both fallopian tube and ovaries pregnancy appears to predispose women to adnexal torsion

Symptoms • Acute abdominal and pelvic pain • nausea and vomiting • fever

Torsion management • conservative operation for young women – laparoscope or via laparotomy

• with severe vascular compromise unilateral salpingo-oophorectomy

Endometriosis • •

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a benign disease but a progressive one the presence or growth of the glands and stroma of the lining of the uterus in an aberrant or heterotopic location – Aberrant endometrial tissue grows under the cyclic influence of ovarian hormones mid 30s, nulliparous and involuntarily infertile with symptoms of secondary dysmenorrhea and pelvic pain

Etiology of Endometriosis •

RETROGRADE MENSTRUATION – pelvic endometriosis is secondary to implantation of endometrial cells shed during menstruation

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METAPLASIA – arises from the metaplasia of coelomic epithelium or proliferation of embryonic rests.

4. LYMPHATIC AND VASCULAR METASTASIS – endometrial tissue is transplanted via lymphatic pathways and the vascular system.

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IATROGENIC DISSEMINATION IMMUNOLOGIC CHANGES – the altered function of the immune-related cells are directly involved on the pathogenesis of endometriosis

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GENETIC PREDISPOSITION

Endometriosis PATHOLOGY • ovaries are the most common site • grossly exhibit wide variation in color, shape, size and associated inflammatory and fibrotic changes. •

cardinal histological features 1. ectopic endometrial glands 2. ectopic endometrial stroma 3. hemorrhage into the adjacent tissue.

Endometriosis Signs and Symptoms – Classic symptoms include cyclic pelvic pain and infertility. – Pelvic pain is often inversely proportional to the amount of endometriosis. – cyclic pelvic pain is related to the sequential swelling and the extravasations of blood and menstrual debris in to the surrounding tissue and mediated by prostaglandins and cytokines – Dyspareunia – GI and urinary symptoms – catamenial hemothorax and massive ascites - rare – classic pelvic findings of a retroverted uterus with scarring and tenderness posterior to the uterus

Endometriosis Diagnosis 2. Ultrasound 3. Laparoscopy

Endometriosis Goals of Management 2. relief of pain 3. promotion of fertility • Primary long term goal in management is to prevent progression of the disease process

Endometriosis Medical Management – primary goal of hormonal treatment is induction of amenorhea. – DOES NOT provide a long lasting cure of the disease

Endometriosis Medications for Endometriosis • Danazol • GnRH Agonists* • Oral contraceptives • Medroxyprogesterone acetate (DMPA)

Endometriosis SURGICAL THERAPY • • • •

Often occurs concurrently during laparoscopy to establish diagnosis only option after failed medical treatment for women who have moderate to severe endometriosis Conservative surgery has as its goal the removal of macroscopic visible areas of endometriosis with preservation of fertility.

Types of Surgical Therapy Used 9. laparoscopy 10.laser 11.Total hysterectomy with ovarian preservation 12.total abdominal hysterectomy with bilateral salpingo oophorectomy .

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