Fallopian tubes

The most common disorders in these structures are infections leading to inflammatory conditions, followed in frequency by ectopic (tubal) pregnancy (see discussion later in this chapter) and endometriosis.

Inflammations

Suppurative salpingitis may be caused by any of the pyogenic organisms; often more than one is involved. The gonococcus still accounts for more than 60% of cases of suppurative salpingitis, with chlamydiae less often a factor. These tubal infections are a part of pelvic inflammatory disease, described earlier in this chapter.

Tuberculous salpingitis is extremely uncommon in the United States and accounts for probably not more than 1% to 2% of all forms of salpingitis. It is more common, however, in parts of the world where tuberculosis is prevalent and is an important cause of infertility in these areas.

Tumors and Cysts

The most common primary lesions of the fallopian tube (excluding endometriosis) are minute, 0.1- to 2-cm translucent cysts filled with clear serous fluid, called paratubal cysts. Larger varieties are found near the fimbriated end of the tube or in the broad ligaments and are referred to as hydatids of Morgagni. These cysts are presumed to arise in remnants of the müllerian duct and are of little significance.

Tumors of the fallopian tube are uncommon. Benign tumors include adenomatoid tumors (mesotheliomas), which occur subserosally on the tube or sometimes in the mesosalpinx. These small nodules are the exact counterparts of those already described in relation to the testes or epididymus (Chapter 21) and are benign. Primary adenocarcinoma of the fallopian tubes is rare and is defined as an adenocarcinoma with a dominant tubal mass and luminal and mucosal involvement. These tumors are detected by pelvic examination, abnormal discharge, or bleeding, and occasionally, cervical cytology. Approximately one half are stage I at diagnosis, but nearly 40% of these patients do not survive 5 years. Higher stage tumors have a poorer prognosis.70 Patients are typically managed with ovarian cancer chemotherapy protocols. Recently, occult carcinoma of the fallopian tube has been associated with germline BRCA mutations, as discussed below.

Ovaries

The most common types of lesions encountered in the ovary include functional or benign cysts and tumors. Intrinsic inflammations of the ovary (oophoritis) are uncommon, and usually accompany tubal inflammation. Rarely, a primary inflammatory disorder involving ovarian follicles (autoimmune oophoritis) occurs and is associated with infertility. The ovary has three main histologic compartments: (1) the surface müllerian epithelium, (2) the germ cells, and (3) the sex cord-stromal cells. Each compartment gives rise to distinct non-neoplastic and neoplastic entities, as discussed below.

Non-Neoplastic and Functional Cysts

Follicle and luteal cysts

Cystic follicles in the ovary are so common that they are considered virtually normal. They originate in unruptured graafian follicles or in follicles that have ruptured and immediately sealed.

Morphology. These cysts are usually multiple. They range in size up to 2 cm in diameter, are filled with a clear serous fluid, and are lined by a gray, glistening membrane. On occasion, larger cysts exceeding 2 cm (follicle cysts) may be diagnosed by palpation or ultrasonography; these may cause pelvic pain. Granulosa lining cells can be identified histologically if the intraluminal pressure has not been too great. The outer theca cells may be conspicuous due to increased amounts of pale cytoplasm (luteinized). As discussed subsequently, when this alteration is pronounced (hyperthecosis), it may be associated with increased estrogen production and endometrial abnormalities.

Granulosa luteal cysts (corpora lutea) are normally present in the ovary. These cysts are lined by a rim of bright yellow tissue containing luteinized granulosa cells. They occasionally rupture and cause a peritoneal reaction. Sometimes the combination of old hemorrhage and fibrosis may make their distinction from endometriotic cysts difficult.