This topic covers three common benign lesions: Bartholin gland cysts and abscesses, uterine fibroids (leiomyomas), and endometrial polyps. Benign ovarian tumors are covered with ovarian tumors.

Bartholin gland cyst and abscess

• The paired Bartholin glands lie at about the 4 and 8 o'clock positions of the vaginal opening and lubricate the vestibule. Blockage of the duct produces a cyst; infection of the cyst produces an abscess.
• Abscesses are usually polymicrobial (skin and vaginal flora, anaerobes, E. coli); Neisseria gonorrhoeae and Chlamydia trachomatis are occasional causes.
• A new, firm, fixed, or painless mass in a woman 40 years or older, or one that keeps recurring, needs biopsy to exclude Bartholin gland carcinoma (rare).

Uterine fibroids (leiomyomas)

• Benign smooth-muscle tumors of the myometrium — the most common pelvic tumor in women. Estrogen- and progesterone-dependent: they grow during the reproductive years and pregnancy and usually shrink after menopause.
• Risk factors: increasing age in the reproductive years, Black race (earlier onset, more and larger fibroids), family history, early menarche, obesity, nulliparity. Parity and hormonal contraception are associated with lower risk.
• Malignant transformation to leiomyosarcoma is rare; a fibroid that grows after menopause needs evaluation.

• Degeneration (especially red degeneration in pregnancy) causes acute pain, low-grade fever, and tenderness when the fibroid outgrows its blood supply.

Endometrial polyps

• Localized overgrowths of endometrial glands and stroma projecting into the uterine cavity; linked to estrogen exposure (obesity, tamoxifen, anovulation).
• Usually benign; risk of malignancy is higher after menopause, especially with postmenopausal bleeding.
• Unlike fibroids (which arise from muscle), polyps arise from the endometrial lining.

Bartholin cyst/abscess

• Cyst: painless or mildly uncomfortable swelling at the lower, posterior labium majus; discomfort with walking, sitting, or intercourse
• Abscess: acute, severe pain, a hot, red, tender, fluctuant mass; possible fever
• Check temperature and signs of spreading cellulitis or sepsis

Fibroids

• Often asymptomatic; heavy menstrual bleeding with clots, prolonged periods, dysmenorrhea
• Pelvic pressure, urinary frequency, constipation, low back pain radiating to the legs
• Enlarged, irregular, firm uterus on bimanual exam; abdominal mass if large
• Signs of anemia: fatigue, pallor, tachycardia, dizziness
• Ask how many pads or tampons are soaked per day and how often — objective measure of blood loss

Endometrial polyps

• Abnormal uterine bleeding — intermenstrual spotting, heavy menses, postmenopausal bleeding; sometimes infertility; often found incidentally

• Pregnancy test in reproductive-age clients with bleeding or a pelvic mass
• CBC (anemia), ferritin; type and screen before surgery
• Transvaginal ultrasound — first-line imaging for fibroids and polyps
• Saline infusion sonohysterography or hysteroscopy — best to outline lesions inside the cavity (submucosal fibroids, polyps)
• MRI — maps fibroids before myomectomy or embolization and helps distinguish fibroids (well-circumscribed) from adenomyosis (diffuse, ill-defined)
• Endometrial biopsy — AUB in clients 45 or older, or with unopposed estrogen risk; any postmenopausal bleeding
• Bartholin abscess: clinical diagnosis; NAAT for gonorrhea and chlamydia when STI risk exists; culture of pus if recurrent or complicated; biopsy of a solid or persistent mass in women 40 and older

Bartholin cyst/abscess

• Small asymptomatic cyst: no treatment; warm sitz baths several times daily may promote drainage
• Abscess: incision and drainage with placement of a Word catheter (small balloon catheter) left in place for about 4–6 weeks so a permanent drainage tract epithelializes — simple incision alone often recurs
• Marsupialization (suturing the cyst wall edges open) for recurrence; excision of the gland for repeated recurrence or suspected malignancy (more bleeding and pain)
• Antibiotics are not routinely needed after adequate drainage; they are given for surrounding cellulitis, systemic signs, recurrent abscess, immunosuppression, or a positive STI test (treat per CDC regimens; partners treated for STIs)

Fibroids

Procedures

• Myomectomy (hysteroscopic, laparoscopic, or abdominal) — removes fibroids and preserves the uterus and fertility; fibroids can recur; a cesarean birth may be advised after deep myometrial incisions
• Uterine artery embolization (UAE) — interventional radiology blocks fibroid blood supply through a femoral or radial artery catheter; not preferred when future pregnancy is desired
• Radiofrequency ablation, MRI-guided focused ultrasound
• Hysterectomy — definitive; ends fertility
• Morcellation (cutting tissue into pieces for minimally invasive removal) carries a risk of spreading an unsuspected uterine sarcoma — the FDA advises contained morcellation and careful selection

Endometrial polyps — hysteroscopic polypectomy is the standard treatment; small asymptomatic polyps in premenopausal women may be observed; all removed polyps go for pathology.

Listed in priority order.

1. Assess for hemorrhage and anemia — vital signs, orthostatic changes, pad count, hemoglobin; safety first with anemia: rise slowly to prevent syncope
2. Assess for infection and sepsis with Bartholin abscess — temperature, heart rate, blood pressure, spreading redness. Sepsis presents with fever or hypothermia, tachycardia, tachypnea, hypotension, and altered mental status
3. Post-procedure care
   • After UAE: check the arterial puncture site for bleeding or hematoma and the distal pulses, color, and temperature of the limb; keep the leg straight or wrist immobilized per protocol; expect post-embolization syndrome (cramping pain, nausea, low-grade fever) — give scheduled analgesia and antiemetics
   • After hysteroscopy or polypectomy: monitor bleeding and pain; report heavy bleeding, severe or increasing pain, or fever (possible uterine perforation, fluid overload from distension media, or infection)
   • After Word catheter or marsupialization: confirm the catheter is in place; perineal hygiene; sitz baths as ordered
   • After myomectomy or hysterectomy: standard postoperative care — pain, bleeding, early ambulation, VTE prophylaxis, urinary output
4. Pre-procedure: confirm NPO status, consent, pregnancy test, allergies, and anticoagulant or antiplatelet use
5. Pain management — NSAIDs, heat, positioning; acetaminophen when bleeding risk is a concern
6. Iron therapy — give correctly; monitor response
7. Emotional support — decisions about fertility, body image, and hysterectomy; present all treatment options

• Iron: take on an empty stomach with vitamin C if tolerated (with food if GI upset); not with milk, calcium, antacids, tea, or coffee; expect dark stools
• GnRH agonists: hot flashes and vaginal dryness are expected and reversible; take calcium and vitamin D; use nonhormonal contraception; do not massage the injection site of depot products
• Word catheter: it stays about 4–6 weeks and may fall out on its own; sitz baths as instructed; intercourse is usually avoided while the catheter is in place; report fever, increasing pain, or swelling
• After hysteroscopy: mild cramping and light bleeding or discharge for several days are expected; no tampons, douching, or intercourse for about 2 weeks or as instructed; use acetaminophen or prescribed analgesics — avoid aspirin unless prescribed, since it increases bleeding
• After UAE: pain peaks in the first days; report fever, foul discharge, or severe pain (infection or fibroid expulsion); avoid heavy lifting for a few days
• After myomectomy: avoid heavy lifting and strenuous exercise for about 4–6 weeks (abdominal approach); the first menstrual period may be heavier or more painful; discuss timing of pregnancy and mode of birth with the surgeon
• When to seek care: soaking one pad per hour for 2 hours, passing large clots, fainting, fever, or foul-smelling discharge
• Postmenopausal women: any bleeding must be reported — it is never "just a period"

• Bartholin abscess: severe pain, hot tender mass — check temperature; treat with I&D plus Word catheter (4–6 weeks)
• Recurrent Bartholin cyst → marsupialization; repeated recurrence or suspicious mass → excision
• Solid, fixed Bartholin mass at 40 or older → biopsy for carcinoma
• Fibroids = benign, hormone-dependent smooth-muscle tumors; shrink after menopause
• Submucosal fibroids → heavy bleeding and anemia; subserosal → pressure symptoms
• Assess heavy bleeding with pad counts and vital signs; rise slowly with anemia
• GnRH agonists: temporary shrinkage before surgery; hot flashes and bone loss; not permanent
• Myomectomy preserves fertility; hysterectomy is definitive
• After UAE: check puncture site and distal pulses; expect post-embolization pain
• MRI distinguishes fibroids (well-defined) from adenomyosis (diffuse)
• Endometrial polyp: AUB is the main symptom; TVUS first; hysteroscopic polypectomy; malignancy risk higher after menopause
• Avoid aspirin after gynecologic procedures unless prescribed