Thursday, March 11, 2010

Cystectomy For Grapefruit Size Dermoid Cyst On Ovary


Question:

Hello, I'm writing from Nevada. I went in for an appointment with my MD a few weeks ago after trying to conceive for 1 year. While I was there he did a pap and routine exam as well. In the exam he found my uterus was small or off to the side a bit and wanted me to have an ultra-sound done. When we did this they found a grapefruit-sized dermoid cyst in my left ovary. We're planning on having it surgically removed but I have a few questions.

1. With the size of the cyst is there any chance of keeping a portion of my ovary?

2. If it MUST be removed, is there any possibility of saving my eggs?

3. With a cyst of this size is it wise to do the procedure laparoscopically or should it be done with one large incision?

I have no issue with work and recovery time, I just want it done in the safest way to keep my ovary if possible. I do have another appointment with my MD to discuss this information, just looking for some suggestions or input. Thank you.

Answer:

Hello K. from Nevada,

A skilled gynecologist will usually remove the Dermoid cyst without sacrificing the ovary. Make sure that your's will do that. The procedure is called a cystectomy. There is no reason the ovary should be removed.

The technology for preserving eggs certainly exists, although the pregnancy rates are not as good. However, we do recommend this in women that have cancer since they would otherwise lose the option of getting pregnant with their own eggs. This will have to be done in an IVF center, and must be done BEFORE the surgery, not during or after. The ovary has to be stimulated to grow the eggs so that they can be removed and frozen.

The cystectomy procedure should also be done by a method called laparoscopy, using a scope and small incisions. I do this procedure all the time. If your doc can't do it laparoscopically, then find one that can. This is the best method to preserve your ovary and cause minimal damage so that your fertility is not compromised. Try not to have an open (laparotomy) procedure if you can.

I hope this helps,

Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program

58 comments:

  1. This is a very good and healthy post i think. Good to write and share about. Have a great writing and have a great readership. Thanks...

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  2. Hi, I'm from the UK and my problem is similar to K from Nevada. I am not sure how to actually post a proper blog, sorry! My question is, I have a cyst 10 x 9 x 9 centimetres that looks dermoid by ultrasound. I really want a cystectomy rather than an oophorectomy but because I am 50, they say the risk of ovarian cancer means they are not willing to do this. In fact, they wanted to remove both my ovaries and I refused. My original consultant (who is quite a distance from here) had said he would be willing to do a cystectomy, but if there was any spill and any chance of malignancy, I would have to start chemo. I have read that the chances of malignancy are 2% but was led to believe this was much higher by the last two consultants I have been sent to. My reasons for keeping the ovary is 1) to maintain some oestrogen in the body after menopause (I am not menopausal and do not have any major symptoms) and 2) because I am a completist and want to have both ovaries for symmetry (the opposite of body dysmorphia??) which is a bit paranoid but it is really what I would like. I accept oophorectomy as a last resort but feel like I am being railroaded into a situation which I think could be salvageable. Please help!
    Debs
    ps, I bet the US Open was fantastic, was it?

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  3. Hi Debs,

    I don't necessarily see a need to remove both ovaries as long as the opposite ovary is normal. Yes, you probably have a few months to years of ovarian function for natural hormone production, but you are probably going to enter into menopause somewhat soon. In women over 48 years old with an ovarian tumor, it is standard practice to counsel to remove both ovaries if one is diseased. Ovarian cancer is a deadly cancer and often not diagnosed until too late. That is why the treatment is more aggressive.

    Dermoid tumors in general are benign and the chances of a malignancy within are very small. A cytectomy is usually adequate for this tumor and the ovary does not have to be removed. But one has to individualize treatment and come to a mutuallly acceptable decision. If you are absolutely keen on keeping your ovary, and willing to take the risk of a malignancy in that ovary, then your doctor should be willing to work with you and do a cystectomy. If the pathology returns showing a malignancy, even if the whole ovary were removed, they would still have to proceed in the same way with additional surgery to remove the remaining ovary and uterus, and radiation or chemotherapy.

    I hope this helps.

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  4. Hello,

    I live in rural Montana and had two large dermoid cysts removed from each of my ovaries via laparotomy about a year and a half ago. My doctor told me a laparotomy was necessary due to the size of the dermoids (one the size of a orange and the other described as a pie tin after it was removed). I was 25 at the time and was very aware that I wanted to have children in the future. My doctor told me not to worry and I should still ovulate as long as they did not have to remove the ovaries. After the surgery he did say I may have difficulty due to scarring because it was a "major surgery." After reading this post I am worried that my fertility may be effected and I have now been trying to get pregnant for four months. I know there is nothing I can do about it now but I am wondering if I am just spinning my wheels in hoping to get pregnant without seeing a specialist. Any advice would be greatly appreciated!

    Thank you!
    E

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  5. Hello E,

    Certainly having had a laparotomy (open surgery) and surgery on your ovaries signficantly increases your risk for having scar tissue (adhesions) around the ovaries, tubes and pelvis. However, this is not 100%. Some patients do not form scar tissue so I wouldn't jumpt to any conclusions as yet. Keep in mind that the average woman under 30 years old will take 8-12 months to get pregnant. So, you have not been trying long enough yet. It may still come on its own. If you are unable to get pregnant after one year of trying, then it would be prudent to see a fertility specialist and undergo an evaluation. Again, I wouldn't jump to the conclusion that scar tissue is the problem, but I would certainly advise a laparoscopy to check, in addition to the rest of the infertility evaluation.

    Good luck,

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  6. Hi Dr. Ramirez,

    I am a 52 year old woman with a 3cm dermoid on my left ovary. My Dr. wants to take the ovary along with the cyst, but I am afraid of getting heart disease which they now say is more likely with the removal of an ovary? Do you agree with my Dr? Or should I go somewhere where they will just take the cyst? Thank you in advance.

    ReplyDelete
  7. Hello,

    There is some more specific information that I need in order to give you a more specific answer. But I will try to give you as much information as possible to consider.

    At 52 years old, you may already be menopausal. The increased risks of heart disease is not from the loss of an ovary but the lack of estrogen from having both ovaries removed. We know that estrogen is a vital hormone for a woman's body so we want her to have that natural hormone as long as possible. Once menopause occurs, estrogen then should be replaced as hormone replacement therapy. If only one ovary is being removed, you should have another ovary that will produce the estrogen unless it has already been removed in the past. If you are already menopausal, then either or both ovaries can be removed without any change in risks.

    If you were my patient, and either have a second ovary present (as most women normally do) or are menopausal, I would recommend to remove the entire ovary rather than do a cystectomy as it is a much easier, and therefore, safer procedure. If you were younger and wanted to preserve your fertility, then I would recommend a cystectomy ONLY. The main reason for this difference is because the ovary carries the eggs that are needed for achieve pregnancy and removal of the entire ovary will removed a large number of eggs, even though pregnancy can occur with only one ovary.

    I hope this answers your question.

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  8. Hi Dr.Ramirez,

    Thanks for answering my question so promptly. I am the "anonymous" (Margo) in the above post. (52 yrs old w/dermoid) My surgery is next week so I really appreciated your prompt reply!
    I stopped having periods a year and half ago. My other ovary is intact and she is not taking that one. I understand the lack of estrogen is why the heart disease goes up, but I was never offered estrogen replacement. I hear estrogen can up your chances of breast cancer, so that is scary also and I may have refused it, if offered. Also, she is taking my fallopian tube, which she said is often "standard"

    Thanks again,
    Margo

    ReplyDelete
  9. Hello Margo,

    It sounds like you have been menopausal for the last 1.5 years so removal of the ovary or ovaries is not a significant change.

    In terms of estrogen replacement, the studies that surprised everyone regarding HRT is a study conducted here in the U.S. called the Women's Health Initiative (WHI). It showed a non-statistically significant increase in breast cancer in women that were taking the drug Prempro which contained both Estradiol and medroxyprogesterone (a synthetic progesterone). However, in a group that took only Estrogen, there was NO increase in breast cancer. Another more recent analysis of the WHI data again confirmed an increased incidence of breast cancer in the Prempro users but not the estrogen only users. Also, prior studies did not show an increase in breast cancer in HRT users. Therefore, as you can see, it is NOT the estrogen that seems to be related to breast cancer, as everyone seems to think, but it is the progesterone component, medroxyprogesterone that may be the cullprit. The only reason you would have to take the progesterone is if the uterus is still intact in order to prevent the formation of endometrial cancer which can occur with unopposed estrogen leading to an overgrowth of endometrial tissue. But even then, at the low menopausal doses, that incidence is very very low and endometrial cancer is readily detected. In addition, no one has tested any other types of progesterone so one cannot extrapolate the WHI findings to all progesterones since only one type was used. Based on these facts, I readily encourage and advise my patients to take HRT.

    More recent studies have shown great benefit for heart disease protection, prevention of osteoporosis, skin health, brain health, emotional stability and vaginal lubrication and elasticity with HRT if it is started within the first 5 years from the onset of menopause. I would advise that you reconsider this. I personally believe that estrogen is an essential hormone for a woman's body, and helps to maintain some of her youthfulness.

    In terms of removing the tube, it is standard to remove the tube at the time of removal of the ovary since they are in close proximity and because it makes the surgery easier. Since fertility is not an issue, there is no reason to keep the tube intact.

    In my patients with an ovarian mass after menopause, I will often counsel them regarding the option of removing the opposite ovary and uterus as well. Again, the main reasoning is that you are past childbearing, and the ovaries are no longer functioning so these structures are not essential any more. In addition, the risk of ovarian or uterine cancers are removed, and you can take HRT of pure estrogen without taking the progesterone. It might be something you would want to discuss with your doctor.

    Good Luck.

    ReplyDelete
  10. Hi Dr. Ramirez,

    Thanks so much for clearing up the confusion of the HRT and breast cancer link. I will definitely talk to my Dr. about getting on that.

    More importantly, thanks for your following statement: "It sounds like you have been menopausal for the last 1.5 years so removal of the ovary or ovaries is not a significant change." My Dr had also told me the same thing, but I was feeling insecure about it because I have found several sights online that say our ovaries are beneficial to ward off heart disease and osteoporosis, all through life, even after menopause, due to the estrogen and other hormones they produce. Perhaps those sights were incorrect? Or perhaps it is up for debate. Or, like you said, HRT can help replace what we lose.

    Thanks again,
    Margo

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  11. PRIVATE:
    I am the above Margo, 52 year old postmenopausal woman having my ovary out due to a dermoid cyst. Well I had it out, and turns out it was not a dermoid cyst, it was a fibroma. Are the two often confused on an ultrasound? Seeing it was just a fibroma and not a dermoid, did I just unnecessarily have my ovary out? Or was there no way of telling it was a fibroma before surgery? Could we not have just kept on eye on it to make sure it didn't grow? Or would you have also counciled to have the ovary out if there is a fibroma on it?
    I am very scared and would appreciate any info. My email is margozeman@yahoo.com THANKYOU

    ReplyDelete
  12. Hello Margo,

    I would not have changed my recommendations and stand by what I recommended previously. Because there is no way to know what type of cyst or tumor it is until it is removed, and because you are menopausal, I still think it and the ovary needed to be removed. I don't think you made the wrong decision. Whenever we see a tumor in the ovaries in an older woman, we have to suspect ovarian cancer, and we can't rule that out by following the cyst. It has to be removed and examined pathologically.

    Good Luck,

    Edward J. Ramirez, M.D., FACOG
    Executive Medical Director
    The Fertility and Gynecology Center
    Monterey Bay IVF Program
    www.montereybayivf.com

    Monterey, California, U.S.A.

    for additional information check out my blog at http://womenshealthandfertility.blogspot.com check me out on twitter with me at @montereybayivf and facebook @montereybayivf

    ReplyDelete
  13. There is any connection between the occurrence of ovarian cysts as DERMOID and sudden fluctuations in the level of prolactin??? Nina,33,from Serbia,europe

    ReplyDelete
  14. Hello,

    Dermoid tumor, also known as teratomas, are made of of all the base cells that create all the tissues in our body. As a result, they have the potential to form any tissue including neural tissue, therefore have the potential to produce pituitary tissue that creates prolactin. However, this is very uncommon, maybe even a rare finding, and I would suspect the usual cause of elevated prolactin before suspecting a Dermoid. The most common cause of elevated prolactin is increased tissue in the pituitary from a micro-tumor or a visible larger tumor.

    Good Luck

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  15. I was not clear ... after discontinuation of therapy, bromocriptine, appeared to me dermoid ovarian cyst.I wonder if it is possible that the premature termination of therapy may cause the appearance of dermoidne cysts? Thank YOU,Nina,Europe

    ReplyDelete
  16. Hello Again,

    The elevated prolactin or discontinuation of the bromocriptine did not cause the formation of the Dermoid cyst. It was probably there already. It is a tumor you usually develop from birth.

    ReplyDelete
  17. Hello Doctor:

    Almost three years ago I had one ovary removed as it was completely surrounded by a dermoid teratoma, and part of my other ovary removed due to a dermoid teratoma on it(bilateral dermoid teratomas.) Now my most recent bloodwork shows that I have extremely high progesterone levels. My doctors asked me if I was taking progesterone. I am not. I have many of the symptoms associated with having high progesterone. My testosterone and estrogen/estrodial levels were normal. My thyroid levels were normal as well. Do you think this could mean a new dermoid on my remaining ovary is putting all of this progesterone in my system?

    ReplyDelete
  18. Hi,

    A Dermoid is rarely hormonally active, but because it by it's nature has all the cells that compose a person's body, if there were endocrine tissue in a Dermoid and it were producing progesterone, that could be a reason for an elevated progesterone. That, however, is not something that I would automatically expect. It would be the exception to the rule.

    I am curious as to know what your progesterone level is and why it is considered "elevated" as I don't think anyone has every made such a diagnosis.

    ReplyDelete
  19. Hi Doctor Ramirez,

    I have a history of PCOS. Never been overweight, but had acne problems and period problems. At 27 years old now, I came off Yasmin (birthcontrol) in February after 7 years, due to risk of stroke (migraines). For 5 months I was fine and then Aug/Sep/Oct my hormones went haywire. Felt depressed and down, had bad pms, stopped getting my periods again, and my acne came back mildly around my jawline even though i was on the antibiotic lymecycline. After the problems persisting I pursued it with a gynaecologyst and discovered i had a 7cm dermoid cyst on my left ovary and a small one on my right ovary. I had them both removed 2 weeks ago. Obviously i am in recovery healing, but in this second week my skin has got a little worse.

    Could my hormones be out of balance after the surgery and need a little time to sort out and calm down?

    I have lost a little weight after the surgery and have decided now to take agnus castus to help my hormones.

    is it normal after dermoid cyst removal for the hormones to take a couple of months to sort themselves out?

    very kind regards
    Natalie

    ReplyDelete
  20. Hi Natalie,

    The Dermoid was an incidental finding and not related to your hormonal problems. In general, Dermoids do not produce hormones although there are types that can if it contains endocrine tissue. The majority don't.

    You hormonal problems are attributable to PCOD and removal of the Dermoids did nothing for that. In all likelihood, you will return to the state that you were in before the surgery.

    Why did you stop the Yasmin? Were you diagnosed to be at increased risk of stroke because of a DVT or increased clotting disorder, or were you spooked by the ads on TV and newspaper articles? The risk with Yasmin is no more higher than the risk with any birth control pill. The advantage that Yasmin has over the other BCP's is that the progesterone type blocks the testosterone (male hormone) receptors, which are increased by PCOD. An alternative is their new low dose pills such as Yaz.

    Good Luck

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  21. Hi Dr Ramirez,

    Thank you for your reply.

    I stopped Yasmin, as I mentioned to the Doctor that I had had migraines, and suffered from the 'aura' every week. I actually haven't experienced one of these sine I have come off the pill.

    I'm wandering whether also the emergency contraceptive might have disrupted my hormones too. I took it 4 times within the first 5 month period and wondering whether that might have had an effect?

    I will look in Yas...

    My symptoms are slightly different to before going on the pill. The acne is now confined to the jaw line and much milder, but still no period since july!!

    Have you heard of the herb agnus castus?

    thanks
    Natalie

    ReplyDelete
  22. Hi

    I have not heard of that herb. Since I am not a naturopathic or Eastern medicine specailist, I'm afraid my knowledge of herbal medicine is very limited.

    Hopefully the Yaz will give you less side effects since it is a much lower dosage of hormone.

    Good Luck.

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  23. HI DR RAMIREZ,I have HPV 52.Tell me what what to do? how much risk HPV 52? whether cervical conization necessary? thanks,Maja,europe

    ReplyDelete
  24. Hello Maja,

    There are many different types of the HPV virus and some are known to be associated with cancers such as cervical cancer, oropharyngeal cancer and anal cancer. HPV-52 is one of those types that are considered high risk. This does not mean that you will necessarily get or have cancer. It only means that it is very very important for you to have your pap smear done every year. If an abnormality is diagnosed by pap smear, it is often earlier enough that the abnormality can be treated and removed before it turns into cancer.

    A cervical conization or LEEP procedure are not required just because there is HPV present. It is only required if abnormal cells, called dysplasia, has been found on the pap smear, biopsy or colposcopy.

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  25. Hello,
    My friend has a cyst near her ovary in the size of a grapefruit, which sounds huge to me. But her dr refuses to take it out. they just say it is normal. She is trying to have babies and had no luck. She had a miscarriage once in the first month of her pregnancy.
    I really want to help her. How come that the dr says that she should just try to have babies even with this huge cyst?
    Please help! :)

    ReplyDelete
  26. Hello May 16th,

    Sorry for the delay in answering your question.

    A cyst the size of a grapefruit is NOT NORMAL and needs to be removed surgically. It is most likely a tumor of some form (usually a benign tumor). She should see a BETTER doctor.

    Good Luck

    ReplyDelete
    Replies
    1. Thank you so much Dr. Ramirez!
      I think the same thing.
      You are great help!
      T.

      Delete
  27. Hi Dr. Ramirez,

    My girlfriend is 38, and has been diagnosed with a Dermoid that has entirely engulfed her right ovary. Her left has a much smaller tumor, thought also to be Dermoid. The doctor gives the smaller one 3-5 years before it will HAVE to be removed. The doctor wants to remove both in the same surgery, very soon. My girlfriend says "I REALLY don't want to be in menopause by Friday." I don't want that for her either.

    Given her age, should we put off removal of the ovary with the small tumor? Is there a way to excise that smaller tumor laparoscopically, or would she have to have full open surgery? Is it inevitable that it would just re-grow?

    Thanks for any insight!

    Regards,

    Sean

    ReplyDelete
    Replies
    1. Removing a Dermoid DOES NOT REQUIRE removal of the entire ovary! If your doctor is planning to do that, then you need to find a doctor with better skills. Your girlfriend needs to have a "CYSTECTOMY" which is specifically to shell out the Dermoid and leave the bulk of the ovarian tissue behind. DO NOT ALLOW A DOCTOR TO TELL YOU THAT YOU NEED TO LOSE BOTH OVARIES AND BE THRUST INTO MENOPAUSE. That doctor would be doing more harm than good. Dermoids need to be removed, however since they are a form of a tumor and can cause other problems.

      Delete
  28. Hello

    I just want to thank you for all the info on this site - I have had more success in learning about ovarian cysts,
    I am 54 and found out quite by accident 6 mths ago that I have an ovarian cyst which was a size of an orange then. Did not really have any discomfort that I was aware of from this - now following up after recent ultrasound - there has been discomfort - nausea, heaviness, bloatedness, discomfort in lower pelvic area especially if standing or walking for a couple of hrs, lower back ache (almost constant) is this normal?

    ReplyDelete
    Replies
    1. Most ovarian cysts are benign but when I find cysts in your age group, there has to be a high suspicion for ovarian cancer. It is not something to be taken lightly. Some blood tests can be done to evaluate the possiblity of ovarian cancer, but inevitably, surgery would be required to be able to pathologically evaluate the cyst and rule out ovarian cancer. My recommendation is to have this done sooner than later.

      Good Luck

      Delete
  29. Dr. My husband and I tried unsuccessfully to conceive for a year. During this time I had irregular periods. Upon a routine exam a dermoid tumor was found. I had this removed along with scar tissue and since then my periods have regulated. however, its been 7 months and we still have not conceived. Should we see a fertility dr.?

    ReplyDelete
    Replies
    1. Hello,

      Yes, I would recommend that you see a fertility specialist and undergo evaluation. Dermoids don't tend to be a cause for infertility but the resultant scar tissue formation can interfere with movement of the egg from the ovary to the tube. Any surgery can also cause scar tissue, so it is highly likely that you have more scar tissue formed.

      Good Luck.

      Delete
  30. hello sir
    I am 22 and got myself operated for a dermoid cyst last month at 4th of June.But i dont have my periods this month till now. Do i need to consult my doctor or wait for sometime.

    ReplyDelete
    Replies
    1. Your surgery should not have affected your cycles or periods, but I would wait one month just to see if it returns to normal on its own. If it does not, then you should consult your gynecologist.

      Delete
  31. Hi Dr. Ramirez,

    In 2005 I had a grapefruit sized dermoid (primarily bone) that was found to have engulfed my right ovary and I had to have my right ovary and fallopian tube removed.

    When I got pregnant at 31yo in the fall of 2011 I learned that my left ovary also had dermoids on it (I was told 2, approx. 1.5 and 1.8cm each). I have had serial ultrasounds about every 6months since then. Just last week, I learned that there are now 3 dermoids growing on that ovary....ranging in size from 1.1-a little over 2cm-- total cm of dermoids about 6cm. My OBGYN told me to follow-up with another ultrasound in 6weeks and I guess from there determine the plan. I guess he wasn't all that impressed. He, however, isn't the one with his fertility on the line =)

    My son is now 14months old and my husband I realize that there is more urgency now in getting pregnant-- we would like to have at least 1 more child, possibly 2. I have begun weaning my son from breastfeeding. We are not preventing getting pregnant, but I also have only had 3 periods so far and they have ranged from 32-48 days apart.

    I have recently (probably because I'm looking for it and paying closer attention) started to notice pangs on my left side...sometimes sharp, but most of the time dull with a little throb and similar to a running stitch. No pain really. I have no other symptoms and did not develop symptoms with my last dermoid (it was found on exam).

    I have several questions:
    1. At what point should I be worried that my left ovary will also become engulfed with dermoids? How quickly do these things grow? Do you think they are actually 3 separate dermoids or is it all the same dermoid engulfing my ovary?
    2. Do you think we should start looking into infertility (removal of eggs?) due to the risk that my ovary will become engulfed or twist before I would be able to get pregnant. (I will be traveling to Africa at the end of September and taking malaria meds, so we aren't really going to try hard to conceive until October). Should I be doing something about this now before my 6week Ultrasound follow-up and/or before my trip to Africa at the end of September or do you think we have time??
    3. If we did remove eggs and I was to lose my ovary, how easy is it to get pregnant/keep a pregnancy. Any stats on that? I would then need hormone replacement without ovaries. Is this hard on the body and difficult to conceive/keep a pregnancy?
    4. I have heard that removing dermoids can injury the ovary/put stress on the ovary (because you often have to cut into the ovary to get the dermoid off) and that keeping my ovary and trying to get pregnant now would be better than the risk of trying to take the dermoids off first. Do you agree? At what point/size is that no longer the case? Do you think I've reached that point? If so, I would need to collect eggs first, right because it's so risky, right? Then surgery to remove?
    5. I run 4-5x a week. How big is the risk of torsion?? I do feel some twinges on my left side now and again while I'm running-- then again it could be a little in my head!

    I would love to have 1-2 more children and then have the dermoids removed without all of the cost and hardship of infertility tx's. I would appreciate any thoughts and advice you have for me. I'm really concerned and down right worried about my fertility.

    Thanks in advance,
    Ft Collins, CO

    ReplyDelete
    Replies
    1. Hello. Let me take your questions in sequence:
      1. It is highly unusual to have more that one Dermoid in any given ovary. It is either all the same Dermoid, or the ultrasound is being over-read (meaning they are not Dermoids at all). Dermoids tend to grow very very slowly so doing ultrasounds every 6 months is also a little overkill.
      2. Currently, egg perservation is certainly a viable option. Considering that you are going to a third world county, and who knows what will happen there, it might be wise to have some eggs retrieved and frozen as a back up. I would do it before you move.
      3. You only needs ovaries to obtain eggs in terms of achieving a pregnancy. If the eggs have been previously preserved, then you can get pregnant without ovaries. The same goes for using donor eggs. In terms of success rates, they are good but now as good as using fresh eggs with IVF, but the technology gets better and better with time. The uterus does not age and as long as you have a uterus, you can get pregnant and the pregnancy can be supported with supplemental hormones. For 8 weeks of the pregnancy on, the placenta produce all the hormonal support that the pregnancy needs.
      4. I agree that you should not do surgery on the ovary if not absolutely necessary i.e. it is a cancerous tumor, causing severe pain or lifethreatening. Removing the dermoid requires making an incision into the capsule and shelling out the Dermoid tumor. The ovary should not have to be removed. That is what should have been done the first time. The ovary will recover from that surgery and function normally without reduction in fertility potential if the ovarian capsule (where the eggs lie) is kept intact. If too much of the capsule is removed by the surgeon, then yes, it could reduce your ovarian reserve.
      5. Ovaries only torse if there is a large (>5 cm) cyst on it to cause it to swing around its axis. I think the "twinges" are in your imagination. The sizes that you described are not big enough to be causing any synmptoms.

      I think that for now you should disregard the Dermoid issue, because part of me is doubtful of that diagnosis, and proceed with getting pregnant. An annual ultrasound would be able to keep tabs on the size of the Dermoid and once it is greater than 3 cms, then it can be removed by a minimally invasive surgical technique called laparoscopy. Make sure you see a GOOD doctor, however. Not all doctors are alike. That is one of the biggest misunderstandings among people in the U.S. Everyone thinks that all doctors are equal. They are not!

      Delete
  32. Dr.Ramirez,
    Wow! I'm so impressed! Thanks for the quick response and for all of your advice! I appreciate all the time you spent responding.
    A few additional/follow-up questions:
    1. I have been told for almost 2years now that I have 2 dermoids growing on my left ovary-- and then just in the last week-- 3. Are you saying that you really don't think that this is correct? What else looks like a dermoid that it could be? Could it just be one big one perhaps?
    2. If I do find out at the next US that they are all dermoids (although I know you are saying that this is highly unlikely), do I then worry about the amt of dermoids I have hanging on this ovary? (each one approx. 2cm= 6cm) or that this is one dermoid taking over/engulfing my ovary? With 6cm of dermoids then I would be at risk for torsion, right? (or is that if each of these dermoids was >5cm individually)
    3. Do you think I should ask about CA-125?
    4. I will only be in Africa for 2 weeks at the end of September. We were planning to start REALLY trying to get pregnant when I get back and am off the malaria meds. It sounds like dermoids typically are slow growers, so I'm guessing we shouldn't (God willing!) need to take any other measures before then, would you think?
    5. Should I desire your opinion of my ultrasound results, would you be able to review them and charge me a consultation fee?

    Thanks again!
    Fort Collins, CO

    ReplyDelete
    Replies
    1. 1. Probably only one big dermoid. Not three.
      2. Whether one or three, they should come out and this is done as a laparoscopic cystectomy.
      3. Yes
      4. Yes
      5. Yes. You would do that by contacting me via my website.

      Delete
  33. Hi Dr. Ramirez,

    I am 32 years old and scheduled to get my ovarian cyst removed (10cm x 19 cm x18 cm). It appears to be a mucinous cystadenomas. The gyn/oncologist is doing the procedure and recommended a minilaparotomy (not laparascopy). He also said that if the the ovary is stretched out too much from the large cyst, he may have to do a salpingo-oophorectomy. I only want a cystectomy and keep the ovary intact. What are your suggestions?

    ReplyDelete
    Replies
    1. Find a doctor who feels that they can go the cystectomy WITHOUT removing the ovary. You should try to preserve the ovary if you can and it may take a good surgeon to do that, especially if you want to preserve your fertility.

      Delete
  34. Hi Dr.Ramirez,i am 32 old,not birth,
    Is it possible that we are just in the 32 years to be discovered a dermoid cyst in the ovary, but only when I inspected vaginal probe, and if it is possible, if it was encapsulated, to grow rapidly due to loss of hormone therapy bromocriptine?Second, whether the occurrence of fibroids do with hormones and which?Thank you! Maja from Serbia

    ReplyDelete
    Replies
    1. Dormoids are not responsive to hormones and will not reduce with bromocriptine. Fibroids, on the other hand, are response to estrogen and will grow as long as estrogen is present. One of the treatments to reduce fibroids temporarily is to use an estrogen blocker such as Lupron but once the medication is stopped the fibroids will grow back. It is only given in preparation for surgery to remove the fibroids.

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  35. HI DR RAMIREZ,
    Can high prolactin affect the encapsulated dermoid cyst to open up, to rise (10 cm), to infiltrate the ovary, since abdominal ultrasound probe until then had never seen, only then vaginal probe
    Thanks in advance
    Maja,Europe

    ReplyDelete
  36. Hi Dr Ramirez,
    I recently (7 weeks ago) had a 7cm cyst removed from my left ovary and a 10cm dermoid cyst from my right ovary via cystectomy. I have heard these can return. How often should I visit a gynaecologist or have scans to check me over? Do i need to have 6 monthly check ups for the next few years or once a year, or more regularly? I have had 1 appointment after the operation. Thanks, Claire UK

    ReplyDelete
    Replies
    1. Dermoids, once removed don't usually recur. No special precautions are required. The only statistic that is notable with Dermoids is that there is a 50% chance of having a Dermoid on the other ovary.

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  37. Demoid recipients:

    I just wanted to share my experience after finding very little information on line regarding the causes.
    I had a "grapefruit" sized tumor removed at age 19 in 1973. One ovary and tube in the process.
    Continued to have excessive bleeding, monthly pain, headaches, and one child at age 37.
    One 3 mm size tumor found in 1995. After multiple consultations and ultra sounds, had a complete hysterectomy in 1998. Diagnosed with multiple fibroids and severe endometriosis.
    The surgeon cut open my bowel and a week later I was fitted with a stoma for ten months.
    The complete hysterectomy at age 44 changed my entire health. I aged 20 years. Try and keep your ovaries at all cost. Find the best, most experienced surgeon.

    ReplyDelete
    Replies
    1. Hi. Thanks for the comment. First, people forget that doctors are NOT all alike, trained alike and equally competent. Yes, we can learn surgical technique and treatments, but nothing can train us to have the best decision making skills. You want a doctor that is going to make the best decisions for you. So in terms of your experience, Dermoids DO NOT REQUIRE that the entire ovary be removed! The Dermoid can be removed from the ovary. Also, fibroids and endometriosis are two separate and additional diseases. Taking all of this into consideration is where the decision need to be made. It sounds like a hysterectomy was an appropriate choice but the doctor should have left the remaining ovary. Recent studies show that removing the ovaries in a young women lead to health detriments, so in the U.S., it is recommended to leave at least one ovary behind in all cases except for cancers. Removing your ovaries thrust you into menopause and that is HARMFUL to your health. The estrogen that the ovary produces is VITAL to your body, your brain and your emotions. YES, I also think it helps to keep your vitality and slow the aging process, that is why I recommend hormone replacement to ALL my perimenopausal and menopausal patients. If you are not already on HRT, I would strongly recommend it. All the recent studies show benefit and there is NO increase in any cancers. Because you don't have a uterus, you can take only estrogen. You'll feel a lot better!

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  38. I am 42 years old, have one child at 40, and trying for another baby.Two weeks ago, a huge dermoid cyst was detected on my left ovary. It's size is 13x13x7cm. I consulted couple of doctors and they have different opinions. One doctor suggested me to do laparoscopic removal of ovary and tube because it has the least risk of spill given the size of my cyst. He feels that fertility will not impacted much since i have my other ovary. Another doctor I saw offered to do minilaparotomy (6cm incision) with the goal to preserve part of ovary with lower risk of cyst rupture. My old ob/gyn doctor doesn't know about minilaparotomy and said if she does open surgery, it will have to be as big as my cyst size which is 13cm. I am torn between these options. I want to pick one which maximize fertility and yet minimize risk of rupture. I do not know in terms of risk of rupture, is laparoscopic oophorectomy lower than minilaparotomy cystectomy or about the same. In term of spill risk which is the main concern , if these two options are the same, isn't it obvious that I should choose minilaparotomy which can preserve part of the ovary? Can you please advice?

    ReplyDelete
    Replies
    1. Hi. Your research shows how doctor's in the same specialty can be very different with differing opinions. You've gotten three answers, recommendations for ways to remove a large Dermoid, so let me give you mine and hope that it helps you make your decision.

      If the Dermoid were smaller, I could remove it laparoscopically WITHOUT removing the ovaries and tube. Removal of the ovaries and tube is an absolute no no in someone wanting to preserve their fertility and have another child. So throw that doctor's recommendations out the window. He/She is incorrect that it will not affect your fertility. It absolutely will. Because of the size of this Dermoid, I don't think that laparoscopy is appropriate because it would be very difficult, but I have a colleague that will do this size laparoscopically. The risk of spillage is no greater than open. The problem is extracting the Dermoid through the small incision, but there are ways to do that within a bag so that it doesn't spill into the abdomen (that is how I extract smaller Dermoids up to 5 cms). So, if you can find someone with this skill, that would be the best option.

      The second best option, which is probably what I would recommend, is to do a minilaparotomy incision. If the surgeon is skilled in this method, it works well. The cyst can be shelled from the ovary, thereby preserving the ovary and tube and then drained above the skin to prevent spillage into the abdomen. Some will do the shelling using the laparoscope and then removal via minilap, which is another good option.

      Despite the large size of the Dermoid, the easiest method for most surgeons, especially those unskilled in laparoscopy is to use an open incision called a laparotomy. It is a C-section sized incision. This is the most invasive and has the highest chances of forming scar tissue that can possibly impair fertility. So, I don't recommend this. On the up side, it is the easiest and safest method because the surgeon has full control over the ovary.

      So, my bottom line recommendation would be a laparoscopically ASSISTED cystectomy where a minilap is used to extract the cyst, or a straight minilap cystectomy.

      Good Luck

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  39. Hi, I'm from UK and 44 years old, had one child at 40 (5 miscarriages, 2 of them missed/silent miscarriages.) I have fibromyalgia which causes intermittent problems and I'm not on meds.

    For the past 2 months I have been having intermittent left ovary/abdominal pain, lower left back pain, bloating (which gets worse throughout the day, but I also have IBS). Sometimes need to urinate more.
    I had been regular with cycles between 22 and 26 days until this year.
    I had a normal period 22 April, then some on/off left side stabbing pains etc started 10 May.
    On 22 May I missed period, had nausea, cramping etc (negative preg test, saw GP - unconcerned). On 27 May (telephone appt with GP - unconcerned) I had a very sharp left ovary pain, then 2 days later, dry stringy dark brown small clots discharge for 5 days. I thought maybe a cyst of some sort had burst?
    On 4 June I saw a different GP - full bloods done- all OK, & CA125 was 15. u/sound referral done). Pains seemed to subside a bit.
    On 16 June - proper period. 2 July GP pelvic exam - ok. 4 July - abdom ultrasound was ok, but transvaginal ultrasound technician said, showed "a small 7mm fat-filled cyst on left ovary."
    I am still waiting for gyne referral. My Mum died of advanced ovarian cancer which had been missed. I am very scared. Ultrasonographer is sending report to GP and didn't elaborate further. I am very worried and still waiting for a gyne appt. Is a fat-filled cyst an automatic cause for concern?
    Thank you very much in advance.

    ReplyDelete
    Replies
    1. Hi. With fibromyalgia you have many nonspecific sources for pain. However, a 7 mm cyst is not usually a worry. I don't know how the ultrasonographer could characterize it as "fat filled" as the ultrasound can only distinguish densities and not substances. Also, 7 mms is so small, how could the sonographer even see it that well. Most cysts are not considered relevant until they reach at least 5 cms. Given your history of ovarian cancer in your mother, you are at significant risk of developing ovarian cancer as well, regardless of the ultrasound findings. In the U.S., we recommend testing for the BRAC mutations, and in your age group, would recommend consideration for removal of your ovaries and tubes since your risk could be significant. This is definitely something that needs to be attended to by a Gynecologist so that you receive proper counseling. Genetic counseling is also required.

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    2. Thanks for your reply. I really appreciate it.
      I attended a gynae appointment last week. She dismissed the current 7mm cyst as irrelevant. Said I most probably had experienced a follicular cyst which caused the elevated symptoms, bleeding and bloating.
      (My bloating has reduced somewhat as my GP also thinks it could be related to lactose intolerance, as it gets progressively worse throughout the day, but by the following morning, much reduced and comfortable again....I am already wheat and gluten intolerant/coeliac.)

      The gynae also dismissed my Mum's death from ovarian cancer - because she contracted it in her early 70s.
      She did however request another tva scan within 3 months and a follow up appt to check the left ovary and any changes with the tiny cyst. She said she may then offer a laparoscopy to have a proper look inside.
      My own GP has requested another CA125 in a months time.
      They all know about my Mum, but because she contracted it later in life, they all say I am not at risk/eligible for BRAC mutation testing. (I am worried) . I have a sister who is 63, with no problems other than endometriosis in her 40s (she was sterilised in her late 30s), and my other sister is 50 who suffers with fibroids, but no further problems since she was fitted with a mirena ? coil. Both started peri menopause mid 40s.
      None of our GPs have recommended any of us have any genetic testing.
      Is this a difference between UK and USA? Would you recommend I go back to my GP to insist upon a referral? Can they even check with not having a blood sample from my Mum?
      Thank you very much

      Delete
  40. Hello doctor

    I am 27 yr old unmarried girl about to get marry in feb. I found bilateral dermoids one is 3.5 cm and other 2.5 cm. my doc recommend to have a baby first and thengo for removal of dermoids. I also have mild pcod. Plz suggest me what should i do. My dermoids are stable and not growing from last 6 mnths.

    ReplyDelete
    Replies
    1. If your doctor is sure that they are dermoids, they should be removed first. Certainly if the surgery is not done well and delicately it can lead to infertility, but there is a small risk of malignancy with Dermoids so they should be removed once diagnosed.

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    2. Thank you doctor for your reply. My doctor did ca125 test and other tumour marker tests and all are normal so he dont want to take risk of surgery before conception and also i dont have any pain or any other symptoms please suggest me you still think i should go for the surgery first??? i want to have children so i am very scared of ending up infertile after surgery. Please suggest me what should i do?? My periods are regular every 35 to 40 days and this delay is cause of pcod not dermoids i believe.

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    3. I certainly understand your doctor's recommendations to preserve your fertility, but the only way to make sure that a cyst/mass in the ovary is benign is to have a biopsy of tissue. That can only be done by doing surgery. For that reason, I think that these still need to be removed. Tumor markers are NOT 100% certain.

      I would approach these by removing them laparoscopically. That should minimize the chances of scar tissue formation and therefore a reduction of your fertility potential. Certainly if it is done as an open (laparotomy) procecure, you can get scar tissue formation and your fertility will be compromised. If that is the only way that you doctor can do the surgery, maybe that is why he is reluctant and it is rightly so. I would recommend a doctor that can do it laparoscopically.

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