Canadian With Recurring Ovarian Cysts And Thick Endometrial Lining: Does She Go On The Birth Control Pill?

QUESTION:

I'm 28 years old and have recently been referred to an OBGYN for recurring ovarian cysts. My most recent pelvic ultrasound suggests that I may also have a slightly thicker than usual uterine lining. My new OBGYN has prescribed a birth control pill (Alesse-21) for paroxysmal but intense pain associated with the cysts, as well as to thin out the lining of the uterus. I havent filled the prescription yet, as I am trying to learn more about its indications prior to doing so. My OBGYN instructed me to take the pills everyday for three months, then take one week off, during which I should get my period. I am supposed to continue on this schedule for at least one year. She did not explain WHY I should take the pills for three MONTHS, then one week off, as opposed to the usual three WEEKS on and one week off. Can you suggest any reason she would perscribe the medication in this way?

Further, I am expected to have a hysterosonogram next month. I was instructed to call in on the first day of my July period in order to schedule the appointment, as they need to make sure that the uterine lining is at its thinnest for the test. However, I will not be having a period next month because I will on the birth control pill (for three months straight). Therefore, does it matter when I schedule the hystersonogram? If I start taking the pills on the first day of my period this month (June), will the lining of my uterus be thin enough at ANY time in July, or should I wait a certain amount of time before scheduling the test?

Finally, I hope to eventually get pregnant. If I thin the lining of my uterus now, and control the growth of the ovarian cysts, does this increase my chances of getting pregnant once I stop the pill?I would really appreciate some knowledgeable guidance. I thank you in advance for your assistance.

Sincerely, M. from Ontario, Canada

Answer:

Hello M. from Canada,

Without reviewing your medical records it will be difficult for me to know exactly what your doctor is thinking and planning. It would be a good idea for you to ask her directly to explain the treatment plan in detail.

If you were found to have an ovarian cyst, there are many types of cysts. The most common type of cyst is a physiologic ovarian cyst and treatment with the birth control pill will help it to go away. However, this should take no more than one month. If the cyst does not resolve after one month on the pill, then there is a likelihood that this is some form of tumor (mostly benign forms) and so surgery will then be required to remove the cyst/tumor.

If the endometrial lining is thickened, there is the possibility of a disorder called "endometrial hyperplasia." Some forms of this can be atypical or precancerous so an endometrial biopsy is indicated. If the biopsy is negative for cancer, then it can be treated with the birth control pill to thin the lining. However, this treatment is NOT done until after a biopsy is taken because you DON'T want to use the birth control pill if precancerous cells or cancerous cells are present in the endometrium. With the birth control pill it can take 1-3 months to thin the lining but the standard treatment is to have a period each month so that the lining can be shed and NOT to use the every 3 month sequence. That sequence is only used for people that need contraception and don't want to have a period every month. So, again this does not make any sense to me.

In terms of the sonohysterogram, once you are on the birth control pill for at least one month, the lining should be thin enough to have it done at any time.

In terms of your fertility, this treatment plan does not work for or against your chances for pregnancy unless you have an endometrial cancer that is missed and then requires a hysterectomy.

I would urge you to speak with your doctor.

Good Luck,
Dr. 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.

COMMENT: You have given me a lot to think about. Thank you for being so thorough in your response. As this doctor of mine seemed to be heading in her own direction with this treatment as opposed to offering any alternatives or discussing the possible risks (as you have outlined here), I am very much inclined to seek a second opinion from another OBGYN. Thanks again for your outstanding assistance.

Ovarian Follicle Size Is Key When Planning For Trigger Shot

Question:

Dear Doctor Ramirez,

I had 3 follicles when I received the trigger shot. 30mm 24mm and not sure what size the 3rd one was. Is the 30mm follicle a good size to have a mature egg to be released?

Thanks, G. from the U.S.

Answer:

Hello G. from the U.S.,

I'm sorry to say but those follicle sizes are way too big. The trigger should be given when the follicle is between 18-23 mms. Once larger than that, the egg becomes over mature and non-viable. In some cases the follicle will not ovulate and be retained as a retained physiologic cyst. This type of situation generally occurs when patients are seeing the wrong type of doctor. I would advise that you consider seeking out a specialist in infertility or at least an ob/gyn who knows how to monitor your cycle properly so that you trigger at the correct time.

Good Luck,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

www.montereybayivf.com

30 Yr. Old TTC'r With Elevated Estradiol Levels- May Be Physiological Cyst

Question:

I am 30 years old and have been trying to get pregnant for 3 years. I have had 4 cycles of Clomid including 3 cycles of IUI. I ovulate on my own, have regular painless periods, and no apparent endometriosis. HSG shows clear tubes.

Bloodwork done 7 months before shows estradiol, FSH and progesterone within the normal range. My husband who is 32 has low sperm motility (about 47%) and morphology shows 71% abnormal sperm heads. We decided to go ahead with IVF+ICSI and since my RE thought I may not need to supress my ovaries too much, I was on birth control pills for only 2 weeks starting in the luteal phase. For my baseline appointment and bloodwork they discovered that I had elevated levels of estrogen (about 190) so I was called in after 4 days.

I did my second set of bloodwork today (had taken my lupron shot before going in) and my level was 185 which they thought was still high so they have canceled my IVF this month. Since I live in a small town and we have just one RE I have been scheduled for November. I am very disappointed and I wonder what went wrong. Can you please help me understand why the levels went so high.

Answer:

Hello, to answer your question as best I can without being able to evaluate your condition myself, an elevated Estradiol level is an indication of ovarian hormone production. The ovary needs to be down regulated prior to starting the stimulation medications. Usually a persistent elevated Estradiol occurs because there is a persistent cyst present in the ovary.

This cyst is producing the estrogen. If then continued the cycle, you would not stimulate well, and pregnancy would not ensue. I would have cancelled the cycle as well. I'm sorry that you have to wait until November, however.

I presume that your RE put you back on OCP's so technically you would be ready to start the cycle in September.

Follow Up Question:

Thank you so much Dr.Ramirez, however I have not been diagnosed with PCOS and my ovary did not seem to have a cyst during any ultrasounds. I was always told that the ovaries looked great and the lining was great.

Do you think it might have been missed?? :-( I have been reading on the internet and came across an article about how a weak liver can not filter the estrogens. I have had malaria thrice and maybe the meds I took made my liver weak? I have also worked in a research lab and handles a lot of teratogenic material..do you think that might have affected something?

I know I sound paranoid, but it's the first time I have had a test report that was not normal.

Follow Up Answer:

The cyst I was referring to is a physiologic cyst, not the cysts of PCOS. If there was no cyst at the time of your baseline ultrasound, then something is producing estrogen. There are very few things that produce estrogen. It is not from your history of malaria. The liver has to be in failure before it significantly affects the processing of hormones and medications. You would know if you were in liver failure!

Your history of working with teratogenic materials would also have no impact. Something else is producing hormones. You might want to ask your doc what it could be. Hormones can only be produced from hormone producing structures and the ovary is the only structure that produces estrogen. You are not taking estrogen from another source such as medication are you? The only non-ovarian source would be certain types of tumors.

If the estrogen level goes down after your course of birth control pills, then that would rule out any type of tumor. In that case you should be good to go.

Good Luck!

Edward J. Ramirez, M.D.

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

http://www.montereybayivf.com/

Monterey, California, U.S.A.

Ovarian Cysts

Question:

I am writing from Melbourne, Australia.

After two months of erratic menstruation, I was referred for an ultrasound which found the following: "The uterus is of normal contour with a normal endometrial echo. Both ovaries were visualised with a large dominant follicle on the left measuring 3.9cm in diameter. There is no septation or other change to indicate it is a pathological cyst. Follicle development is also present on the right ovary with the largest follicle measuring 1.6cm in diameter. There is no free pelvic fluid or other change."

My doctor has advised I wait and book for another ultrasound in 3 months time.

Should I follow this advice or seek a second opinion from a different doctor?

Answer:

Hello,

I don't think you need to wait three months. You should have an ultrasound done within the first 7 days of your next period to see if the cyst is still there. If it is, I would recommend a one month treatment with the birth control pill then another repeat ultrasound. If it is still there after that, then it is probably not a physiological cyst and needs to be removed by laparoscopy.

Sincerely,

Edward J. Ramirez, M.D.,FACOG

Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
Monterey, California, U.S.A.