{"id":428,"date":"2020-08-13T20:37:04","date_gmt":"2020-08-13T20:37:04","guid":{"rendered":"https:\/\/brooksidepress.org\/basic_obgyn\/?page_id=428"},"modified":"2020-08-13T20:37:04","modified_gmt":"2020-08-13T20:37:04","slug":"pelvic-mass","status":"publish","type":"page","link":"https:\/\/brooksidepress.org\/pa_obgyn\/advanced-training\/pelvic-mass\/","title":{"rendered":"Pelvic Mass"},"content":{"rendered":"<p><iframe loading=\"lazy\" src=\"https:\/\/www.youtube.com\/embed\/iFMApEy1X24\" width=\"560\" height=\"315\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\"><\/iframe><\/p>\n<p>Duration 16:23<\/p>\n<input type='hidden' bg_collapse_expand='69e9b57c3b9b31051721846' value='69e9b57c3b9b31051721846'><input type='hidden' id='bg-show-more-text-69e9b57c3b9b31051721846' value='Show Teaching Transcript'><input type='hidden' id='bg-show-less-text-69e9b57c3b9b31051721846' value='Hide Teaching Transcript'><button id='bg-showmore-action-69e9b57c3b9b31051721846' class='bg-showmore-plg-button bg-blue-button  '   style=\" color:#ffffff;\">Show Teaching Transcript<\/button><div id='bg-showmore-hidden-69e9b57c3b9b31051721846' ><\/p>\n<p><a href=\"https:\/\/21stcenturymeded.com\/wp-content\/uploads\/2019\/06\/Ovarian-Neoplasm-Teaching-Script-JHUFinal_Page_1.jpg\" target=\"_blank\" rel=\"noopener\"><img loading=\"lazy\" decoding=\"async\" class=\"alignnone size-large wp-image-2417\" src=\"https:\/\/21stcenturymeded.com\/wp-content\/uploads\/2019\/06\/Ovarian-Neoplasm-Teaching-Script-JHUFinal_Page_1-791x1024.jpg\" alt=\"\" width=\"525\" height=\"680\" title=\"\"><\/a><\/p>\n<p><a href=\"https:\/\/21stcenturymeded.com\/wp-content\/uploads\/2019\/06\/Ovarian-Neoplasm-Teaching-Script-JHUFinal_Page_2.jpg\" target=\"_blank\" rel=\"noopener\"><img loading=\"lazy\" decoding=\"async\" class=\"alignnone size-large wp-image-2418\" src=\"https:\/\/21stcenturymeded.com\/wp-content\/uploads\/2019\/06\/Ovarian-Neoplasm-Teaching-Script-JHUFinal_Page_2-791x1024.jpg\" alt=\"\" width=\"525\" height=\"680\" title=\"\"><\/a><\/p>\n<p>&nbsp;<\/p>\n<p class=\"p1\">Teaching Script: Ovarian Neoplasm<\/p>\n<p class=\"p2\">Clinical Case Applicability:<\/p>\n<p class=\"p3\">Adnexal Mass, Complications of Metastatic Disease<\/p>\n<p class=\"p2\">Learning Objectives:<\/p>\n<p class=\"p3\">1) Understand the different cell types involved in ovarian neoplasms<\/p>\n<p class=\"p3\">2) Review use of biochemical markers in identifying ovarian neoplasms (CA125 and larger sequence used)<\/p>\n<p class=\"p3\">3) Review genetic predispositions to ovarian neoplasm (briefly BRCA and Lynch syndrome)<\/p>\n<p class=\"p2\">Clinical Presentation:<\/p>\n<p class=\"p3\">Pregnancy with ovarian mass; Perimenopausal with gastrointestinal symptoms and adnexal mass<\/p>\n<p class=\"p2\">Considering anatomy and histology of the ovary, what cell types may evolve into ovarian neoplasms?<\/p>\n<p class=\"p3\">\u2022 Ovarian Anatomy<\/p>\n<p class=\"p3\"><span class=\"s1\">o <\/span>Premenopausal ovaries are about 3x2x2 cm in size; suspended between the ovarian ligament medially and the<\/p>\n<p class=\"p3\">infundipulopelvic ligament laterally and superiorly.<\/p>\n<p class=\"p3\"><span class=\"s1\">o <\/span>Outer cortex: ova and follicles; Inner medulla: fibromuscular layer of blood vessels and connective tissue<\/p>\n<p class=\"p3\">\u2022 Ovarian Cell types: 3 main types of which several neoplasms can emerge.<\/p>\n<p class=\"p3\"><span class=\"s1\">o <\/span>Epithelial: derived from stem cells that would give rise to the fallopian tube and ovarian surface epithelium<\/p>\n<p class=\"p3\"><span class=\"s1\">o <\/span>Germ Cell Tumors: derived from primordial germ cells of the ovary<\/p>\n<p class=\"p3\"><span class=\"s1\">o <\/span>Sex Cord Stromal Tumors: derived from stems cells that would create the ovarian stroma or follicles<\/p>\n<p class=\"p3\">\u2022 Epithelial Tumors (90% of ovarian malignancies)<\/p>\n<p class=\"p3\"><span class=\"s1\">o <\/span>Benign Epithelial tumors include: serous cystadenoma, mucinous cystadenoma or endometroid<\/p>\n<p class=\"p3\"><span class=\"s1\">o <\/span>Malignant Epithelial tumors include:<\/p>\n<p class=\"p3\">\u00a7 High grade serous carcinoma: key feature is marked cytologic atypia with prominent mitotic activity.<\/p>\n<p class=\"p3\">\u00a7 Endometrioid carcinoma: usually presents in women 40-50yo and diagnosed at an early<\/p>\n<p class=\"p3\">\u00a7 Clear cell carcinoma: arises from endometriosis in perimenopausal women. Tubal ligation protective.<\/p>\n<p class=\"p3\">\u00a7 Mucinous carcinoma: nearly all present stage I; usually perimenopausal women, usually very big up to 20cm and<\/p>\n<p class=\"p3\">confined to one side, have KRAS mutation that seems to indicate the mucinous cyst carcinoma arises from<\/p>\n<p class=\"p3\">mucinous cystadenomas and mucinous borderline tumors<\/p>\n<p class=\"p3\">\u00a7 Low grade serous carcinoma: key feature is hyalinized stroma with numerous psammoma bodies<\/p>\n<p class=\"p3\"><span class=\"s1\">o <\/span>Epithelial Ovarian Cancer Growth Factors (GF)<\/p>\n<p class=\"p3\">\u00a7 GF cell signaling promotes tumor cell growth and angiogenesis; three main growth factors that are involved:<\/p>\n<p class=\"p3\">\u2022 Fibroblast Growth Factor: binding of FGF to FGF Receptor (FGFR) helps drive tumor cell growth and<\/p>\n<p class=\"p3\">angiogenesis; expressed on endothelial, vascular smooth muscle, and ovarian cancer cells.<\/p>\n<p class=\"p3\">\u2022 Platelet Derived Growth Factor: PDGF binds to PDGF Receptor (PEDGFR) is expressed on<\/p>\n<p class=\"p3\">pericytes\/vascular smooth muscle cells; promotes angiogenesis by stabilizing new blood vessels.<\/p>\n<p class=\"p3\">\u2022 Vascular endothelial growth factor: VEGF and VEGF Receptors (VEGFR) are central mediators of<\/p>\n<p class=\"p3\">angiogenesis. They promote proliferation, migration and survival of vascular endothelial cells.<\/p>\n<p class=\"p3\">\u2022 Germ Cell Tumors (20-25% of all ovarian neoplasms but only 5% of the malignant; usually in young women 10-30yo)<\/p>\n<p class=\"p3\"><span class=\"s1\">o <\/span>Benign: Cystic 95% mature teratomas (dermoid) most common ovarian germ cell tumor<\/p>\n<p class=\"p3\">\u00a7 Differentiates to somatic cell types cell (ectoderm, endoderm, and mesoderm); rare condition associated with<\/p>\n<p class=\"p3\">mature and immature teratomas is N-methyl d-aspartate (NDMA) receptor encephalitis<\/p>\n<p class=\"p3\">\u00a7 Characteristically has hair, teeth, and fat on gross pathology; solid prominence \u201cRokitansky Protuberance\u201d is at<\/p>\n<p class=\"p3\">the junction between normal ovary and teratoma, and must evaluate for any malignant potential.<\/p>\n<p class=\"p3\"><span class=\"s1\">o <\/span>Malignant:<\/p>\n<p class=\"p3\">\u00a7 Immature teratoma: 0.2-2% rate of malignant transformation; most likely ectodermal component<\/p>\n<p class=\"p3\">\u00a7 Dysgerminomas: 1\/3 of malignant tumors in young women (teens), usually grow rapidly<\/p>\n<p class=\"p3\">\u00a7 Yolk sac tumors: 1\/3 girls with this tumor are premenarchal, Schiller -Duval bodies in this tumor type<\/p>\n<p class=\"p3\">\u00a7 Very Rare: mixed germ cell, pure embryonal carcinomas, non-gestational choriocarcinomas, pure polyembryoma<\/p>\n<p class=\"p3\"><span class=\"s1\">o <\/span>Can be associated with hormonal or enzymatic activity used as sensitive marker for disease<\/p>\n<p class=\"p3\">\u00a7 HCG, AFP, LDH<\/p>\n<p class=\"p3\">\u2022 Sex Cord Stromal Tumors: 1.2% all primary ovarian cancers; derived from cells that give rise to structures surrounding oocyte<\/p>\n<p class=\"p3\"><span class=\"s1\">o <\/span>Granulosa Cell: can secrete large amounts of estrogen; consider endometrial sampling for endometrial hyperplasia<\/p>\n<p class=\"p3\">\u00a7 Most common malignant sex cord stromal tumor; usually very large and unilateral; Call-Exner bodies<\/p>\n<p class=\"p3\">\u00a7 Most useful marker is inhibin; found as A and B isoforms; should order both<\/p>\n<p class=\"p3\"><span class=\"s1\">o <\/span>Sertoli-Leydig Cell: often produce androgen or androgen precursors, less than 20% are malignant<\/p>\n<p class=\"p3\"><span class=\"s1\">o <\/span>Thecoma: solid, benign tumor; can be very large; 15-25% stimulate endometrial and uterine pathology<\/p>\n<p class=\"p3\"><span class=\"s1\">o <\/span>Fibroma: most common sex cord stromal tumor; benign solid neoplasms and usually postmenopausal women;<\/p>\n<p class=\"p3\">\u00a7 Associated with Meigs\u2019 syndrome: ovarian fibroma, ascites and pleural effusion probably due to VGEF that<\/p>\n<p class=\"p3\">increases capillary permeability<\/p>\n<p class=\"p2\">Which ovarian biomarkers are useful in detecting ovarian neoplasms?<\/p>\n<p class=\"p3\">\u2022 Problem is ovarian cancer is the most common gyn cancer and the most common cause of gyn cancer death in US<\/p>\n<p class=\"p3\">\u2022 Ovarian cancer usually identified in late stage; and early identification requires surgery for mostly benign tumors removal<\/p>\n<p class=\"p3\">\u2022 A few biomarkers are currently available to help physicians triage adnexal masses<\/p>\n<p class=\"p3\">\u2022 No current tumor markers are both sensitive and specific for epithelial ovarian cancer so still rely on multimodal tools<\/p>\n<p class=\"p3\"><span class=\"s1\">o <\/span>Ca 125: large transmembrane glycoprotein derived from both coelomic and Mullerian epithelia<\/p>\n<p class=\"p3\"><span class=\"s1\">o <\/span>HE4: monitors for recurrent or progressive disease in epithelial ovarian cancer; derived from human epididymis protein<\/p>\n<p class=\"p3\">and a product of the WFDC2 gene that is overexpressed in patients with serous and endometroid cancer<\/p>\n<p class=\"p3\"><span class=\"s1\">o <\/span>Risk of Malignancy Algorithm (AROMA)<\/p>\n<p class=\"p3\">\u00a7 Includes CA125 and HE4; for helping to assess risk of women with mass who may undergo surgery<\/p>\n<p class=\"p3\">\u00a7 Menopausal status of a patient used to help assign either low or high risk of malignancy<\/p>\n<p class=\"p3\"><span class=\"s1\">o <\/span>OVA 1 Panel: aka multivariate index assay; includes 5 biomarkers<\/p>\n<p class=\"p3\">\u00a7 Interpretation based on menopausal status and given high or low probability of malignancy<\/p>\n<p class=\"p2\">What are known genetic predispositions to ovarian cancer?<\/p>\n<p class=\"p3\">\u2022 Most ovarian cancer due to sporadic mutation; however, if it is genetic most likely BRCA 1 or BRCA 2<\/p>\n<p class=\"p3\">\u2022 Inherited in an autosomal dominant fashion and are germ line mutations<\/p>\n<p class=\"p3\">\u2022 Other less common mutations include<\/p>\n<p class=\"p3\"><span class=\"s1\">o <\/span>Peutz-Jeghers syndrome: mutation in SKT11, mucocutaneous pigmented lesions and nonepithelial ovarian tumor<\/p>\n<p class=\"p3\">\u00a7 Increased risk of GI cancer, breast and ovarian<\/p>\n<p class=\"p3\"><span class=\"s1\">o <\/span>Lynch Syndrome: mutation in mismatch repair MMR genes and the epithelial cell adhesion molecule EPCAM gene;<\/p>\n<p class=\"p3\">\u00a7 Associated with colon, endometrium, ovary, and stomach<\/p>\n<p class=\"p3\">\u2022 A number of moderately increased gene mutations are also associated with ovarian cancer; about 3-5% of patients that come for<\/p>\n<p class=\"p3\">testing for hereditary breast and ovarian cancer have a mutation in any one of several \u201cmoderately increased risk\u201d gene mutations;<\/p>\n<p class=\"p3\">however, exact information on what to do for these patients is limited.<\/p>\n<p class=\"p2\">Figures:<\/p>\n<p class=\"p3\">1. Ovarian Cancer Types<\/p>\n<p class=\"p3\">2. Epithelial Tumor Growth Factors<\/p>\n<p class=\"p3\">3. Germ Cell Tumor Markers<\/p>\n<p class=\"p3\">4. Familial Cancer Syndromes<\/p>\n<p class=\"p2\">References:<\/p>\n<p class=\"p3\">\u2022 Williams Gynecology, 3<span class=\"s2\">rd <\/span>edition. 2016<\/p>\n<p class=\"p3\">\u2022 Hacker and Moore\u2019s Essentials of Gynecology, 6<span class=\"s2\">th <\/span>edition. 2016<\/p>\n<p class=\"p3\">\u2022 Ovarian Germ Cell Tumors: Pathology, Clinical manifestations and diagnosis. UpToDate. November 30, 2017<\/p>\n<p class=\"p3\">\u2022 Epithelial Carcinoma of ovary, fallopian tube and peritoneum. UpToDate. June 26, 2017<\/p>\n<p class=\"p3\">\u2022 Overview of Sex Cord Stromal Tumors of the Ovary. UpToDate. August 22, 2017<\/p>\n<p><\/div>\n<hr \/>\n<p><iframe loading=\"lazy\" title=\"vimeo-player\" src=\"https:\/\/player.vimeo.com\/video\/112182015\" width=\"640\" height=\"360\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\"><\/iframe><\/p>\n<p>Duration 15:09<\/p>\n<input type='hidden' bg_collapse_expand='69e9b57c3c38b1007389831' value='69e9b57c3c38b1007389831'><input type='hidden' id='bg-show-more-text-69e9b57c3c38b1007389831' value='Show Transcript'><input type='hidden' id='bg-show-less-text-69e9b57c3c38b1007389831' value='Hide Transcript'><button id='bg-showmore-action-69e9b57c3c38b1007389831' class='bg-showmore-plg-button bg-blue-button  '   style=\" color:#ffffff;\">Show Transcript<\/button><div id='bg-showmore-hidden-69e9b57c3c38b1007389831' ><\/p>\n<p><strong>Introduction<\/strong><\/p>\n<p>Adnexal masses may be encountered during a routine examination of an asymptomatic patient. They may be found while evaluating a patient with pain, bleeding, or other troublesome symptoms. Most of these masses will be benign and largely self-resolving, while a few will prove dangerous or life-threatening. The challenge, of course, is to determine which is which.<\/p>\n<p><strong>Simple Ovarian Cysts are the most common cause for an adnexal mass.<\/strong><\/p>\n<p>An ovarian cyst is a fluid-filled sac arising from the ovary.<\/p>\n<p>Ovarian cysts can be broadly categorized as having two origins: physiologic cysts that occur as a consequence of ovulation, and neoplastic cysts. Of the two, ovulation- related cysts are by far the more common.<\/p>\n<p>Functional cysts are common and generally cause no trouble. Each time a woman ovulates, she forms a small ovarian cyst (about 3.0 cm in diameter or less).<\/p>\n<p>Depending on where she is in her menstrual cycle, you may find such a small ovarian follicular cyst. Large cysts (&gt;7.0 cm) are less common and should be followed clinically or with ultrasound.<\/p>\n<p>Occasionally, simple ovarian cysts may cause a problem by: Delaying menstruation, Rupturing , Twisting , or Causing pain .<\/p>\n<p>About 95% of clinically significant ovarian cysts disappear spontaneously, usually after the next menstrual flow. Those that remain and those causing problems are often removed surgically.<\/p>\n<p><strong>Most Unruptured Ovarian Cysts will have no symptoms<\/strong>, but they can cause pain, particularly with strenuous exercise or intercourse. Treatment is symptomatic with rest for those with significant pain. The cyst usually ruptures within a month.<\/p>\n<p>Once ruptured, symptoms will gradually subside and no further treatment is necessary. If it doesn\u2019t rupture spontaneously, surgery is sometimes performed to remove it. This will relieve the symptoms and prevent torsion.<\/p>\n<p><strong>A Ruptured Ovarian Cyst\u00a0<\/strong>is a cyst that has ruptured and spilled its\u2019 contents into the abdominal cavity.<\/p>\n<p>If the cyst is small, its\u2019 rupture usually occurs unnoticed. If large, or if there is associated bleeding from the torn edges of the cyst, then cyst rupture can be accompanied by pain. The pain is initially one-sided and then spreads to the entire pelvis. If there is a large enough spill of fluid or blood, the patient will complain of right shoulder pain.<\/p>\n<p>Symptoms should resolve with rest alone. Rarely, surgery is necessary to stop continuing bleeding.<\/p>\n<p><strong>Torsion of an Ovarian Cyst\u00a0<\/strong>occurs when the cyst twists on its\u2019 vascular stalk, disrupting its\u2019 blood supply. The cyst and ovary (and often a portion of the fallopian tube) die and necrose.<\/p>\n<p>Patients with this problem complain of severe unilateral pain with signs of peritonitis (rebound tenderness, rigidity). This problem is often indistinguishable clinically<\/p>\n<p>from a pelvic abscess or appendicitis, although an ultrasound or CT Scan can be helpful in making this distinction.<\/p>\n<p>The Treatment is surgery to remove the necrotic adnexa. If surgery is unavailable, then bedrest, IV fluids and pain medication may result in a satisfactory, though prolonged, recovery. In this suboptimal, non-surgical setting, metabolic acidosis resulting from the tissue necrosis may be the most serious threat. Mortality rates from this condition (without surgery) are in the range of 20%.<\/p>\n<p><strong>An Endometrioma\u00a0<\/strong>is a form of an ovarian cyst that results from ectopic endometrial tissue being present in the ovary. During the normal cyclic hormonal changes, this ectopic endometrium responds with proliferative growth, decidualization, and then sloughing, accompanied by bleeding. As the blood is trapped within the ovarian capsule or stroma, it gradually accumulates, forming a chronic hematoma, known as an endometrioma. If large enough, these masses can be found during an examination or identified on ultrasound.<\/p>\n<p>The most troublesome aspect of endometriomas from a diagnostic standpoint is that they can mimic any of the ovarian neoplasms. Classically, the endometriomas have a ground-glass, slightly speckled appearance on sonar, but may demonstrate both cystic and solid components.<\/p>\n<p><strong>Ovarian Neoplasms\u00a0<\/strong>vary in seriousness from annoying, to slowly growing, to aggressively invasive. Their clinical significance may not be related to their microscopic appearance. For example, Dermoid tumors, rarely malignant, are very threatening because of their tendency to twist on their vascular stalk, causing ovarian necrosis.<\/p>\n<p>Ovarian neoplasms may be primarily cystic, solid, or mixed. Some are benign, some are malignant. Some produce enough hormone to cause symptoms for the patient.<\/p>\n<p><strong>Dermoid Tumors are\u00a0<\/strong>common neoplasms that contain a variety of elements of dermal origin, including teeth, hair, sebaceous glands, and hormone-producing thyroid cells.<\/p>\n<p>They are also called ovarian teratomas, are usually benign and occasionally malignant. Bilaterality is common.<\/p>\n<p>Dermoids have several annoying features:<\/p>\n<ul>\n<li style=\"list-style-type: none\">\n<ul>\n<li>They can rupture and spill their epithelial contents into the abdominal cavity where they may implant and grow, making later removal difficult.<\/li>\n<li>They may produce enough thyroid hormone to produce frank hyperthyrodism.<\/li>\n<li>They may twist on their vascular pedicles, causing necrosis, an acute abdomen, and the need for emergent surgical intervention.<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p><strong>Uterine Fibroid Tumors (Leiomyomas)<\/strong><\/p>\n<p>Typically, uterine fibroid tumors are easily identified within the uterus, both by clinical exam, and by such imaging studies as diagnostic ultrasound. Sometimes, uterine fibroids are growing in an area that cannot be distinguished from the adnexa. In these cases, the fibroids may appear to be a solid adnexal mass.<\/p>\n<p>Ultrasound is usually but not always helpful in tracking the base of the fibroid back to the uterus. Occasionally, it will only be through surgical intervention that the source of this adnexal mass will become clear.<\/p>\n<p><strong>Ovarian Cancer<\/strong><\/p>\n<p>The life-time risk for a woman to develop ovarian cancer is about 1%, but varies with race, socioeconomic status, and continent. However, there are other factors that may increase or decrease that risk.<\/p>\n<ul>\n<li style=\"list-style-type: none\">\n<ul>\n<li>Taking oral contraceptive pills decreases the risk of developing ovarian cancer, particularly if the OCPs have been taken for a long The initial reduction of risk of about 40% increases with increasing use.<\/li>\n<li>Pregnancy decreases the risk of ovarian A single full-term pregnancy lowers the risk by about 40%, and each subsequent pregnancy decreases it somewhat more.<\/li>\n<li>Having a tubal ligation or hysterectomy (with preservation of the ovaries) decreases the risk of ovarian cancer by about 50%.<\/li>\n<li>Removal of one ovary does not change the risk of later development of ovarian<\/li>\n<li>Using fertility-enhancing medications to stimulate ovulation may increase the risk of ovarian This risk is relatively small and not all studies agree that the risk increases.<\/li>\n<li>A family history of breast or ovarian cancer increases the patient\u2019s risk of ovarian<\/li>\n<li>The presence of the BRCA1 or BRCA2 gene increases the lifetime risk of developing epithelial cell ovarian cancer to about one in<\/li>\n<li>The incidence of ovarian cancer steadily increases with age, peaking in the mid-60s. Ovarian cancer among younger women is rare. Prior to age 30, the incidence is 5\/100,000.<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p><strong>Detection<\/strong><\/p>\n<p>Ovarian cancer can be difficult to detect. Unlike uterine cancer (that tends to cause visible bleeding at a relatively early stage), ovarian cancer usually remains\u00a0symptomless until fairly late in the disease process. Symptoms associated with ovarian cancer include pelvic discomfort and bloating. Unfortunately, these symptoms are so non-specific as to be nearly useless in evaluating a patient for possible ovarian cancer. Further, by the time a patient develops these symptoms, the ovarian cancer has frequently spread to distant sites.<\/p>\n<p>Blood tests are of limited value. Serum CA-125 increases in the presence of most ovarian epithelial cancers.<\/p>\n<p>Unfortunately, it also increases in the presence of anything that irritates the peritoneal surface, including infection, endometriosis, ovulation, and trauma. Further limiting its usefulness has been the observation that by the time the serum CA-125 levels increase in response to ovarian cancer, it is no longer in its early stages.<\/p>\n<p>Transvaginal ultrasound scanning has been used, with some success, to identify ovarian cancer. Ultrasonic findings that can be suspicious for ovarian cancer include unusually large amounts of free fluid in the abdominal cavity, solid ovarian enlargement, mixed cystic and solid enlargement of the ovaries, and thick- walled or complex ovarian cysts. Like CA-125, diagnostic ultrasound has some limitations to its usefulness.<\/p>\n<p>By the time the macroscopic changes of ovarian cancer are detectable by ultrasound, most ovarian cancers are well beyond the early stage of the disease. Also, most abnormalities seen by ultrasound are not, in fact, cancer, but are benign findings that require no treatment.<\/p>\n<p>For these reasons, most ultrasound screening programs for early detection of ovarian cancer have been discontinued. The vast majority of the abnormalities found (and surgically removed) actually required no treatment, and the few cancers that were successfully identified and removed were far enough advanced that it remained doubtful that the ultrasonic detection of them made any difference.<\/p>\n<p>That said, using CA-125 and ultrasound (and CT scanning or MR imaging) to evaluate an adnexal mass can be helpful. Simple ovarian cysts are virtually never malignant, and observing more complex masses over time can distinguish between the many that are benign (corpus luteum cysts, for example), and the few that are malignant and growing.<\/p>\n<p><strong>Ovarian Cancer Management<\/strong><\/p>\n<p>Specific management of ovarian cancer hinges on the cell type (and grade), the extent of spread (stage), and sometimes may be modified by particular patient characteristics (such as a desire to preserve childbearing capacity).<\/p>\n<p>The histologic evaluation requires a tissue specimen from the cancer that can be evaluated by the pathologist. For some ovarian cancer cell types, the histologic grade had prognostic significance (the more well-differentiated, the better). For other cell types, histologic grade has not been shown to have much of an independent prognostic value.<\/p>\n<p>Staging of the cancer is usually accomplished at the time of surgery and takes into account the spread of the disease. Guidelines for staging come from the International Federation of Gynecology and Obstetrics (FIGO). Stages include:<\/p>\n<ul>\n<li style=\"list-style-type: none\">\n<ul>\n<li>Stage I (Growth limited to the ovaries, and subdivided into Stage IA, IB, and IC, depending on the number of ovaries involved, presence or absence of ascites, tumor cells on the external surface of the ovaries or in peritoneal washings)<\/li>\n<li>Stage II (Growth beyond the ovaries, but limited to the Stage II is further subdivided into IIA, IIB, and IIC, depending on the specific areas of\u00a0extension, presence of ascites, and tumor cells in peritoneal washings)<\/li>\n<li>Stage III (Growth out of the pelvis, but still within the epithelial surfaces of the abdominal cavity. This is subdivided into IIIA, IIIB, and IIIC, depending on the location of the growth and its location)<\/li>\n<li>Stage IV (Distant metastases outside the confines of the abdominal cavity or within the liver parenchyma).<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p>The prognosis for early stage cancer of the ovary is generally good, the earlier the better. Unfortunately, not many Stage IA ovarian cancers are detected and treated. Most are of a more advanced stage where the prognosis is more guarded, the higher, the worse.<\/p>\n<p>Surgical treatment options include local excision, TAH\/BSO, and such debulking procedures as omentectomy and bowel resection. Even if the entire tumor cannot safely be removed surgically, reducing its bulk by at least 90% will often result in improved survival.<\/p>\n<p>Depending on the cell type, radiotherapy and\/or chemotherapy can also be used with good results. Occasionally, sub-optimal surgical treatment will be accepted as a compromise to enable other worthy goals. For example, an early ovarian cancer might optimally be treated with TAH\/BSO, but instead, a simple oophorectomy is performed to preserve the woman\u2019s childbearing capacity. In such a case, the woman must be prepared to accept the increased risk of treatment failure as the appropriate trade-off in retaining her capacity to have children.<\/p>\n<p><strong>Fallopian Tube Masses<\/strong><\/p>\n<p>Tubal ectopic pregnancy can present with an adnexal mass as either a primary or incidental finding. These masses can arise in two ways. If the ectopic pregnancy is\u00a0large enough (and it must be quite large), then it may be found on physical examination or ultrasound exam.<\/p>\n<p>Another commonly-found adnexal mass is the corpus luteum frequently found on the opposite side of the ectopic pregnancy. Ectopic pregnancy treatment options are many.<\/p>\n<p>Pelvic inflammatory disease can sometimes lead to a fallopian tube abscess or a fluid-filled tube (hydrosalpinx). If large enough, this mass can be palpated on examination or seen on ultrasound. If asymptomatic, these masses are usually ignored. If they are causing significant symptoms, they are removed surgically.<\/p>\n<p><strong>Evaluation<\/strong><strong>\u00a0of the patient with an adnexal mass\u00a0<\/strong>The primary goal of this evaluation is to distinguish those patients with an innocent, self-resolving mass\u00a0from those who will need intervention to achieve the best results.<\/p>\n<p>There are several Evaluation techniques that may prove useful.<\/p>\n<ul>\n<li style=\"list-style-type: none\">\n<ul>\n<li>\n<p class=\"p2\">You can Re-examine the patient after the next menstrual flow to see if the mass has disappeared.<\/p>\n<\/li>\n<li>\n<p class=\"p2\">You can perform an Exam under anesthesia if the normal exam is equivocal or difficult.<\/p>\n<\/li>\n<li>\n<p class=\"p2\">Pregnancy tests identify the presence of a pregnancy, Beta HCGs tell you whether the pregnancy is normal or not, and ultrasound scanning, combined with serial HCGs can determine the location of the pregnancy.<\/p>\n<\/li>\n<li>\n<p class=\"p2\">You can Have the patient use an enema to cleanse the lower bowel of stool and then re-examine the patient to see if the mass has disappeared.<\/p>\n<\/li>\n<li>\n<p class=\"p2\">A Pelvic ultrasound scan can identify the sonographic characteristics of the mass.<\/p>\n<\/li>\n<li>\n<p class=\"p2\">Serum CA-125 level will indicate if the peritoneal surface is being irritated<\/p>\n<\/li>\n<li>\n<p class=\"p2\"><span class=\"s1\">\u00a0<\/span>A CT scan (with contrast) of the abdomen and pelvis can be very helpful in identifying a non-gynecologic source for the mass, such as a pelvic kidney, diverticular abscess, or colon carcinoma.<\/p>\n<\/li>\n<li>\n<p class=\"p2\">Culdocentesis or paracentesis of ascitic fluid can be microscopically evaluated<\/p>\n<\/li>\n<li>\n<p class=\"p2\"><span class=\"s1\">\u00a0<\/span>You may elect to perform Laparoscopy to look directly at the pelvic mass, with possible laparoscopic removal<\/p>\n<\/li>\n<li>\n<p class=\"p2\">Or, a Laparotomy can be performed to explore the mass and remove it.<\/p>\n<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p><\/div>\n<hr \/>\n<p><iframe loading=\"lazy\" src=\"https:\/\/www.youtube.com\/embed\/QyjMLflyhes?start=30\" width=\"560\" height=\"315\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\"><\/iframe><\/p>\n<p>Duration 3:17<\/p>\n<input type='hidden' bg_collapse_expand='69e9b57c3cb6e4024625211' value='69e9b57c3cb6e4024625211'><input type='hidden' id='bg-show-more-text-69e9b57c3cb6e4024625211' value='Show Transcript'><input type='hidden' id='bg-show-less-text-69e9b57c3cb6e4024625211' value='Hide Transcript'><button id='bg-showmore-action-69e9b57c3cb6e4024625211' class='bg-showmore-plg-button bg-blue-button  '   style=\" color:#fcfcfc;\">Show Transcript<\/button><div id='bg-showmore-hidden-69e9b57c3cb6e4024625211' ><\/p>\n<p>I was running one day again and I had<br \/>\n00:05<br \/>\nbeen getting slower and slower all year<br \/>\n00:06<br \/>\nlong I knew something didn&#8217;t feel right<br \/>\n00:08<br \/>\nand I just felt a sort of this pain in<br \/>\n00:10<br \/>\nmy abdomen but I just didn&#8217;t feel well<br \/>\n00:12<br \/>\nand then two weeks later my birthday in<br \/>\n00:16<br \/>\nJune I was running with two friends and<br \/>\n00:19<br \/>\nI had to stop I just did not feel well<br \/>\n00:21<br \/>\nand I could feel it in my stomach and<br \/>\n00:23<br \/>\nthen maybe a week later that that was a<br \/>\n00:26<br \/>\nwe could just kind of was very<br \/>\n00:27<br \/>\npersistent and I just felt terrible and<br \/>\n00:30<br \/>\nthen I figured I had to go make another<br \/>\n00:32<br \/>\ndoctor appointment and I was diagnosed<br \/>\n00:34<br \/>\nwith a hernia and so then I went to<br \/>\n00:38<br \/>\nanother doctor who&#8217;s the hernia<br \/>\n00:40<br \/>\nspecialist and he checked me out and<br \/>\n00:42<br \/>\nsaid you don&#8217;t have a hernia and I said<br \/>\n00:45<br \/>\nwhat do you think I have and he said I<br \/>\n00:47<br \/>\ndon&#8217;t know and so my gut just said okay<br \/>\n00:49<br \/>\nI have to go back to my doctor and go<br \/>\n00:51<br \/>\nfor an OB GYN exam and so I went back to<br \/>\n00:54<br \/>\nmy doctor and she did an exam and after<br \/>\n00:57<br \/>\nthat she called me back and said are you<br \/>\n01:01<br \/>\ndriving which I was she said do you want<br \/>\n01:04<br \/>\nto pull over and I said no just tell me<br \/>\n01:05<br \/>\nwhat you have to tell me we have a list<br \/>\n01:08<br \/>\nof math there but they didn&#8217;t know what<br \/>\n01:10<br \/>\nit was she said I want you to go to<br \/>\n01:12<br \/>\nRoswell and she got me in right away and<br \/>\n01:14<br \/>\nI saw dr. Akers it was amazing and dr.<br \/>\n01:17<br \/>\nAkers<br \/>\n01:18<br \/>\nsaid okay yes there&#8217;s a mass it could be<br \/>\n01:21<br \/>\nsomething it could be nothing I won&#8217;t<br \/>\n01:25<br \/>\nknow until I actually go in and biopsy<br \/>\n01:26<br \/>\nit and when I got here and had my<br \/>\n01:28<br \/>\nsurgery it was something but very<br \/>\n01:31<br \/>\nluckily for me I was at stage 2 so she<br \/>\n01:34<br \/>\ndid a complete hysterectomy took out<br \/>\n01:36<br \/>\nboth ovaries and and the next week I<br \/>\n01:38<br \/>\ncame in and saw dr. Akers and she said<br \/>\n01:40<br \/>\nwell here are your options you can go<br \/>\n01:41<br \/>\nwith no chemo I wouldn&#8217;t necessarily<br \/>\n01:43<br \/>\nrecommend that you can go with<br \/>\n01:46<br \/>\ntraditional chemo which would be just a<br \/>\n01:48<br \/>\nchest port or you can go with the IP<br \/>\n01:51<br \/>\ntreatment and the chest port and it&#8217;s<br \/>\n01:54<br \/>\nmost aggressive and she said it&#8217;s very<br \/>\n01:56<br \/>\ntough it&#8217;s brutal on your body and it is<br \/>\n01:59<br \/>\nbut the day after I came home I saw my<br \/>\n02:02<br \/>\nfriends walking by and I got off the<br \/>\n02:04<br \/>\ncouch and they all helped me down the<br \/>\n02:07<br \/>\nsteps and we took about four steps down<br \/>\n02:09<br \/>\nthe driveway and then back off<br \/>\n02:11<br \/>\nand each day I&#8217;d walked a little further<br \/>\n02:13<br \/>\nso&#8211;but truly I mean quite literally got<br \/>\n02:16<br \/>\nme walking and I would see them every<br \/>\n02:18<br \/>\nday and it was you know what I would<br \/>\n02:20<br \/>\nlook forward to and then that Monday<br \/>\n02:21<br \/>\nwould feel good and Tuesday and have<br \/>\n02:22<br \/>\nchemo again and start all over anytime<br \/>\n02:25<br \/>\nthere was a problem anytime I had the<br \/>\n02:26<br \/>\nallergic reactions they went okay we&#8217;re<br \/>\n02:29<br \/>\ngonna try this instead and I never felt<br \/>\n02:31<br \/>\nlike I was not going to get through some<br \/>\n02:34<br \/>\ndays I wasn&#8217;t thrilled about getting for<br \/>\n02:36<br \/>\nthe chemo but I never thought I wasn&#8217;t<br \/>\n02:37<br \/>\ngonna get past it 18 weeks and then be<br \/>\n02:40<br \/>\ndone and again I&#8217;ll never for a day take<br \/>\n02:42<br \/>\nfor granted that I was lucky enough to<br \/>\n02:45<br \/>\nfeel it because a lot of people don&#8217;t<br \/>\n02:46<br \/>\nfeel it till it&#8217;s too late but usually<br \/>\n02:49<br \/>\nit comes back within one to two years<br \/>\n02:50<br \/>\nbut dr. Akers told me because nurse was<br \/>\n02:53<br \/>\ncaught early it didn&#8217;t spread you had<br \/>\n02:54<br \/>\npretty aggressive chemo and you&#8217;re at<br \/>\n02:57<br \/>\nthree years you&#8217;re already further along<br \/>\n02:58<br \/>\nin survivorship than most people on<br \/>\n03:01<br \/>\nearth I really I&#8217;m glad I came to rise<br \/>\n03:02<br \/>\nalive because I really from the person<br \/>\n03:06<br \/>\nwho cleaned my room and after surgery<br \/>\n03:08<br \/>\nand to dr. Akers to everybody in between<br \/>\n03:11<br \/>\neveryone&#8217;s been amazing<br \/>\n03:14<br \/>\n[Music]<br \/>\n03:16<br \/>\nyou<\/p>\n<p><\/div>\n<hr \/>\n<p><iframe loading=\"lazy\" src=\"https:\/\/www.youtube.com\/embed\/I_i2PGno5EQ?start=30\" width=\"560\" height=\"315\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\"><\/iframe><\/p>\n<p>Duration 13:15<\/p>\n<input type='hidden' bg_collapse_expand='69e9b57c3d25d9093824774' value='69e9b57c3d25d9093824774'><input type='hidden' id='bg-show-more-text-69e9b57c3d25d9093824774' value='Show Transcript'><input type='hidden' id='bg-show-less-text-69e9b57c3d25d9093824774' value='Hide Transcript'><button id='bg-showmore-action-69e9b57c3d25d9093824774' class='bg-showmore-plg-button bg-blue-button  '   style=\" color:#fcfafa;\">Show Transcript<\/button><div id='bg-showmore-hidden-69e9b57c3d25d9093824774' ><\/p>\n<p>00:30<br \/>\nvideo is going to be last week I went to<br \/>\n00:33<br \/>\nthe emergency room for ruptured ovarian<br \/>\n00:36<br \/>\ncysts<br \/>\n00:37<br \/>\nI actually had two ruptured cyst so I<br \/>\n00:40<br \/>\nthink the most watched video on my<br \/>\n00:42<br \/>\nchannel is my er story time from the<br \/>\n00:46<br \/>\nlast time I had a ruptured cyst so why<br \/>\n00:49<br \/>\nnot talk about it again this experience<br \/>\n00:51<br \/>\nwas similar in some ways different in<br \/>\n00:54<br \/>\nother ways and I think it&#8217;s really<br \/>\n00:56<br \/>\nimportant to talk about this stuff I&#8217;ve<br \/>\n00:58<br \/>\ngotten so much good feedback on that<br \/>\n01:01<br \/>\nlast video and if it would interest you<br \/>\n01:04<br \/>\nto watch that video as well I will put a<br \/>\n01:06<br \/>\ncard that was my first experience having<br \/>\n01:08<br \/>\nanything so so severe this one I would<br \/>\n01:12<br \/>\nsay was not precisely worse but just a<br \/>\n01:16<br \/>\nlittle bit different so let&#8217;s get right<br \/>\n01:19<br \/>\ninto it just starting off I have been<br \/>\n01:22<br \/>\nunder quite a lot of stress the last<br \/>\n01:25<br \/>\ncouple months I&#8217;ve been traveling a bit<br \/>\n01:27<br \/>\nmore than usual<br \/>\n01:28<br \/>\nthat is definitely taken its toll on my<br \/>\n01:31<br \/>\nbody my last two periods were very off<br \/>\n01:34<br \/>\nschedule my normal cycle is about 34 or<br \/>\n01:38<br \/>\n35 days my second to last period was<br \/>\n01:41<br \/>\nlike 44 days or something I was like<br \/>\n01:43<br \/>\nwhere is it the following one was like<br \/>\n01:46<br \/>\n21 days last period was just terrible so<br \/>\n01:50<br \/>\npainful I had so much pain in my legs in<br \/>\n01:53<br \/>\nmy rib cage I just had pain all over my<br \/>\n01:56<br \/>\nabdomen my last period what started on<br \/>\n01:59<br \/>\nMarch 9th and then by the time I think I<br \/>\n02:03<br \/>\nhad the system the 21st I went to the<br \/>\n02:06<br \/>\nemergency room for I think it was the<br \/>\n02:07<br \/>\n21st between that time when I first got<br \/>\n02:10<br \/>\nmy period all the way up until<br \/>\n02:12<br \/>\nI wound up in the emergency room I was<br \/>\n02:14<br \/>\njust in a lot of pain and it never<br \/>\n02:15<br \/>\nreally went away like there were some<br \/>\n02:17<br \/>\ndays where it was better and I was able<br \/>\n02:18<br \/>\nto like go for a walk and there were<br \/>\n02:21<br \/>\nother days where it was just so bad I<br \/>\n02:23<br \/>\nbasically really wasn&#8217;t doing very much<br \/>\n02:25<br \/>\ncut to about four or five days before I<br \/>\n02:28<br \/>\nwent to the emergency room I had a lot<br \/>\n02:30<br \/>\nof pain on one side on my left side<br \/>\n02:34<br \/>\nI wasn&#8217;t sure maybe this is just<br \/>\n02:36<br \/>\ndigestive pain what&#8217;s frustrating about<br \/>\n02:39<br \/>\nhaving ovarian cysts and digestive<br \/>\n02:42<br \/>\nissues is you kind of never know what it<br \/>\n02:44<br \/>\nis because everything&#8217;s really in the<br \/>\n02:46<br \/>\nsame area like it&#8217;s very hard to tell<br \/>\n02:48<br \/>\nwhat&#8217;s going on and it wasn&#8217;t clearly<br \/>\n02:51<br \/>\nlike sometimes you have that real clear<br \/>\n02:53<br \/>\novulation middle shmurda pain it really<br \/>\n02:57<br \/>\nwasn&#8217;t that sort of fuzzy it was like a<br \/>\n02:59<br \/>\ndull achy pain and that kind of passed<br \/>\n03:02<br \/>\nand I was able to be a little bit active<br \/>\n03:05<br \/>\nthe day before I went to the emergency<br \/>\n03:07<br \/>\nroom was Sunday I actually went to the<br \/>\n03:10<br \/>\ngym I did some light weight lifting<br \/>\n03:12<br \/>\nwalked in the treadmill I went to yoga<br \/>\n03:14<br \/>\nclass and I felt pretty good I was<br \/>\n03:17<br \/>\nfatigued and I was sort of pushing<br \/>\n03:19<br \/>\nthrough I was pushing myself a little<br \/>\n03:21<br \/>\nbit but nothing too strenuous really at<br \/>\n03:24<br \/>\nall Sunday night the pain started to get<br \/>\n03:27<br \/>\nworse and it was sort of all over my<br \/>\n03:30<br \/>\nabdomen it was on both sides which was<br \/>\n03:32<br \/>\nreally strange it had been really<br \/>\n03:34<br \/>\nconcentrated on the left side for a few<br \/>\n03:36<br \/>\ndays and then it was sort of on the<br \/>\n03:38<br \/>\nright side as well<br \/>\n03:39<br \/>\nthat really confused me because<br \/>\n03:41<br \/>\ngenerally cystic pain or ovulation pain<br \/>\n03:44<br \/>\nis gonna be one side only and it might<br \/>\n03:47<br \/>\nrady but generally it&#8217;s gonna be in the<br \/>\n03:49<br \/>\none side the other thing was that I had<br \/>\n03:51<br \/>\npain on one side of my back a very dull<br \/>\n03:54<br \/>\nachy pain and I was like is this my<br \/>\n03:56<br \/>\nkidney I had a little bit of urinary<br \/>\n03:59<br \/>\nsymptoms but nothing to write home about<br \/>\n04:02<br \/>\nthere so then I woke up Monday morning<br \/>\n04:05<br \/>\nand I was still in a lot of pain the<br \/>\n04:07<br \/>\npain had actually shifted over to the<br \/>\n04:09<br \/>\nright side it had been in the left side<br \/>\n04:11<br \/>\nfor a few days and just feeling mmm not<br \/>\n04:16<br \/>\ngood so I knew I needed to see the<br \/>\n04:19<br \/>\ndoctor I still at that point didn&#8217;t even<br \/>\n04:21<br \/>\nknow if maybe the<br \/>\n04:22<br \/>\nwas a digestive problem I wasn&#8217;t really<br \/>\n04:24<br \/>\nhaving any digestive symptoms actually<br \/>\n04:26<br \/>\nmy digestion was much better than it<br \/>\n04:29<br \/>\nnormally is yeah I was like should I go<br \/>\n04:31<br \/>\nto my family doctor or should I go to my<br \/>\n04:34<br \/>\ngynecologist and I really didn&#8217;t know I<br \/>\n04:37<br \/>\nwas like let me just go to my<br \/>\n04:39<br \/>\ngynecologist so my normal doctor wasn&#8217;t<br \/>\n04:42<br \/>\navailable I think he was off delivering<br \/>\n04:44<br \/>\nbabies or something I saw a family nurse<br \/>\n04:46<br \/>\npractitioner in the same practice she<br \/>\n04:48<br \/>\ndid an internal examination and with<br \/>\n04:51<br \/>\npressing on my belly and the only part<br \/>\n04:55<br \/>\nthat was really tender and painful when<br \/>\n04:57<br \/>\nshe did that was actually my bladder<br \/>\n04:59<br \/>\nwhen she pressed on my ovaries didn&#8217;t<br \/>\n05:01<br \/>\nreally hurt at all and that was very<br \/>\n05:04<br \/>\nsurprising so I had to pee in a cup and<br \/>\n05:06<br \/>\nthat was fine no infection so she said<br \/>\n05:10<br \/>\nwell it&#8217;s probably a cyst<br \/>\n05:12<br \/>\nI&#8217;ll schedule an ultrasound for Thursday<br \/>\n05:14<br \/>\nand then I&#8217;ll see you next week<br \/>\n05:16<br \/>\njust take Advil you&#8217;ll be fine that was<br \/>\n05:19<br \/>\nfirst thing in the morning about 9<br \/>\n05:21<br \/>\no&#8217;clock or so and I went home I did a<br \/>\n05:23<br \/>\nlittle work sat in my office and I just<br \/>\n05:26<br \/>\nthe pain became on bearable I just<br \/>\n05:30<br \/>\ncouldn&#8217;t I had no position I could get<br \/>\n05:32<br \/>\ncomfortable and Advil really didn&#8217;t do<br \/>\n05:34<br \/>\nanything at all the one thing that I<br \/>\n05:37<br \/>\nwould say was really consistent with the<br \/>\n05:39<br \/>\nlast time I had a cyst was peeing was so<br \/>\n05:44<br \/>\npainful so so so painful to the point<br \/>\n05:48<br \/>\nwhere I really felt like I was gonna<br \/>\n05:50<br \/>\npass out from the pain and so I just<br \/>\n05:52<br \/>\ndidn&#8217;t drink a lot of water because I<br \/>\n05:54<br \/>\njust couldn&#8217;t even bear the thought of<br \/>\n05:56<br \/>\npeeing that&#8217;s how painful it was so I<br \/>\n05:58<br \/>\nwas just feeling worse and worse and I<br \/>\n06:00<br \/>\nam a person who has a lot of like<br \/>\n06:01<br \/>\nmedical anxiety so I was just saying to<br \/>\n06:05<br \/>\nmyself I don&#8217;t want to miss something I<br \/>\n06:06<br \/>\ndon&#8217;t want to wait till tomorrow to go<br \/>\n06:08<br \/>\nback to the doctor it was about five<br \/>\n06:10<br \/>\no&#8217;clock I made the decision to go over<br \/>\n06:14<br \/>\nto the emergency room I was fine enough<br \/>\n06:16<br \/>\nto drive but I was feeling pretty<br \/>\n06:17<br \/>\nanxious I you know again I was like if<br \/>\n06:20<br \/>\nit&#8217;s my appendix or something a B it&#8217;s<br \/>\n06:23<br \/>\nmy kidney maybe I have a kidney stone or<br \/>\n06:26<br \/>\nkidney infection you know if it is my<br \/>\n06:28<br \/>\novary generally over ovarian cysts just<br \/>\n06:31<br \/>\nheal on their own they don&#8217;t require any<br \/>\n06:34<br \/>\nintervention at all but there are two<br \/>\n06:37<br \/>\ncases where they would one is a dermoid<br \/>\n06:40<br \/>\ncyst you might want to cover your ears<br \/>\n06:42<br \/>\nif you&#8217;re a sensitive person but<br \/>\n06:44<br \/>\nbasically it&#8217;s one assist grows hair and<br \/>\n06:47<br \/>\nteeth an egg contains stem cells so it<br \/>\n06:51<br \/>\ncan actually form any kind of tissue<br \/>\n06:53<br \/>\nthose do need to be removed surgically<br \/>\n06:55<br \/>\nand I think it&#8217;s like 10% of cysts or<br \/>\n06:58<br \/>\nsomething the other thing would be a<br \/>\n07:00<br \/>\ncyst that&#8217;s so large that it can cause<br \/>\n07:03<br \/>\nthe ovary to twist on its stem and<br \/>\n07:05<br \/>\nthat&#8217;s a medical emergency because the<br \/>\n07:07<br \/>\novary will die and the tissue will<br \/>\n07:10<br \/>\nbecome necrotic you know I&#8217;m a person<br \/>\n07:12<br \/>\nwho really likes to stay out of the<br \/>\n07:14<br \/>\nemergency room first of all it&#8217;s<br \/>\n07:16<br \/>\ncrawling with germs but there are some<br \/>\n07:18<br \/>\nthings that I think do require emergency<br \/>\n07:21<br \/>\nattention and I felt like this qualified<br \/>\n07:24<br \/>\nfor that so I went over to the emergency<br \/>\n07:26<br \/>\nroom got triage like pretty quickly all<br \/>\n07:29<br \/>\nmy vitals were normal heart rate blood<br \/>\n07:31<br \/>\npressure all that stuff so that&#8217;s<br \/>\n07:32<br \/>\nreassuring and then I waited in the<br \/>\n07:34<br \/>\nwaiting room for about two hours<br \/>\n07:36<br \/>\nI got seen by a doctor probably within<br \/>\n07:39<br \/>\nfive minutes of getting a bed which was<br \/>\n07:40<br \/>\ngreat he ordered an ultrasound I was<br \/>\n07:43<br \/>\ngetting an ultrasound probably within<br \/>\n07:45<br \/>\nabout 2 and 1\/2 hours of walking into<br \/>\n07:47<br \/>\nthe emergency room which was not bad at<br \/>\n07:49<br \/>\nall an ultrasound confirmed that I had<br \/>\n07:52<br \/>\nnot one but two ruptured cysts I had one<br \/>\n07:56<br \/>\nruptured on the left that had ruptured<br \/>\n07:58<br \/>\nprobably about four or five days before<br \/>\n08:00<br \/>\nand they could tell it had like deflated<br \/>\n08:03<br \/>\nand there was fluid had leaked out of it<br \/>\n08:07<br \/>\na cyst that had ruptured on the right<br \/>\n08:09<br \/>\nprobably that earlier that day and there<br \/>\n08:13<br \/>\nwas like fresh fluid leaking out of<br \/>\n08:15<br \/>\nthere as well and then I had one other<br \/>\n08:17<br \/>\nlarge cyst on my left as well so I had<br \/>\n08:21<br \/>\nthree cysts I think the largest one was<br \/>\n08:24<br \/>\nfour centimeters once I had the<br \/>\n08:26<br \/>\ndiagnosis I felt so much better I felt<br \/>\n08:30<br \/>\nno matter how much pain it is I know<br \/>\n08:32<br \/>\nit&#8217;s not dangerous I know my body will<br \/>\n08:34<br \/>\ntake care of it it was just such a<br \/>\n08:36<br \/>\nweight off my shoulders so I felt so<br \/>\n08:41<br \/>\nrelieved and so glad part two of the<br \/>\n08:44<br \/>\ntale is that while I was in the<br \/>\n08:47<br \/>\nemergency<br \/>\n08:48<br \/>\nI told them I rated my pain between a<br \/>\n08:50<br \/>\nseven and an eight and they asked me if<br \/>\n08:53<br \/>\nI wanted medication for the pain I had<br \/>\n08:55<br \/>\nremembered from the last experience of<br \/>\n08:58<br \/>\nhaving dilaudid which is a very strong<br \/>\n09:02<br \/>\nnarcotic how amazing that was and just<br \/>\n09:06<br \/>\nhow great I felt they offered me<br \/>\n09:08<br \/>\ndilaudid again this time it was awful it<br \/>\n09:13<br \/>\nwas a complete nightmare experience if I<br \/>\n09:17<br \/>\ncould take it back I fully would have it<br \/>\n09:19<br \/>\nwas so so so bad I had it along with<br \/>\n09:23<br \/>\nsome zofran I hadn&#8217;t eaten in about six<br \/>\n09:26<br \/>\nhours before then I&#8217;d had no IV fluids<br \/>\n09:29<br \/>\njust straight on an empty stomach this<br \/>\n09:32<br \/>\nvery strong narcotic talking twice as<br \/>\n09:35<br \/>\nstrong as morphine my main symptom was<br \/>\n09:38<br \/>\njust extremely Ness and that lasted for<br \/>\n09:42<br \/>\nI would say a solid two hours so it was<br \/>\n09:45<br \/>\nan absolute nightmare<br \/>\n09:46<br \/>\nit did relieve my pain I guess but I was<br \/>\n09:49<br \/>\njust so focused on how bad I felt<br \/>\n09:52<br \/>\notherwise that it didn&#8217;t even really<br \/>\n09:55<br \/>\nmatter so if I could do that part of it<br \/>\n09:56<br \/>\nover again I would have probably just<br \/>\n09:58<br \/>\nasked for an Advil or something not<br \/>\n10:01<br \/>\nquite so strong the other time I had it<br \/>\n10:04<br \/>\nit was like the greatest thing on earth<br \/>\n10:06<br \/>\nthis time it was the worst possible<br \/>\n10:09<br \/>\nnightmare so I had to actually stay in<br \/>\n10:11<br \/>\nthe emergency room for a little while<br \/>\n10:12<br \/>\nlonger and have them monitor me on that<br \/>\n10:15<br \/>\nthe other thing that I had that was an<br \/>\n10:18<br \/>\nissue with it was like my whole neck and<br \/>\n10:21<br \/>\nback it&#8217;s just completely seized up<br \/>\n10:24<br \/>\nalmost like just it was such it was such<br \/>\n10:26<br \/>\na terrible terrible feeling so start to<br \/>\n10:29<br \/>\nfinish I was in the emergency room for<br \/>\n10:31<br \/>\nabout six hours I got home and paced<br \/>\n10:34<br \/>\naround for probably about half an hour I<br \/>\n10:36<br \/>\nactually called the emergency room and<br \/>\n10:38<br \/>\ncalled the doctor and was like is this<br \/>\n10:40<br \/>\nnormal I really feel so so so bad and he<br \/>\n10:43<br \/>\nwas a little impatient he was like yeah<br \/>\n10:45<br \/>\nyou&#8217;re fine go to bed but I did feel<br \/>\n10:47<br \/>\nwhen I went to sleep that I was just<br \/>\n10:49<br \/>\ngonna stop breathing<br \/>\n10:50<br \/>\nlike I was probably taking three breaths<br \/>\n10:52<br \/>\na minute or something like I was just<br \/>\n10:55<br \/>\nridiculous I woke up a few hours later<br \/>\n10:57<br \/>\nmy pain was back in full force it was<br \/>\n11:00<br \/>\neven worse but<br \/>\n11:01<br \/>\nleast the effects of the dilaudid had<br \/>\n11:03<br \/>\nworn off that&#8217;s pretty much the story I<br \/>\n11:06<br \/>\nhave a few little clips I did make some<br \/>\n11:09<br \/>\nInstagram stories I put all my deepest<br \/>\n11:12<br \/>\ndarkest secrets on Instagram keep that<br \/>\n11:14<br \/>\nstuff off YouTube where things live<br \/>\n11:15<br \/>\nforever<br \/>\n11:16<br \/>\nI like the ephemeral Ness of Instagram<br \/>\n11:18<br \/>\nbut I did save a few stories so I&#8217;m<br \/>\n11:20<br \/>\ngoing to post those at the end of this<br \/>\n11:22<br \/>\nvideo I just want to invite you to stick<br \/>\n11:24<br \/>\naround because I will be posting some<br \/>\n11:26<br \/>\nvlogs from the few days after and my<br \/>\n11:30<br \/>\nrecovery with the ovarian cysts and then<br \/>\n11:32<br \/>\nwhatever is happening going forward with<br \/>\n11:34<br \/>\nit and that&#8217;s pretty much it so if you<br \/>\n11:38<br \/>\nenjoyed this video if you found this<br \/>\n11:40<br \/>\nhelpful please give it a thumbs up that<br \/>\n11:41<br \/>\nreally helps me out so much feel free to<br \/>\n11:43<br \/>\nleave a comment below I think it&#8217;s so<br \/>\n11:46<br \/>\nvaluable that we have this medium to<br \/>\n11:49<br \/>\nconnect with each other I actually know<br \/>\n11:51<br \/>\na few people in real life that this has<br \/>\n11:53<br \/>\nhappened too but I get to meet so many<br \/>\n11:55<br \/>\npeople through the internet who we can<br \/>\n11:58<br \/>\nrelate and share these crazy stories so<br \/>\n12:01<br \/>\nI definitely would love to hear from you<br \/>\n12:03<br \/>\nin the comments below feel free to stick<br \/>\n12:05<br \/>\naround subscribe and stay tuned for more<br \/>\n12:08<br \/>\nvlogs of my life and health and this<br \/>\n12:12<br \/>\nwhole journey thank you so much for<br \/>\n12:15<br \/>\nwatching and I will catch up with you<br \/>\n12:17<br \/>\nguys next time<br \/>\n12:17<br \/>\nhey friends so I&#8217;m still in the ER<br \/>\n12:20<br \/>\ngetting ready to leave pretty soon I&#8217;m<br \/>\n12:24<br \/>\njust waiting up my blood work and three<br \/>\n12:28<br \/>\ncyst on my ovary is part two of the<br \/>\n12:32<br \/>\nstory is that they gave me dilaudid for<br \/>\n12:35<br \/>\nthe pain for the last hour I&#8217;ve just<br \/>\n12:38<br \/>\nbeen so dizzy kind of took one problem<br \/>\n12:43<br \/>\nand made it into a completely other<br \/>\n12:45<br \/>\nbigger profit<br \/>\n12:47<br \/>\nratings from my bathroom I think I might<br \/>\n12:52<br \/>\nsleep down here tonight my face feels<br \/>\n12:55<br \/>\nlike it&#8217;s two sizes too small for my<br \/>\n12:58<br \/>\nface I feel so bad I obviously don&#8217;t<br \/>\n13:02<br \/>\nfeel like myself I feel so weird and<br \/>\n13:06<br \/>\ndizzy and I feel like if I go to sleep<br \/>\n13:08<br \/>\nwe&#8217;re gonna stop breathing so it&#8217;s like<br \/>\n13:10<br \/>\n3:00 a.m. my<br \/>\n13:13<br \/>\nDavo no pain is back and it seems to be<br \/>\n13:16<br \/>\na lot worse that was only seven hours<br \/>\n13:20<br \/>\nago that I had the medication so I don&#8217;t<br \/>\n13:23<br \/>\nthink that roller coaster was worth the<br \/>\n13:25<br \/>\nprice of image so I will just reiterate<br \/>\n13:27<br \/>\nI said earlier don&#8217;t do drugs seriously<br \/>\n13:32<br \/>\nif you can there&#8217;s an alternative<\/p>\n<p><\/div>\n<hr \/>\n<p>&nbsp;<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Duration 16:23 Duration 15:09 Duration 3:17 Duration 13:15 &nbsp;<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":160,"menu_order":10,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-428","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/pages\/428","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/comments?post=428"}],"version-history":[{"count":0,"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/pages\/428\/revisions"}],"up":[{"embeddable":true,"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/pages\/160"}],"wp:attachment":[{"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/media?parent=428"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}