What to Know Down Below™
Welcome to What to Know Down Below™ by Tina’s Wish! We’re here to empower you with the knowledge and tools you need to advocate for your own gynecologic health.
Knowledge is power, and we encourage everyone to join us in learning more about what you need to know, down below!
What to Know Down Below™
Ovarian Cysts: The Basics, Featuring Dr. Shieva Ghofrany
Featuring Dr. Shieva Ghofrany, OBGYN & Co-founder of Tribe Called V, and moderated by Meaghan Repko DeShong, Tina's Wish Board Member & Partner at Joele Frank, Wilkinson Brimmer Katcher.
Learn more about Dr. Ghofrany at:
https://www.instagram.com/drshievag/
https://telleveryamazinglady.org/
https://www.tribecalledv.com/
Welcome to What To Know Down Below by Tina's Wish. We're here to empower you with the knowledge and tools you need to advocate for your own gynecologic health. Knowledge is power and we encourage everyone to join us in learning more about what you need to know down below.
Speaker 2:Hi everyone. I'm Megan Repko and welcome to What To Know Down Below. Um, I am so excited to be back. We are here with board certified OB GYN , Dr. Shiva Gorani , who might be my new favorite doctor ever <laugh> . Um , thank you. So welcome back and today we are going to be covering the basics of ovarian cysts because I think this could be probably a much longer <laugh> Yes . Podcast. Yes . If we, we took a deep dive into it. Mm-hmm <affirmative> . I also had ovarian cysts. Um, I had gone through an IVF journey and that's how I found out that I had them there and I had them surgically removed three times. Um, so I'm familiar with 'em , but I also was like kind of in my own head of kind of the IVF world. And so I think we can really teach our listeners some stuff today about this 'cause I know it's also something that's very common but not always found. Yeah.
Speaker 3:Very. Yes. Well, hi Megan . How are you? <laugh>?
Speaker 2:Hi. I'm good. How are you?
Speaker 3:Uh, well I'll go through a like ten second intro in case someone didn't listen to our last episode. But basically I have been an OB GN for 25 years and myself had, I mean I, I , I say this, it sounds funny because I feel like I say it like it's a laundry list as if it's not important. But it is just like your journey. It's very much part of whom I am. It's very much a part of who shaped me as a doctor and as a woman and as a mother. So I don't mean to make it sound like no big deal. They were all big deals. And yet here you and I are on the other side of all of these, but I had six miscarriages. I had endometriosis, I had HPV , I've had again multiple other issues as well. And then I had ovarian cancer when I was 46 years old, eight years ago. Um, and in my situation, my ovarian cyst that I first had when I was 29 years old was a 17 centimeter. So again, the size of a grapefruit, it was a 17 centimeter endometrial, which is a very specific type of ovarian cyst that has endometriosis within it. So something that you and I should talk about is what kind of cyst did you have and what are the different types of cysts? Because just like we talked about in our fibroid episode, fibroids are very, very common. Those are growths of the muscle of the uterus as well. Ovarian cysts are very common because the ovaries change every single day of the month and every single month as we ovulate. So the most common type of ovarian cyst is what we call a functional cyst or a follicular cyst, you might hear it be called. Or a simple cyst which just filled with water filled , just filled with fluid. Those are incredibly common, but there are a variety of other types as well. Um, and so what type did you have?
Speaker 2:I , um, I'm trying to remember it. I think, I think it was referred to as simple mm-hmm <affirmative> . But because it was, I was doing IVF mm-hmm <affirmative> . Right, like they didn't wanna do a transfer of an embryo because just in case they want it to be as right, like the perfect home for you know, the embryo to arrive in. Yeah. So they might've probably left it there if I wasn't going through right . IVF but
Speaker 3:Instead . Well, and I wonder, do you remember how big it was by any chance? And you might not,
Speaker 2:Not as large as yours. Yeah,
Speaker 3:No. I'm sure it was not, it's almost not, it's not impossible, but it's rare for a simple cyst to be that as big as mine. Yeah . I suspect in your case, because we talked about you had fibroids and you were having surgery for the multiple fibroids and then they incidentally also saw the cyst. There is a chance that had they only seen the cyst, which was in your ovary, not in your uterus, they might have said, let's leave it alone. It'll go away within a cycle or two. It depends. Um, and so that's something really valuable for people to realize that cysts are not a monolith. I mean, again, there are simple clear cysts that are just filled with fluid. Sometimes those simple clear cysts that come up because of your cycle, because you ovulate, they either go away within one cycle because you've ovulated and that cyst has shrunk from like, let's say it's two centimeters, three centimeters, it goes away or it keeps getting bigger, but continues to be a simple clear cyst. At which point we would maybe operate once it gets too bigger than seven to 10 centimeters. Right. Or it sometimes bleeds into itself. And I don't know if you've ever had that, but it's a very dramatic term. It's called a hemorrhagic cyst. And it just means that that simple cyst grew and the wall of the cyst, so imagine like a balloon has blood vessels within it and one of those blood vessels essentially tore and bled within the cyst. So now you have a , a cyst filled with fresh blood. So they call it hemorrhagic. You're not hemorrhaging, but it's a cyst filled with blood. And those cysts can be very painful and they can take anywhere from, you know, one to one week to 3, 4, 5 weeks to resolve as your blood , as your body reabsorbs them. And then even less likely that cyst wall with the blood vessel bursts externally. So you bleed into your pelvis and sometimes in that case you need immediate surgery. Right . Um , what's a really common story that I'm sure friends of yours or your mom, like you mentioned your mom in our last episode, or you might have had in the past is oh my god, terrible pain all of a sudden really acute to the point where you're driving to the doctor's office, you're driving to work and every bump you hit on the road makes you double over in pain. They do an ultrasound, they may see a cyst or they may see nothing in your ovaries, but they see what we call free fluid, meaning fluid floating around in your pelvis because a cyst had been there and burst. As long as they can ascertain that you are stable, that you are not bleeding internally, which most of the time you're not, then they should say to you, okay, this will likely resolve in the next couple of days. You take anti-inflammatories like ibuprofen and you have pretty clear guidelines by the doctor, ideally that like in the next 1, 2, 3 days, your pain should be slowly getting better and then let's revisit and do a follow follow-up ultrasound in a couple of weeks to make sure the fluid has resorbed. And so that is an incredibly common thing. And I have patients who say to us all the time, oh my God, I guess it's all the time they burst all the time and it must be part of my family 'cause it happened to my mom as well. And the answer is, it could be part of your family, but the truth is what's part of your family is that you're a woman, your mother's a woman, you have ovaries and ovarian ovaries mean that we can get ovarian cysts.
Speaker 2:Okay, that makes a lot of sense. So I think we kind of covered that this is a very common thing that can happen. There's different types, right. But what is, is there a , I think I know the answer to this already, which is who is at risk Yeah . For having, forgetting these. I'm assuming the answer, and you can tell me if I'm wrong, is being a woman, you
Speaker 3:Know , anyone with ovaries, I mean, and here's the truth. Anyone with ovaries, listen, women, young girls before they've gone through puberty can get cysts. Like, believe it or not, we have babies in utero where we diagnose ovarian cyst in babies in utero. Not so common, but we see it. So, and then you can get cyst even before you've gone through your cycle. So before you've reached your period, those types of cyst tend to be different. Um, and then even women who are postmenopausal where their ovaries are no longer active and as you might guess postmenopausal women and and girls who have not yet gotten their period when they have cysts, we have to take them more seriously because by definition they are not functional because their ovaries aren't functioning, which means they might be cysts that are actually not benign. Because the word cyst again just means basically like a pocket of fluid in the ovary in this case. And so outside of the follicular functional simple cysts that we talked about and the ones that can bleed, you also can have endometriosis in a, in a cyst. And those need to be addressed. You can have cysts that are solid. I don't know if in your research you saw something called a dermoid cyst, derm means skin and all the things that are on the outside like hair, nails, teeth. So dermoid means those cysts, those pockets, the ovary can be filled with hair, teeth, nails, bone. I know they're gross, they sound gross and they are gross, but they're not uncommon. And if anyone decides to Google it, they'll see crazy pictures of it. But those cysts are benign but again, can cause pain and can cause the ovary to twist and all kinds of things. So again, are cyst is a , is one term that encompasses a lot, but suffice to say again, common to have cyst, especially the type we talked about first that are clear, simple . Yeah .
Speaker 2:And you kind of mentioned this, but like let's talk symptoms and kind of typical signs. Yeah . Because we wanna , you know, this is where we can learn the most of you know what to do as we talked about in our previous one of advocating for ourselves. Yes . Like if we're having certain feelings. Yeah . Like yes . So
Speaker 3:Yeah, so if you have, if you are a person with ovaries and you have pain that you're not used to, do not let everyone essentially say to you like, oh, it's normal, it's normal, it's normal. It might be normal. It might be very common, it might be something completely that does not need to be dealt with. But we don't know that until we've looked into it. So if you have pain during your period, outside of your period pain, during sex pain or pressure for example, I feel like I have to pee a lot. It feels like there's something sitting on my bladder. I feel like I have to poop a lot. It feels like there's something sitting on my rectum. These are all reasons that you should go to the doctor. And even if the doctor does a pelvic exam where she doesn't feel anything , she should, and if she doesn't you should ask her for a pelvic ultrasound because a pelvic exam where we put our hand in is really considered to be a very nonsensitive exam. I don't mean sensitive emotionally, I mean sensitive in the scientific sense of it doesn't pick up a lot. You actually would have to have a very, very large mass in your pelvis and be very, very lean in order for us to potentially feel it. Many pelvic exams are normal when in fact someone had something growing in their pelvis. And again, I don't want us to be scared about that 'cause most of the things that are growing are benign. But if you have symptoms, you absolutely need a pelvic ultrasound. But again, the symptoms are typically pain, pressure, bloating, rarely is irregular bleeding the sign of a cyst. But it can be in rare circumstances. Um Okay . Bleeding often is things like a fibroid or a polyp in the uterus, whereas pain and pressure can be fibroids or cysts.
Speaker 2:Okay. And so then that kind of leads me to the next question, which is how are they diagnosed? It's, it's so because as you're saying it's not just a simple pelvic exam, you kind of have to go Yeah. A couple steps further Yes. To figure that out. Yeah . Right.
Speaker 3:Well, and so first and foremost, we still should be good diagnosticians, right? I should be able to listen to your symptoms and already have, in my mind I think it could be A, B, C and how am I gonna differentiate and prove or disprove. And the first step is almost always a pelvic ultrasound, which is, as you know, typically done in two ways. You typically come in with a full bladder and the doctor puts a probe or the ultrasound tech puts a probe on the outside of your pelvis, right above your bladder. Then they have you pee and then they do a transvaginal probe, which for anyone who's had it, it's of course uncomfortable but should not hurt. Um, and then they may be able to diagnose right from that ultrasound what type of cyst it is. But sometimes we need something further. Sometimes we need for example, an MRI because an MRI can sometimes differentiate between the different types of cysts. And so it really depends. But first and foremost almost always should be a pelvic ultrasound. Now the variations are sometimes you go to the ER first and the ER because they don't have access to an ultrasound tech, but they do have the CAT scan machine there. They might do a , a CAT scan or a ct. Uhhuh . Rarely would the emergency room do an MRI just because the type of technology it is and the type of technician involved. All of these are radiology tests. Again, ultrasound is the most beneficial because it's not radiation and it's actually the least expensive.
Speaker 2:Right. So then I , we kind of touched on this, that there's different, well there's so many different types of cyst. So there's so many different types of treatments I imagine. Yes . Um, but I think, you know, I think it's good to say that not every cyst has to result in surgery. Definitely
Speaker 3:Not . But in fact, the majority of cysts do not result in surgery.
Speaker 2:Right. And, and for me personally, there was a reason behind having those surgeries because of, you know, what I was prepping my body to do. Yes . Um, and in carrying a , a child through IV up . Yes . So it makes a lot of sense. Um, but I guess it's, I guess my question is like what, what sets different cysts apart from needing surgery Yes. To not needing
Speaker 3:Surgery. Great question. So the different reasons would be often size and type of cyst as well as symptoms. So let's assume the most common type of cyst is a simple clear cyst. Right? Again, just a little bubble filled with fluid. You might come in for an ultrasound with me 'cause you have a little bit of pain and I see a cyst that looks simple and clear, which are words we use radiologically. And that just means it looks like it was just a black bubble on the screen and it's filled with fluid. And if it's two to seven centimeters, I will likely say to you, if you're not in a lot of pain right now, then let's wait and watch, repeat the ultrasound in six to eight weeks. Give it a couple of cycles, see if this goes away on its own. It will most likely shrink on its own. If it does, we're done. If it doesn't shrink, then we decide do we leave it alone because it's stable? So maybe we need to keep watching it or do we remove it based on a variety of things. Pain your intention with, again, maybe pregnancy, things like that. Sometimes putting you on the birth control pill because it stops ovulation won't necessarily regress an already formed cyst, but it will stop new ones because it does seem like some people just create more cysts than others. Now that's, if it's again, simple and clear. If that simple and clear cyst like we talked about, bled into itself and became hemorrhagic, if I can tell clearly it's just a hemorrhagic cyst, I would still just wait and watch for a period of time. Again , six to eight weeks, let's say the patient is not in a lot of pain. They have, they understand they can always call us. If things change, then we would wait and watch. And if it goes away, we're done. If on the other hand we think it looks like old blood, which is an endometrioma again from endometriosis mm-hmm <affirmative> . I can't say everyone should do this, although I think everyone should do this, but it's not necessarily yet part of the standard guidelines. I believe that if it is found on an ultrasound and suspected that person should also have an MRI , because that's often how they can differentiate between does it really seem like a benign endometrioma versus the very rare. But what happened to me, which is when my endometrioma malignantly transformed into cancer. Rare, but it can happen. And that would be the difference between surgery or not because an endometrioma alone might cause so much pain that you need it removed even when it's four centimeters. But other patients live with it at four centimeters and either stay on the birth control pill to help decrease it from growing mm-hmm <affirmative> . Or they go on medication just like we talked about with fibroids, these, these anti-hormone medications, like something called Lupron or they get it removed. But again, this is all assuming that your doctor has done their due diligence to figure out maybe through a series of tests that it is benign.
Speaker 2:Right. Right. And then you, you kind of just touched on this, that there's some people who they just develop cysts more, you know, they recur more often. Yes. Right. And so for those people, like what, what advice would you give to that, that patient?
Speaker 3:Yeah. And when I say that, the truth is it's not like we have scientific evidence as to like why do some people create more cysts ? But we hear people and we see people, and I know people who be , again, they, many of my patients who are all off birth control pills and some seem to have more recurrent cysts than others that we've seen and we've documented. So the truth is the only for sure way to decrease the chance of those cysts, assuming they don't want their ovaries removed, is to stop ovulation. Because again, the , the majority of these recurrent cysts we're talking about are those that we talked about follicular, they're called follicular simple or functional cysts, meaning that ovary, ovulated and that little bubble of fluid that released the egg created a cyst and persisted. So those patients, when they go on the pill or the birth control patch or the birth control ring, all of which stop ovulation, they have less likelihood of developing those cysts. So that's the only concrete scientific way we know to stop those cysts. Do I think there are holistic natural ways maybe I'm, I'm always a fan of saying like, I don't, I don't know what I don't know. Right. But if you said to me, what is the best way for me to stop these cysts? That is scientifically proven, it is stop ovulation.
Speaker 2:Okay. Um, and I know I asked this question about fibroids, but I think it's important , um, to ask here. Yeah. Which is, if you are someone that develops cyst or you've had maybe just one , um, does it increase your risk of other gynecologic issues ?
Speaker 3:Great question. With fibroids, I could say probably not meaning with people commonly have fibroids, people come , they have cysts with cyst, it's a little different because again, it depends on the type. If it was a functional follicular simple cyst like we talked about, doesn't seem like that increases your risk of anything else. If it was an endometrioma, meaning endometriosis in the ovary, then it means you have an increased chance of endometriosis in other parts of your body and other parts of your pelvis, which can certainly cause pain and fertility issues. Um, if it was a dermoid that really yucky one that had the hair and all those things, it doesn't increase your risk of anything else. So again, it really depends on the type of cyst that you have.
Speaker 2:And so then it just to reinforce also what you just said, which is it depends what type of cyst someone has and, and it could, depending on the type of cyst impacts fertility or pregnancy.
Speaker 3:Absolutely. Meaning again, if it's endometrioma, those can impact fertility for sure. We know that if it's a benign dermoid, again, yes, it's gross, it's got hair and teeth and things like that in it, but it won't impact it. If it's a simple follicular cyst, then it depends really on the size, meaning in general, I would say those simple cysts don't impact fertility. But if it gets too big in theory, could there be some hormonal reactivity? Maybe in your case, I think you had mentioned that it might have also impacted your, your tube. So if it was going into your tube, that can impact fertility because we don't know what kind of fluid is communicating into the tube and going back into the uterus. Um, and then by the way, we didn't even touch upon, 'cause that's an entirely different topic, two topics, which is can you have cyst in your fallopian tubes, for example? And the answer is you can, and and those are actually less common and more concerning. One is because that can affect impact fertility 'cause the tubes directly communicate with the uterine lining. Right. But also because we now know that ovarian cancer actually starts most fall , most likely in the tube itself. And so this is why we know from data that removing someone's tubes if they're done with fertility, really decreases their risk of ovarian cancer significantly. Um, and the other topic which we'll have to do another podcast on is polycystic ovarian syndrome. PCOS. Right . Which is a terrible name because it actually doesn't imply that you are more likely to get true cysts in the way you and I are talking about. That's an entirely different entity where your ovaries just have multiple tiny little pockets of fluid, but the term cyst in Latin means pocket of fluid. And so we, we've kind of wrongly called that polycystic ovarian syndrome, meaning it's accurate, but it's not accurate if you think that cyst means something big.
Speaker 2:Okay . If that makes sense . That's helpful. And do you think there are any myths or common misconceptions about ovarian cysts that we should kind of hit on?
Speaker 3:I think the biggest , um, well, two myths that , that oppose each other. I think the biggest myth is that people get scared that ovarian cysts mean cancer. They all mm-hmm <affirmative> . The good news is they almost never mean cancer.
Speaker 2:That
Speaker 3:Right . The contralateral part is sadly also true. Ovarian cancer still , um, presents itself as a very challenging thing for us to diagnose. We don't have any screening tests for it. I'm assuming you know that, but even my smartest of people don't know that your pap smear is not a screening test for ovarian cancer. You can have a normal pap smear, no , a normal pelvic exam, no family history. And unfortunately you could still develop ovarian cancer. And we don't have a screening test. We have diagnostic tests, meaning you come in with, with pain, we should do an ultrasound, but no screening test. So while most of the time cysts are not cancer, sometimes we see cyst and it's hard to differentiate which ones are cancer or not. Sometimes again, the majority will be benign. I wanna keep saying that to decrease fear mm-hmm <affirmative> . But we have to be finicky as doctors and I need you to know that to kind of push the doctors who aren't being finicky to really follow up until they are 100% sure that it is benign.
Speaker 2:Okay. And then we're gonna do our, our last thing. Rapid fire . Yeah . What are the three takeaways we did four last time? Well , you could do four <laugh> , um, takeaways that you'd like the listeners to know about ovarian cyst and today's episode.
Speaker 3:Okay. So I guess I'll , it'll be kind of similar to the fibroids. Like, first of all, cysts are common, not as common as fibroids as far as we know, but that's not really true. We just don't have data and they're not, again, a monolith. So it's harder to extrapolate what percentage of women have ovarian cyst. But the truth is, in your lifetime almost everyone will have a couple of ovarian cysts, even if they were never diagnosed because you ovulate. So cyst are common. Don't be scared of cysts, but make sure that you are advocating for yourself. And if your doctor is not suggesting a pelvic ultrasound, if you have pain, pressure or bloating, then please ask for a pelvic ultrasound because this is the fourth one when it comes to ovarian cancer, which is rare, but not easy to diagnose, the best way for us to diagnose it is for women to know their body and understand when their body is different and not wait too long. All the data shows that women unfortunately push off their symptoms for six to eight months and doctors unfortunately don't intervene quickly and easily for a variety of good and bad reasons. Things like our ultrasounds always covered by insurance, they're not always covered by insurance. Right . Um, so advocate for yourself, if you have pain, pressure, bloating for more than two weeks, you absolutely should be going to see the doctor.
Speaker 2:Okay.
Speaker 3:Okay.
Speaker 2:Good. Well, thank you Dr. Gani . I really appreciate it so much. Um, and I think these talking about things that are somewhat common, like sometimes get overlooked. So I'm so happy that we can actually take some time and hopefully people feel a little bit more educated and empowered to, you know, know their bodies, advocate for themselves. Um, and I really appreciate the time that you've given us. Thank you. Um , and our listeners, thank you because it's really important information that not everybody wants to talk about, but we need to do more. I know ,
Speaker 3:I know. Well, thank you. I appreciate it . And I would love everyone to actually go over to tell every amazing Lady Teal . I'm the president actually of this nonprofit that has done some work with Tina's Wish, and it's a wonderful nonprofit that really helps educate people mostly on ovarian cancer. But starting, we're starting to dip our toes into menopause and perimenopause. Um, so I think it's really valuable for people to support that organization. But also you and I both know, unfortunately, we cannot leave our health information up to the teachers, our mothers or our doctors because in that group of three teachers, mothers, doctors, they either don't have the knowledge or don't have the time. So we have to learn about it ourselves and then we Yeah . And then we can do better for the next generation.
Speaker 2:100%. I agree with that. So another thank you to all of our listeners. We hope you feel like I said, empowered, educated, all of that , um, when it comes to your gynecological health. And please feel free to share this with your friends and family and others because if you don't wanna have the conversation with folks, we just did it for you. Um, and so it makes it easier to educate people about these very important , um, gynecological health topics. So thank you for joining us again today. Thank
Speaker 3:You.
Speaker 1:For more information about gynecologic health, visit tina's wish.org/what to know . That's tina's wish.org/w H-A-T-T-O-K-N-O-W . And like, follow or subscribe wherever you listen to your favorite podcasts.