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Having Irregular Cycle. Diagnosed With Fibroid And Cyst In Left Ovary. MRI Done. Any Suggestion?
Question: Dear Dr. Gouri,
A few weeks ago my wife XXXXXXX had contacted you woth her problems, on which you had advised.
If you may recollect, she was having irregular cycles and diagnosed with a fibroid and cyst in left ovary. She was asked to go fro CA125 (when she was bleeding profusely) and as such it turned out to be 190.5. With this information the local gyn (Max Health care IP Extn) asked her to report for immediate surgery. The Gyn also followed up with repeated telephone calls indicating the consequences of delaying the process - which made us panic.
However, we decided to get another opinion. Based on an MRI recently done (16.6.2012) there were two cysts in left ovary of which one was about 4cm and another one a bit smaller. The right ovary also had a cyst of similar size. All were follicular/lueteal. No free flowing fluid or adnexal mass. We also got a second CA125 then and it read 59.
We also had an US done on July 24, 2012 the left ovary cysts were 2.1 cm (hemorghagic) and another 3.3 cm. No free flowing fluid / adnexal mass, etc.
Ultra Sound results (24.July.2012):
Ultrasound Scan: Pelvis
Transabdominal & transvaginal scan with 2D, 3D, 4D & power Doppler studies.
The uterus measures 68x62x77 mm. The endometrium is 06 mm thick. It is homogeneous & avascular: dysfunctional change. No focal lesion is seen in it. The configuration of the cavity is normal. There is asolitary fibroid. This is in the anterior wall & measures 62 mm across. This has an interstitial & a subserous component but no submucous component and is minimally vascular. The right ovary has a normal contour, echo pattern & size. It measures 13x12x11 mm across & 0.94 ml in volume. The left ovary measures 56x42x54 mm across &. 68.53 ml in volume. It shows a 21 mm thin-walled, hemorrhagic, avascular cystic area and a 33 mm thin-walled, clear, avascular cystic area. Both these cystic areas are unilocular. No adnexal mass is delineated. There is no free fluid in the pelvis.
MRI Results (16 XXXXXXX 2012):
Multiplanar T1 and T2 weighted MR images of the pelvic region were obtained using
TSE and STIR sequences.
FINDINGS:
Urinary bladder is distended No wall thickening or mass lesion seen. The uterus is enlarged in size with a mass of heterogenous intensity in anterior fundus and body of approximate size measuring 5.14 x 4.33 cm in the myometrium suggestive of fibroid. Endometrium is thin, central and smooth in outline with unremarkable
endomyometrial junction.
Cervix is unremarkable in size and signal pattern.
Bilateral ovaries shows cysts of approximate size measures 3.98 x 3.95 cm on left
side and 3.17 x 2.13 on right side. Another small cyst is seen in left ovary. The
cysts show hypointensity on T1WI and hyperintensity on T2WI (homogenous fluid
intensity. Margins are well defined. The visualized bowel loops are unremarkable.
The rectum is unremarkable.
The perirectal fat planes are intact.
No pelvic / inguinal lymphadenopathy is seen.
No free fluid is seen in the pelvis
IMPRESSION: MRI findings reveal:-
Fibroid uterus.
Cysts bilateral ovaries -- ?follicular / ? luteal cysts.
Serum fetoprotein levels to rule out ne•plasia
Advice: Clinical correlation & follow up scan after 2 months
What would you suggest now?
Regards.
XXXXX
A few weeks ago my wife XXXXXXX had contacted you woth her problems, on which you had advised.
If you may recollect, she was having irregular cycles and diagnosed with a fibroid and cyst in left ovary. She was asked to go fro CA125 (when she was bleeding profusely) and as such it turned out to be 190.5. With this information the local gyn (Max Health care IP Extn) asked her to report for immediate surgery. The Gyn also followed up with repeated telephone calls indicating the consequences of delaying the process - which made us panic.
However, we decided to get another opinion. Based on an MRI recently done (16.6.2012) there were two cysts in left ovary of which one was about 4cm and another one a bit smaller. The right ovary also had a cyst of similar size. All were follicular/lueteal. No free flowing fluid or adnexal mass. We also got a second CA125 then and it read 59.
We also had an US done on July 24, 2012 the left ovary cysts were 2.1 cm (hemorghagic) and another 3.3 cm. No free flowing fluid / adnexal mass, etc.
Ultra Sound results (24.July.2012):
Ultrasound Scan: Pelvis
Transabdominal & transvaginal scan with 2D, 3D, 4D & power Doppler studies.
The uterus measures 68x62x77 mm. The endometrium is 06 mm thick. It is homogeneous & avascular: dysfunctional change. No focal lesion is seen in it. The configuration of the cavity is normal. There is asolitary fibroid. This is in the anterior wall & measures 62 mm across. This has an interstitial & a subserous component but no submucous component and is minimally vascular. The right ovary has a normal contour, echo pattern & size. It measures 13x12x11 mm across & 0.94 ml in volume. The left ovary measures 56x42x54 mm across &. 68.53 ml in volume. It shows a 21 mm thin-walled, hemorrhagic, avascular cystic area and a 33 mm thin-walled, clear, avascular cystic area. Both these cystic areas are unilocular. No adnexal mass is delineated. There is no free fluid in the pelvis.
MRI Results (16 XXXXXXX 2012):
Multiplanar T1 and T2 weighted MR images of the pelvic region were obtained using
TSE and STIR sequences.
FINDINGS:
Urinary bladder is distended No wall thickening or mass lesion seen. The uterus is enlarged in size with a mass of heterogenous intensity in anterior fundus and body of approximate size measuring 5.14 x 4.33 cm in the myometrium suggestive of fibroid. Endometrium is thin, central and smooth in outline with unremarkable
endomyometrial junction.
Cervix is unremarkable in size and signal pattern.
Bilateral ovaries shows cysts of approximate size measures 3.98 x 3.95 cm on left
side and 3.17 x 2.13 on right side. Another small cyst is seen in left ovary. The
cysts show hypointensity on T1WI and hyperintensity on T2WI (homogenous fluid
intensity. Margins are well defined. The visualized bowel loops are unremarkable.
The rectum is unremarkable.
The perirectal fat planes are intact.
No pelvic / inguinal lymphadenopathy is seen.
No free fluid is seen in the pelvis
IMPRESSION: MRI findings reveal:-
Fibroid uterus.
Cysts bilateral ovaries -- ?follicular / ? luteal cysts.
Serum fetoprotein levels to rule out ne•plasia
Advice: Clinical correlation & follow up scan after 2 months
What would you suggest now?
Regards.
XXXXX
hi XXXXXX,
welcome again,
Thanks for the query.
according to your description,
the cysts are possibly follicular cysts which can be seen frequently in association with fibroid, cause for both is hyperestrogenism,
when follicle rupture to release ovum some amount of bleeding can occur internally which forms hemorrhagic cyst.
as per the cysts are concern they appear to be benign because of factors like,
-less than 5 cms in size,
-unilocular,
-well defined wall,
-avascular cyst,
-size of left cyst reduced and right cyst disappeared in 1 month period,
so you can follow the cysts with regular ultrasound examinations for 3 months period which will possibly regress by that time.
CA 125 levels will be elevated in conditions other than malignancies also, fibroid is one of them, so that may be the reason for elevation in the levels.
now regarding fibroid,
the treatment option depends on whether she is symptomatic or asymptomatic.
as you told she is having irregular cycles,
if she is having heavy bleeding for prolonged periods, pain abdomen etc features, as that can affect her general health and as she is in 40 plus age the option is hysterectomy.
if she is not having symptoms, as the fibroids can regress after menopause and she is in perimenopausal age group she can wait for regression of fibroids.
if she is having any high risk factors for surgery or you want to postpone the surgery for sometime to decrease the size of fibroid or for any other cause you can go for medical treatment.
Hope I have answered your query. I will be available to answer your follow up queries. If you are satisfied with all my answer, please rate the answer after closing the discussion.
Take care.
welcome again,
Thanks for the query.
according to your description,
the cysts are possibly follicular cysts which can be seen frequently in association with fibroid, cause for both is hyperestrogenism,
when follicle rupture to release ovum some amount of bleeding can occur internally which forms hemorrhagic cyst.
as per the cysts are concern they appear to be benign because of factors like,
-less than 5 cms in size,
-unilocular,
-well defined wall,
-avascular cyst,
-size of left cyst reduced and right cyst disappeared in 1 month period,
so you can follow the cysts with regular ultrasound examinations for 3 months period which will possibly regress by that time.
CA 125 levels will be elevated in conditions other than malignancies also, fibroid is one of them, so that may be the reason for elevation in the levels.
now regarding fibroid,
the treatment option depends on whether she is symptomatic or asymptomatic.
as you told she is having irregular cycles,
if she is having heavy bleeding for prolonged periods, pain abdomen etc features, as that can affect her general health and as she is in 40 plus age the option is hysterectomy.
if she is not having symptoms, as the fibroids can regress after menopause and she is in perimenopausal age group she can wait for regression of fibroids.
if she is having any high risk factors for surgery or you want to postpone the surgery for sometime to decrease the size of fibroid or for any other cause you can go for medical treatment.
Hope I have answered your query. I will be available to answer your follow up queries. If you are satisfied with all my answer, please rate the answer after closing the discussion.
Take care.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Thank you for the response Dr. Gouri. Your explanation of details mean a lot to us, particularly as we are surrounded by this highly commercial medical environment in Delhi. I do wish to acknowledge that we are highly impressed by your insights and feel confident with your responses.
Can we administer progesterone cream (natural and not synthetic) through external applicationin pelvic area. If so, is there any time period for use of this. She had her last cycle in XXXXXXX 12, 2012 and has not yet had her periods.
As regards her fibroids is concerned, she has so far not complained of anything disturbing. She is presntly 84 kg (5ft 7 inch tall) and is now regular in her walks to reduce weight. Further her diet is also regulated with lots of greens. Can you suggest any diet. And are we on right track.
Regards.
XXXXXXX
Can we administer progesterone cream (natural and not synthetic) through external applicationin pelvic area. If so, is there any time period for use of this. She had her last cycle in XXXXXXX 12, 2012 and has not yet had her periods.
As regards her fibroids is concerned, she has so far not complained of anything disturbing. She is presntly 84 kg (5ft 7 inch tall) and is now regular in her walks to reduce weight. Further her diet is also regulated with lots of greens. Can you suggest any diet. And are we on right track.
Regards.
XXXXXXX
hi XXXXXX,
though some articles are there suggesting the use of progesterone cream for fibroids,
actually that can only reduce the excessive bleeding due to fibroids and can regularize the periods, but shrinkage of fibroids that too of 6 cms size may not be possible with progesterone cream.
actually anti-progesterones like mifepristone is used in treating the symptoms of fibroids and in decreasing the size, which can be used for maximum period of 3 months.
actually there is no role of particular diet in reducing the size of fibroid, as general measures she can decrease fat content in the diet and can follow her regular exercise.
so if you are sure that she is not having any symptoms because of fibroids, you can go for expectant management like,
you can observe the fibroid by periodic checkups for 6 months, in this time if symptoms appear or size of the fibroid increases you can go for surgery.
you can go for expectant management because,
-diagnosis is certain,
-size of the uterus is less than 12 weeks of pregnancy size,
-follow up is possible,
-there is only 0.1% malignant change in fibroids,
-and mainly she is asymptomatic.
but you have to remember if she develops symptoms you have to consult gynecologist and take medical treatment prior to surgery or go for direct surgery.
don't worry nothing wrong with expectant management in asymptomatic woman as I told the chance of malignant change is very less, if the size regresses it is good surgery can be avoided, if symptoms appear or size increases then it is clear that surgery has to be done.
Wish you Good Health, If you are satisfied with my response please rate the answer after closing the discussion.
Take care.
though some articles are there suggesting the use of progesterone cream for fibroids,
actually that can only reduce the excessive bleeding due to fibroids and can regularize the periods, but shrinkage of fibroids that too of 6 cms size may not be possible with progesterone cream.
actually anti-progesterones like mifepristone is used in treating the symptoms of fibroids and in decreasing the size, which can be used for maximum period of 3 months.
actually there is no role of particular diet in reducing the size of fibroid, as general measures she can decrease fat content in the diet and can follow her regular exercise.
so if you are sure that she is not having any symptoms because of fibroids, you can go for expectant management like,
you can observe the fibroid by periodic checkups for 6 months, in this time if symptoms appear or size of the fibroid increases you can go for surgery.
you can go for expectant management because,
-diagnosis is certain,
-size of the uterus is less than 12 weeks of pregnancy size,
-follow up is possible,
-there is only 0.1% malignant change in fibroids,
-and mainly she is asymptomatic.
but you have to remember if she develops symptoms you have to consult gynecologist and take medical treatment prior to surgery or go for direct surgery.
don't worry nothing wrong with expectant management in asymptomatic woman as I told the chance of malignant change is very less, if the size regresses it is good surgery can be avoided, if symptoms appear or size increases then it is clear that surgery has to be done.
Wish you Good Health, If you are satisfied with my response please rate the answer after closing the discussion.
Take care.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Dear Dr. Gouri, Thanks for your response once again. But my question regarding progesterone cream was for reducing the size of cysts. Will it help ?
Regarding fibroid, if we decide to go for surgical removal, what type of surgery would be recommeded for 6 cm fibroid - laproscopic, conventional or removal from vaginal area.
Regards
Regarding fibroid, if we decide to go for surgical removal, what type of surgery would be recommeded for 6 cm fibroid - laproscopic, conventional or removal from vaginal area.
Regards
hi XXXXXXX,
as I told previously the cysts she is having will fit into the criteria for conservative management, that will possibly resolve soon, followup with ultrasound examination for 3 months should be done.
anyhow if your doctor prescribed progesterone cream then that can be used which will possibly prevent the occurrence of new cysts but its efficacy in decreasing the size of present cyst is some what doubtful.
according to manufacturers it should be taken from 10th day of cycle to 26th day, as at present she didn't get her periods since XXXXXXX 12th, if you decided to use, she can start now and can apply on anyone of the areas like face, neck, upper chest etc for 16 days then let her stop probably after that she will get her periods.
better to use natural progesterone.
as your wife is having single fibroid with uterine size less than 12 weeks of pregnancy size she can go for laparoscopic surgery.
vaginal approach is usually followed when there is some amount of descent.
Wish you Good Health, If you are satisfied with my response please rate the answer after closing the discussion.
Take care.
as I told previously the cysts she is having will fit into the criteria for conservative management, that will possibly resolve soon, followup with ultrasound examination for 3 months should be done.
anyhow if your doctor prescribed progesterone cream then that can be used which will possibly prevent the occurrence of new cysts but its efficacy in decreasing the size of present cyst is some what doubtful.
according to manufacturers it should be taken from 10th day of cycle to 26th day, as at present she didn't get her periods since XXXXXXX 12th, if you decided to use, she can start now and can apply on anyone of the areas like face, neck, upper chest etc for 16 days then let her stop probably after that she will get her periods.
better to use natural progesterone.
as your wife is having single fibroid with uterine size less than 12 weeks of pregnancy size she can go for laparoscopic surgery.
vaginal approach is usually followed when there is some amount of descent.
Wish you Good Health, If you are satisfied with my response please rate the answer after closing the discussion.
Take care.
Note: Revert back with your gynae reports to get a clear medical analysis by our expert Gynecologic Oncologist. Click here.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
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