Ovarian Cysts

Ovarian cysts are fluid filled sacs that form on the ovary.  These cysts are very common and occur every month when your ovary is stimulated by your brain to release an “egg” during ovulation.  We use the term cyst and follicle interchangeably and sometimes this can be very confusing for patients.

What can cause an ovarian cyst?

  1. Ovulation:  If you are not in menopause, every month one of your follicles is stimulated to mature.  As the follicle grows it forms a little cyst which will eventually rupture mid-cycle releasing the egg.  These are called “functional” ovarian cysts and they do not need surgical intervention as they typically resolve on their own.
  2. Dermoid cyst:  Are made of “germ cells” which are present since you were a fetus growing in your mother’s belly.  They are also called teratomas and can contain teeth, hair, nerve cells, fat…pretty much any type of tissue found in your body.  They are usually found in women once a doctor does an ultrasound which is usually between the ages of 20-40. These types of cysts are usually benign but once found should be removed because a rare form of teratoma can be cancerous.
    Teratoma with teeth
    Teratoma with a tooth and hair








3. Polycystic Ovarian Syndrome (PCOS):  Women with PCOS have difficulty with ovulation and if you do not ovulate, the follicles never rupture which means that the ovary is left with many small cysts that over time can become very large and painful. Birth control pills can help  

4. Endometriosis: Women with endometriosis can form “endometriomas” which are ovarian cysts filled with blood.  When the blood is trapped and kept in place for a while, it darkens.  During surgery, if the endometrioma is ruptured, the blood looks like dark chocolate so another name for endometrioma is “chocolate cyst”.

5. Pregnancy:  Believe it or not, pregnancy has a cyst that supports the pregnancy during the first twelve weeks of gestation until the placenta develops.  This cyst is called a corpus luteum cyst and it is completely benign.  It usually resolved on its own by week 12 of gestation.

6. Infections:  If you get pelvic inflammatory disease from either a sexually transmitted infection or a ruptured appendix, your body will form a cyst wall around the infection called an abscess.  These are cysts that are filled with pus. They can either be drained through the vagina with the help of interventional radiology or surgically.  These types of infections require antibiotics to prevent spread and fertility issues.

7. Cancer: less than 1% of ovarian cysts are cancerous

What are my risks of ovarian cancer if I have a cyst?

Ovarian cancers are extremely rare but there are certain women who may have a higher risk:

  • Family history or genetic predisposition
  • Previous history of breast or intestinal cancer
  • A cyst that appears complex & suspicious with solid and multiple fluid filled areas
  • Fluid collection outside the cyst wall.  Fluid in the abdominal cavity called ascites

What are some symptoms I may feel if I have an ovarian cyst?

  • Cramping abdominal pain or pressure, dull ache may be constant or intermittent
  • If the cyst ruptures, the pain can be sharp and excrutiating
  • If the cyst twists in on itself (torsion) you can get nausea and vomiting, this requires surgery to save the ovary because torsion can cut off the blood supply to the ovary

How do we diagnose an ovarian cyst?

  • Pelvic exam this is why your annual exams are so important
  • Ultrasound
  • CT or MRI

What can a blood test tell me about my cyst?

  • Pregnancy test: will let you know if the cyst might be a corpus luteum cyst
  • CA-125: can be elevated in endometriosis and cancer.  Should only be ordered if a cyst appears suspicious or in a post menopausal female
  • HE-4: produced by epithelial ovarian cancer cells.  Can help you differentiate between and endometrioma and an ovarian cancer.  HE4 will be low in patients with endometriosis


  • Watchful waiting: if no symptoms and the cyst does not appear suspicious, you can repeat the ultrasound in 6 wks to see if it will stay the same, resolve or grow
  • If tumor markers are elevated: surgery to remove the cyst or the ovary
  • If the cyst is greater than 5cm: more likely to require surgery because of the risk of ovarian torsion.

Hysterectomy: The Basics

A hysterectomy is a surgical procedure meant to remove your uterus.

You would be surprised how many women do not know where the uterus is located or that removing it means that they can no longer have children or get periods.

There are four different ways of performing a hysterectomy:

  1. Vaginal Hysterectomy:  the uterus is removed through a vaginal incision.
  2. Laparoscopic Hysterectomy: the uterus is removed via the aid of a tiny camera and small openings in your belly.
  3. Robotic Hysterectomy: similar to a laparoscopic hysterectomy except that the tools are attached to the DaVinci Robot which is then controlled by your surgeon.
  4. Abdominal Hysterectomy: the uterus is removed via a horizontal or vertical incision on your belly.  This may need to be done if the uterus is too large to remove safely via a minimally invasive approach.

Why would I need a hysterectomy?

There are many reasons why a woman may need a hysterectomy.  The most common are uncontrolled bleeding, large tumors (fibroids), herniation or prolapse of the uterus, cancer and severe pelvic pain due to endometriosis or adenomyosis.

Alternatives to hysterectomy:

Removing your uterus should be the last resort (unless you have cancer) because of the risks involved with surgery.  If your issue is heavy bleeding, you can try hormonal options (birth control pills or progesterone), tranexamic acid (Lysteda), Progesterone containing IUDs, GnRH agonist (Lupron).  Other surgical options like endometrial ablation, uterine artery embolization, or myomectomy (removal of the fibroid/s.


Many women need a hysterectomy but are concerned about child-bearing.  You have options and each case is unique.  Having a hysterectomy does not take away your ability to conceive.  We just need to be a little more creative.  Advanced reproductive technology now allows women to preserve their eggs and if need be have a child via a surrogate.

What other organs are removed during a hysterectomy?

Typically we recommend removing the cervix and fallopian tubes because both are attached to the uterus.  In the past it was believed that preserving the cervix helped with sex and support however multiple studies have shown that this is not the case and that preserving the cervix only places you at risk for cervical cancer in the future.  New studies have shown that the fallopian tubes should be removed to avoid a rare type of cancer that is found in the tubes.

Do my ovaries need to be removed?

Yes if you are in menopause.  No if you are not in menopause or feel very strongly about preserving them.  Ovaries make our hormones and our hormones are vital to prevent osteoporosis, Alzheimer’s, dementia, hot flashes, night sweats, mood swings, insomnia, weight gain….the list is endless.  So if your ovaries are still functional…meaning you are not in menopause, you should try to preserve them.  If you have gone through menopause, the recommendation is to remove them because of the risk of ovarian cancer and the fact that they are no longer functional.

Am I still going to be woman if I get my uterus taken out?

Absofuckenlutely!!! Please do not let anyone tell you otherwise.  In fact, most women who need a hysterectomy have had such debilitating disease for so many years that once they have this procedure done they realize how amazing their life can be.  You will be even more of a woman because you will now be able to enjoy all of the “womanly” things that you missed out on because your uterus got in the way.  Almost 99.9% of my patients report such an improved quality of life that they are upset they didn’t do the surgery sooner.  My advice is talk to your doctor.  Each case is unique and they will help you figure out what is the best approach for you.

The new 21st Century Mona Lisa and Lasers

Da Vinci's Mona Lisa
Da Vinci’s Mona Lisa

Perhaps the most visited, talked about and parodied work of art in the world is Leonardo da Vinci’s, Mona Lisa.  Medicine is fascinated with Leo.  First, we named a surgical Robot after him and now, an amazing laser called the Mona Lisa Touch.

It is the new talk of the town in the US but has been in Europe for almost 10 years.  It only recently gained FDA approval in December 2014. The FDA is like the bouncer with a chip on his shoulder at the most coveted night club, giving you the stare-down because you are wearing your Skechers, “Shape-ups” and you should be wearing your  “Louboutins”.  The fact that Mona Lisa got in the club despite her 16th century wardrobe was a big deal and her dance moves have been revolutionary.

The Mona Lisa laser is the only non-hormonal option for women suffering from vaginal dryness, painful intercourse and mild stress incontinence (leaking of urine while jumping, running, coughing, sneezing, laughing too hard).  This is revolutionary because in the past, women who did not or could not take hormones really had no other option but to suffer in silence.

austin powersThe Mona Lisa Touch is not the type of laser beam that Austin Powers wanted to use on his shark’s heads.  It is very gentle, relatively benign and it will not attack you. It can be done in the office with no anesthesia and completed in just 3 sessions, 6 weeks apart.  Those of you who are fascinated with Madonna’s fountain of youth and wonder how a 57 yr old can look like this:


should know that her secret is the fractional CO2 laser. Without getting too technical discussing reflectors, couplers, kilowatts and power; the laser is special becauses it causes small columns of injury to the skin which then trigger a healing response in our bodies. New collagen, elastin and fibrin are deposited at the site of injury to plump up our skin and make us look more youthful.

The applications for the C02 laser in Gynecology are many.  We use the C02 laser to treat endometriosis, cut through tissue, vaporize warts and other HPV lesions. We also use it to “rejuvenate” the vaginal wall and external genital labia.

I am the biggest skeptic when it comes to gimmicks. I have to admit that when the Mona Lisa Touch received FDA approval, my interests peaked because I knew that there were clinical trials proving its efficacy.  I have yet to regret purchasing this laser for my patients.

I have many breast cancer survivors who are not candidates for hormone replacement therapy.  Their only option is the laser.  Despite a cancer diagnosis, patients want to lead normal lives which includes being able to have sex without pain. There is no shame in wanting this…it is a primal need for many and in my humble opinion, an essential part of every relationship.

We are lucky that we can now talk about these things.  Women in the 16th Century probably had to “grin and bear it”.  It doesn’t have to be the Sahara Desert or sand paper, ladies, your vagina will thank you for the rejuvenation. Who needs People Magazine or the Louvre to be glorified.  With the Mona Lisa Touch your partner will certainly be in awe of you and your new-found laser. Welcome to the 21st Century!

A Rare Form of Ectopic Pregnancy… Cornual Pregnancy

Location for ectopic pregnancies
Locations for Ectopic Pregnancies

An ectopic pregnancy is a pregnancy that occurs outside of the uterine cavity 98% of ectopic pregnancies occur within the fallopian tube. There is a rare type of  ectopic pregnancy  that occurs at the junction between the fallopian tube and the uterus. These are called interstitial or cornual pregnancies  and can be extremely dangerous, often times leading to  rupture at the site of implantation and internal hemorrhage.   Recently, I had a patient who unfortunately developed a cornual ectopic pregnancy one year after having a myomectomy (removal of fibroids).  In her situation,  the site where the fibroid was removed was at the  junction between the fallopian tube and the uterus.  The pregnancy implanted at this site and unfortunately the patient ended up needing a hysterectomy to protect her life.   There was no way we could salvage the pregnancy  or her uterus without causing severe bleeding.  The pathology specimen showed  that the pregnancy had not only developed at the cornua but it had also started to invade the muscle which would have led to an accreta (placenta gets imbedded in the muscle and at the time of delivery does not detach and causes severe  hemorrhaging.

Uterus with Cornual Pregnancy
Uterus with Cornual Pregnancy
Uterus Removed with Ectopic Pregnancy seen on the Right Corner.  Fibroids also visible.
Uterus removed with fetus seen on the left corner. Fibroids also visible.

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