Treatment of Ovarian Conditions

Premenopausal women — 

In premenopausal women,  ovarian cysts less than 5 cm are usually functional and will resolve.  Watchful waiting usually involves monitoring for symptoms (pelvic pain or pressure) and repeating the pelvic ultrasound after six to eight weeks.  Some premenopausal women will be advised to take a birth control pill during this time to help prevent new ovarian cysts from developing.

If a cyst decreases in size or does not change, the ultrasound is often repeated at regular intervals until your health care provider is certain that the cyst is not growing. If the cyst resolves, no further testing or follow-up is required.  However, patients with recurrent symptomatic cysts might consider oral contraceptives.  

Persistent cysts may be due to a number of causes including

• Endometriomas
• Anovulatory cysts
• Ovarian tumors
• Paraovarian cyst
• Hydrosalpinx (may be confused for an ovarian cyst
• Pseudocyst due to loculated peritoneal fluid with adhesions

Postmenopausal women — 

Realize the vast majority of cysts are benign (not cancer) in both premenopausal and postmenopausal patients.  The types of persistent cysts are similar to premenopausal patients, but typically we don't tend to see endometriomas in postmenopausal patients.  If the cyst shows typical benign features by ultrasound (simple cyst, nearly simple cyst or hydrosalpinx), then you can be reassured that the cyst really is benign, regardless of it's size.  Followup ultrasound is still suggested, initially in about 3-6 months and then yearly until shown to be stable for 3 years.  Blood tests like CA 125 levels really are not helpful when the ultrasound shows a typical benign cyst.  Unlike premenopausal patients, cysts seen in postmenopausal patients usually do not resolve, unless the women is perimenopausal in which case the cyst may still be functional. 

If in doubt following ultrasound, measurements of CA 125 should be considered.
If the CA 125 levels increase or the cyst grows or changes in appearance,  or if the cyst is unusually large, then surgery to remove the cyst should be considered.   

Surgery is the last resort and rarely required for ovarian cysts  

However, surgery may be recommended in the following situations:

• A cyst is causing persistent pain or pressure, or may rupture or twist.
• A cyst appears on ultrasound to be caused by endometriosis and is removed for fertility reasons.
• Very large cysts (>10  cm) are more likely to require surgical removal compared with smaller cysts. However, a large size does not predict whether a cyst is cancerous.  Ultrasound is very good and showing typical benign features so if the cyst appears benign, then you can be reassured that the cyst is benign regardless of size.  
• If the cyst appears suspicious for cancer. If you have risk factors for ovarian cancer or the cyst looks potentially cancerous on imaging studies, your health care provider may recommend surgery.
• If the suspicion for ovarian cancer is low but the cyst does not resolve after several ultrasounds, you may still choose to have it removed after a discussion with your health care provider. However, surgical removal is not usually necessary if the ultrasound shows typical benign features. 

Surgery to remove ovarian cysts — 

If surgery is needed to remove an ovarian cyst, the procedure is usually done in a hospital or surgical center. Whether the surgery involves removing only the cyst or the entire ovary depends upon your age and what is found during the procedure. 

• If there is suspicion of cancer, the whole ovary must be removed since cutting into a cancerous cyst may lead to cancer spread. In some cases, the whole ovary is removed and the cyst turns out to be benign. Having one ovary removed will not cause you to go through menopause and will not cause you to be infertile.

• If the cyst appears non-cancerous and is able to be removed through small incisions, it may be removed laparoscopically (through several small incisions) and you may be able to go home the same day.

• If the cyst is large or appears suspicious for cancer, it may be necessary to have an open incision (called a laparotomy) and the surgeon may need to remove the entire ovary and surrounding tissues. You will need to stay in the hospital for one or more nights after a laparotomy.

 The first and most important step in treatment is to establish the correct diagnosis.  High quality ultrasound  can usually establish the correct diagnosis, although other conditions require blood tests, hormonal analysis or visual inspection and swab (cervical conditions).   Once properly diagnosed, a treatment plan needs to be put in place, based on several factors including the cause and severity of the condition, current health and medical history, how it affects the woman’s life, the likelihood of improvement over time and whether the woman plans to have children.  Once the above factors have been reasonably considered, there are several treatment options available.Treatment options include:

• Vitamin D has been found to be very important in many organs, and is a anti-fibroid agent.  Vitamin D deficiency also been found to be associated with endometriosis and PCOS.  See below. 
• Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) – like ibuprofen.  These can help to reduce menstrual blood loss. NSAID’s have the additional benefit of relieving painful menstrual cramps (dysmenorrhea);
• Tranexamic Acid (Lysteda) – these can help to reduce menstrual blood loss. They only need to be taken at the time of the bleeding;
• Hormonal treatment — In premenopausal women,   hormonal  treatment works well when a hormonal or metablolic imbalance is identified, and there are no other conditions that require surgery or other treatment.  Birth control pills can be useful to regulate periods and decrease ovarian cysts.   Aside from providing birth control, oral contraceptives can help regulate menstrual cycles and reduce episodes of excessive or prolonged menstrual bleeding; 
• Oral progesterone – the progesterone can help correct hormone imbalance
• Hormonal IUD – intrauterine devices release a type of progestin called levonorgestrel. This makes the uterine lining thin and decreases menstrual blood flow and cramping;
• Iron Supplements for those who are suffering from anaemia  Iron corrects the iron deficiency caused by heavy periods, AND it lightens periods by increasing blood viscosity. If you’re deficient in iron, take 15 to 50 mg of a gentle supplement such as iron bisglycinate. The best food sources are red meat and eggs.

Boost Progesterone naturally

• Magnesium  Magnesium is in some of the best foods: dark chocolate, nuts, avocados. It’s also found in beans and legumes.  Magnesium supplements help relax your muscles and alleviate anxiety and improves sleep.
• Zinc   Research carried out by the World Health Organization has shown that nearly 75% of Americans suffer from a zinc deficiency. Zinc helps your pituitary gland regulate hormones, including FSH which tell your ovaries to produce progesterone. Aside from these hormonal benefits, Zinc also helps boost your immune system and promote overall wellbeing. Foods that are rich in Zinc include meat, shellfish, nuts, seeds, dark chocolate and whole grains.
• Vitamin B6 and B12  One research study showed that increasing B6 vitamin consumption to 200-800 mg each day can raise progesterone levels and reduce estrogen enough to improve symptoms of PMS.  Other research shows the potential to increase fertility by up to 120% and reduce miscarriage rates by around 50%.  B6 has gained infamy as an essential vitamin that is hard to get an a vegan diet.  Salmon or lean meat can provide almost 100% of all the B12 you need. 

Other natural treatments for heavy periods, suggested by Dr. Briden

• Avoid cow’s dairy    Avoiding cow’s dairy (A1 casein) is a way to make periods lighter and it could be because avoiding dairy reduces mast cell activation which has recently been identified as a cause of heavy periods.  A dairy-free diet works particularly well for the heavy periods of teenagers.Tip: Butter, goat and sheep milk products they don’t have A1 casein.
• Turmeric   Turmeric or curcumin is a possible treatment for heavy periods. It works by reducing prostaglandins and lowering estrogen (by blocking the enzyme aromatase). You can take turmeric every day of the cycle and then increase the dose during your period. Turmeric can also relieve period pain and endometriosis.
• Calcium d-glucarate  The active part of this supplement is glucarate (not calcium). Glucarate makes periods lighter by reducing estrogen. It promotes estrogen detoxification both in the liver and in the gut where it inhibits beta-glucuronidase (a bacterial enzyme that causes estrogen to be reabsorbed). 

If the above has been unsuccessful then your consultant may need to offer a surgical treatment or additional procedures. These include:

• Endometrial Biopsy may be necessary to determine the cause of abnormal uterine bleeding, especially in postmenopausal patients.  It is a minor procedure performed in the doctor's office where a small tube is inserted through the cervix into the uterine cavity to obtain a sample of the endometrium for analysis.   
• Hysteroscopy is a procedure which allows your doctor to visualize the inner lining of the uterus by inserting a very narrow scope with a camera into the cervical canal. Seeing the uterine lining on the monitor gives us a clear view of the interior of your uterine cavity. Abnormal tissue, such as polyps or thickening of the lining, can be biopsied or removed at the time of the hysteroscopy. The removal of tissue would be done with a dilation and curettage (D&C). This procedure is usually performed under anesthesia in our office. 
• Another way to visualize the inner cavity is by instillation of saline or sterile water, and looking with ultrasound.  This is called a hysterosonogram.  This method can also confirm or exclude suspected polyps.  
• Dilation and Curettage (D&C) – A cervix is dilated (opened) so the lining of the uterus can be scraped away. This procedure is common and successfully treats acute or active menstrual bleeding, a series of D&C procedures may be required;
• Uterine Artery Embolisation – this is used when menorrhagia is caused by a fibroid issue(s). It shrinks uterine fibroids by blocking the uterine arteries and cutting off their blood supply;
• Focused Ultrasound Surgery – shrinks fibroids with ultrasound waves to destroy the fibroid tissue. There are no incisions required for this procedure;
• Myomectomy – this involves the surgical removal of uterine fibroids. Depending on their size, number and location your surgeon may choose to perform the myomectomy using open abdominal surgery with several small incisions (laparoscopically) or through the vagina and cervix (hysteroscopically);
• Endometrial ablation – this procedure involves destroying (ablating) the lining of the uterus (endometrium). This can be done with heat, a laser or radiofrequency onto the endometrium to destroy the tissue. However, getting pregnant afterwards has many associated complications. If you have endometrial ablation, the use of reliable or permanent contraception until menopause is recommended;
• Endometrial resection – an electrosurgical wire loop is used to remove the lining of the uterus although pregnancy isn’t recommended after this procedure;
• Hysterectomy—  is a permanent procedure that causes sterility and ends menstrual periods. Resection of the entire uterus may be required for symptomatic fibroids which haven't responded to other treatment, women with endometrial carcinoma, and for women with prolonged heavy bleeding of any cause that fails more 

Uterine Artery Embolisation (the s for Brits) is a Very Good Option

 Uterine fibroid embolization (UFE) is a less invasive procedure to surgery, often as an alternative to a myomectomy or hysterectomy.

Nice guidelines:  Current evidence on uterine artery embolisation (UAE) for fibroids shows that the procedure is efficacious for symptom relief in the short and medium term for a substantial proportion of patients. There are no major safety concerns. Therefore this procedure may be used provided that normal arrangements are in place for clinical governance and audit. 

Procedure:

• With the patient under conscious sedation and local anaesthesia, a catheter is inserted into the femoral artery (bilateral catheters are sometimes used). Fluoroscopic guidance is used to manipulate the catheter into the uterine artery. Small embolisation particles are injected through the catheter into the arteries supplying the fibroids, with the aim of causing thrombosis and consequent fibroid infarction. 
•  A register of 1387 patients reported that 84% and 83% of patients had an improvement in their symptoms after UAE at 6 and 24 months respectively. The register of 1387 patients reported an improvement in mean health-related quality of life scores (on a scale from 0 to 100) from 44.1 at baseline to 79.5 after UAE at a maximum 3-year follow-up (p < 0.001). 
•  The register of 1387 patients reported a mean uterine volume reduction of 40% (n = 666) and a mean reduction in fibroid diameter of 2.2 cm (n = 847). 
•  One case of bowel perforation treated by laparotomy was reported in the register of 1387 patients. 
•  An RCT of 177 patients treated by UAE or hysterectomy reported that 28% (23/81) of UAE-treated patients had required hysterectomy at 5-year follow-up.  randomised controlled trial (RCT) 
•  An RCT of 121 women treated by UAE or myomectomy reported that 50% (13/26) of women who tried to conceive after UAE became pregnant compared with 78% (31/40) of women after myomectomy at a mean follow-up of 25 months (p < 0.05). The rate of spontaneous abortion or missed miscarriage was 64% in the UAE group and 23% in the myomectomy group (p < 0.05). 

• Preservation of the uterus
• Decrease in heavy menstrual bleeding from symptomatic fibroids
• Decrease in urinary dysfunction
• Decrease in pelvic pain and/or pressure
• Virtually no blood loss
• Covered by most insurance companies
• This procedure lasts approximately 60-90 mintues. Most patients will either go home 4-6 hours after the procedure or stay one night in the hospital while they recover
• UFE offers a shorter hospital stay, a faster return to work, and fewer complications after 30 days when compared to having a hysterectomy(1).
• More confidence with less chance of soiling events
• Overall significant improvement in patient’s physical and emotional well-being
• Overall, uterine fibroid embolization is a safe procedure and is a treatment for uterine fibroids that involves minimal risk

(As with any medical procedure, discuss all risks and complications with your physician)

• Non-target embolization
• Transient amenorrhea (absence of a women’s menstrual period)
• Common short-term allergic reaction/rash
• Vaginal discharge/infection
• Possible fibroid passage
• Post-embolization syndrome (post-procedure pain, fever, tiredness, and elevated white blood cell count)
• Premature menopause
• The effects of UFE on the ability to become pregnant and carry a fetus to term, and on the development of the fetus, have not been determined

Vitamin D has been found to be very important in many organs.  As a hormonal steroid, it is made from cholesterol.  Androgens, estrogens and progesterone are also made from cholesterol.  It would not be surprising to learn that Vitamin D alters the affects of the sex hormones.  Indeed, Vitamin D has been found to have a strong anti-fibroid effect, as well as beneficial effects on PCOS, endometriosis, and many other conditions.  However, this requires higher vitamin D intake over a longer period of time.   Ciavattini et al. studied vitamin D supplementation (50,000/ week for 8 weeks then 2000 IU/ day for a year) which restored correct vitamin D serum concentrations in women with decreased Vitamin D levels (<30  ng/mL) and small burden fibroids (<50 mm in diameter and less than 4 tumors). In these women, treatment with vitamin D significantly reduced progression to an extensive disease, and thus the need of other surgical or medical therapy. 

Most of us should be taking vitamin D supplementation.  The usual dose of Vitamin D supplementation has been suggested to be 400 IU. day.  However, 1000-2000 IU/ day is more likely to have an effect, and for people who are vitamin D deficient, it's suggested that the intake be 5000 or even 7000 IU/ day, or 50,000 IU/ week until vitamin D levels are restored.  You can obtain this amount of Vitamin D with additional sunshine exposure and/or vitamin D supplementation- but not with a general multivitamin.  The best way to determine your optimal vitamin D intake is by following your vitamin D levels and maintaining them between 40-80 ng/mL (some say 40-60 ng/ml).