Ovarian cysts: part one

“I have pain, don’t you understand? It’s on the right side where the cyst is!” She spit the word out like it had a bad taste. For her it very likely did.

I’d never seen her before, but the family doctor had sent an old ultrasound -done a year ago- along with his consult request letter. Under her critical eye, I read the report: a simple 2.5 cm. cyst in the right ovary. Likely functional, it added…

“I’m tired of this!” she said, and she leaned over the desk menacingly. “And I want it out!” She was twenty-five and she knew what she wanted.

I suggested that I would need to examine her to see if the cyst was still present, but this met with a firm “No! My doctor has already examined me. I don’t want to go through that again.”

It’s hard to know how to proceed under such constraints, but I did manage to talk her into another ultrasound to see if it was still there. She glared at me as if I were calling her a liar.

When she came back to the office a week or so later after the ultrasound had been done, she was no less angry. She sat on the edge of her chair, leaned over the desk again, and pounded it with her fist. “I told you there was a cyst! The ultrasound technician showed it to me! You’ve wasted all this time when I told you I had a cyst…”

I tried to keep smiling while I opened up her chart to look at the new ultrasound report. She had a cyst alright, but this time it was in the left ovary. The right ovary was totally normal. Her pain was not coming from the cyst.

So why the little anecdote? It’s certainly not to belittle the patient, or conclude that she had no pain. It’s just that there are many types of cysts, and not all of them should arouse concern in a young woman. A lot of them don’t cause pain and most of them go away. So I thought I would describe one of the more common types and very briefly outline what I mean.

First of all, the ovary is a very active organ throughout the child-bearing portion of a woman’s life. Each month -if she’s not pregnant or on the birth control pill, for example- a tiny little egg is stimulated to develop by a chemical signal from the brain: the follicle stimulating hormone (FSH).  It does so in a little fluid-filled cavity known as a follicle. This signal gets feedback from the egg so it turns off when the egg is mature, or increases in intensity if the egg is not responding.  As the development proceeds, the follicle gets larger. When the egg is finally mature, the follicle bursts open liberating the egg so it can be picked up by the Fallopian tube.

But suppose the little microscopic egg doesn’t respond very well and never really matures -maybe because of stress, or age -or even because that particular egg is not very sensitive? Well, the follicle gets more and more fluid in it as the FSH increases and pretty soon it’s no longer called a follicle -now it’s a cyst. And because it’s part of the normal functioning of the ovary,  we call it a functional cyst. Or a follicular cyst. Or even a simple cyst. These can get fairly large (up to 4 or 5 cm. diameter) but they’re generally quite temporary and eventually disappear (reabsorb). They seldom cause symptoms although if one bursts, it can be painful for an hour or two. In other words, many people likely have cysts without knowing about them.

What are reassuring features on an ultrasound? Well, think of a tiny balloon filled with water. It would have thin walls -no lumps or thickenings; no ultrasound echoes in the fluid; no increased blood flow to the cyst (they can measure this nowadays using Doppler effects); and a size less than, say, 4 or 5 cm. And if so, what to do? Well, we generally do another ultrasound two or three months later to see if it’s till there or has changed in some way. But otherwise, nothing.

Ovarian cysts should be investigated once they’re discovered, of course, but they don’t all need treatment. They aren’t all bad.

And that patient? I eventually laparoscoped her because of her on-going pain and found endometriosis. Normal looking ovaries, though.

Listening

I used to think I was a good listener. I could watch the person speak, hear the words, and keep silent long enough for them to finish. And then, if it was a problem, I’d solve it. If it was a question, I’d answer it. It was easy, really: analyse the sentences, watch for ambiguities, filter out the noise -the anxious, non-essential stories, the nervous laughter- and there, stripped of unnecessary clothing and obscuring adjectives was the reason for their visit. It was a conversation reduced to pragmatic algorithms, one-side to be sure, but no less effective for its simplicity…

Or was it? I had occasion to question the effectiveness of my approach only a few years into my specialty. A young woman had been sent to me by her GP with pelvic pain. She’d seen several other gynaecologists by that time, and the usual tests had been done, accompanied by an exploratory laparoscopy or two. All with the same result: no one had been able to find a source for her pain. She had been put on antidepressants by one of them, but she was not happy with this.

As she sat fidgeting in front of me, inches away from tears, I wondered what I could possibly suggest that had not already been tried. She began describing her problem, glancing at me from time to time, waiting, it seemed, for me to interrupt. But for the life of me, I couldn’t think of anything to say, so I kept silent. Ears never get you into trouble, it’s the mouth that usually destroys rapport.

Finally she stopped, her face neutral, and she stared directly into my eyes. “Well, what do you think, doctor?”

Still puzzled about how to approach her problem, I just smiled a sad smile and said, “What do you think, Judy?”

Her eyes seemed to open for the first time. Now she was at a loss for something to say. She sat back and took a long deep breath. “You know, you’re the first doctor who ever asked me that…” She stopped fidgeting with her notes -yes, she’d brought some notes to the office so she wouldn’t forget anything- and leaned forward. “My mother died of ovarian cancer, my sister is undergoing tests…” She stopped for a moment to collect herself. “Do I have cancer, doctor?” There it was.

It occurred to me that many of us are so solution-oriented, we tolerate listening only until we have solved the word puzzle presented to us. No matter that we have been hearing metaphor and have interpreted it literally. The fact that I’d not been able to solve the problem she’d presented, that I’d had nothing to suggest, required me to keep listening -by then hopelessly entangled in her story. And even hearing things that seemed accusatory and sometimes unreasonable, I was forced by the simple fact that I had no answers, to listen further. To understand, more than to solve. Or rather, to hear more than a litany of symptoms, and a list of treatment failures.

But even now, I occasionally think I don’t have the time to remain silent, to hear the story unfold as my patient wants it to. I want to jump in at her first pause and dazzle her with my solution. It’s often myself I’m dazzling. Sometimes it’s the unheard story they’ve come to tell.

Over thirty-five years of listening and helping, but still not an expert

There’s one thing I have to confess at the start: I am not an expert on women. I do not inhabit a female body, nor, apart from what is in the sample cupboard, do I have special access to estrogen and its secrets. Although I’ve delivered thousands of babies, I cannot honestly say that I know what it would be like to lie there in pain and fear, trapped by process, and yet be coddled with advice from well-meaning onlookers.

I cannot possibly know what menstrual pain or the inevitability of heavy bleeding month after month would be like. Or the tragedy of miscarriage, the worry of an abnormal ultrasound early in pregnancy, the failure to conceive after waiting, perhaps too long, for the right partner… Menopause, breast cancer -I do not know if I could cope with these.

I wish I had the ability to paint pictures with words like Lauren Eiseley, or the gift of a Carl Sagan to make even the everyday events seem extraordinary; I have only the years spent listening, sometimes advising, to recommend my thoughts.

I originally thought the blog might be devoted to teaching what only the years could divulge but the more I reflect on my time in medicine, the more I realize the wisdom of what Lewis Thomas (Lives of a Cell, etc.) once said: he’d rather go to a well-rounded person who’d read Shakespeare and Spinoza and who happened to be a doctor. Maybe they’d have something in common with him. Maybe they’d be better doctors. Maybe they’d know what it was to live in a real world where medicine wasn’t the topic at dinner.

We tend to medicalize a lot of things -pregnancy and menopause to name just two- that we might well look at under a different lens. I’ve always thought of myself as a guide through an unfamiliar woods, helping people choose a better, safer path to the other side. None of us possess omniscience -no one that I know at any rate. There is no correct way; we all come to the forest from different directions, different cultures, different expectations. There are different ways through.

In each of the blogs that follow, I will try to pick a theme -or you can suggest one- and discuss it. Don’t look for answers. I am in possession of no arcane knowledge -or none that will win me a Nobel prize, at any rate. I will approach it as one who has walked down different routes and arrived, often breathless and wide-eyed on the other side… Still smiling.