Dermoids: From Soup to Nuts, the Cyst That Has It All

What has hair, teeth, yellow gooey fluid, and likes to call your ovaries home? No, this is not a bad joke or a fictional character in a fantasy novel. It’s a dermoid cyst, and it’s pretty common in women under the age of 30. Dermoids, also affectionately known in the medical world as ovarian germ cell tumors or mature cystic teratomas, comprise about 25% of all ovarian cysts. The large majority are benign (phew!) but can be quite pesky and occasionally painful.

What makes them so notable is not whom they affect but how they affect them. Let’s take a quick trip back to Bio 101. In our body, we have three types of tissue: endoderm, mesoderm, and ectoderm. These big three make up the basis of every organ in our body, including our skin. Mature cystic teratomas (nickname deromids) are comprised of all of these three cell types. Hence, they have the ability to be whatever or whoever they want. That’s why when they are removed and opened, you can see anything from hair to teeth to nerve tissue to fat cells.

Just like their Houdini-like abilities to transform into everything and anything, they are often invisible when it comes to pain. Many women find they have dermoids totally by accident on an ultrasound for something else or during a physical exam.

Symptoms in general are a side effect of size. The larger the dermoid, the more likely you will have pain, pressure, cramping, etc. Occasionally, dermoids will present with acute pain, nausea/vomiting, and a trip to the operating room. This is called ovarian torsion. When cysts take up residence in the ovaries, the size of the ovary can increase substantially. The bigger an ovary, the more apt it is to twist.

Very rarely, a dermoid cyst will make itself known by rupturing, that is, opening up. When it does this, that yuck fluid escapes its “jail” and has now leaked all over your pelvis/abdomen. This can be pretty painful and almost certainly requires a surgery to do a major clean out. Your body can react very strongly to this unwelcome substance, and unless treated ASAP, major scar tissue and other serious issues can occur.

When dermoids say cheese to our camera (the ultrasound), they have a very characteristic smile. This is a good thing because it allows us to be pretty confident in what we are dealing with. Once it is confirmed, or as close to confirmed as we can get, a treatment plan is devised. Depending on the size (and symptoms) of the cyst, surgery may be recommended. Most of the time these cysts can be removed with the aid of a laparoscope (a.k.a. camera) and a few small incisions.

This minimally invasive approach allows women to come in and go home within a few hours. While the ovary is almost always left inside in women who still have babies and pregnancy on their brain, for women who are done with the baby thinking, it is ok to remove the entire ovary. Make sure that you discuss the surgical approach and strategy with your doctor before going in. You want to make sure that you are on the same page!

Although most are benign, there is a small subset of ovarian germ cell tumors that are bad (a.k.a. can cause cancer). The names of these are definitely going to be foreign, but we will make a quick intro in case you should run into them in a dark alley. They include dysgerminonams, yolk sac tumors, and mixed germ cell tumors. Luckily, most of us will never ever meet them ourselves or know anyone who will encounter them. However, if you do, make sure you see a GYN who specializes in ovarian cancer (a.k.a. GYN oncologists). Rare ovarian tumors are their bread and butter; they know the best surgery approaches, the best medical treatments, and the best way to tackle this problem.

You may have to travel to see them (not every town/city has one in their zip code), but it’s worth the trip. They may save your ovary, save your fertility, and most importantly, save your life.
When you hear the word cyst, you probably mutter a curse word and ask what does this mean?! And then, when it is followed up by “and it looks like it may have hair, teeth, and yellow stuff,” (and no it is NOT a baby) your psyche gets even more psyched out. But don’t despair. Although dermoids are sort of disgusting to look at, they are not divas to deal with. They are fairly easy to remove, almost always benign, and come back in only about 4% of cases. Find a good doctor who knows what they are doing, and your dermoid doesn’t stand a chance!

Where to Place Your Bet: The Difference Between Egg and Embryo Freezing

Who doesn’t love a good pre-game? Standing in a parking lot with the sun beating down on your back, relaxing with your friends: life couldn’t be better. While you may don a Giants jersey and your friend Eagles green, your pregame rituals are pretty much the same. Good food, good drinks, good times. When you enter the stadium, that’s when things start to change.

The same can be said for the difference between freezing eggs and freezing embryos. The “pre-game” part is pretty much the same—you take injectable gonadotropins (hormones) on a daily (sometimes twice daily) basis. This doesn’t change whether you are freezing eggs or embryos. Additionally, in both cases the medications and the morning visits will most likely start with the start of your period and go on for about 10 days. Therefore, in terms of the stimulation (a.k.a. the pre-game process) the two are pretty much the same. It is not until the eggs are retrieved that you run to opposite sides of the field.

If you’re rooting for team egg freeze, here’s what your game plan will look like once we start to play ball. Shortly after the eggs are retrieved, they will be evaluated for their stage of development (mature versus immature). Those that are mature will be frozen immediately. And this is where the information about your eggs and your fertility ends. You will know nothing more about your frozen friends other than quantity. We cannot tell how many will be “good” (a.k.a. make a baby) and how many will be bad (a.k.a. do nothing). But as most American possessions go, the more, the better. Women who have more eggs frozen will have a better chance of pregnancy from them in the future.

And in the blue corner, we have team embryo freezing! For those that choose to embryo freeze, after the eggs are extracted they will be fertilized with sperm. The resultant embryos will then be watched over the next several days in the laboratory. How they grow, how they divide, and how they develop is very telling for their health. Some, if not several, will drop off along the way—those that can’t hack it in the lab would definitely not hack it in the uterus.

In many ways, the lab is like the ultimate test of survival, or natural selection. At the end of the game, you may only have a few players on the field, but these players are tough, resilient, and really know how to play the game. They have weathered the storm and are your true MVPs.

In many ways, egg freezing is like drafting a player who has demonstrated potential in college but has not yet played in the big leagues. They should be good, but you can’t know for sure. It’s also hard to survey the newbies in spring training and know who and how many superstars you’ll have at the end of the season.

In the same vein, if your ovarian reserve tests are normal and there are no red flags in your medical history, you should have some good potential in your eggs. Embryo freezing is like signing a player who has already won rookie of the year. You know more about the player’s (a.k.a. embryos’) ability to hit it out of the park because they have already been vetted. Take it one step further…if your embryos undergo PGS (also called CCS or TE biopsy—the chromosomal analysis of embryos), we have even more information about their ability to make a baby. You have vetted them in the most aggressive way possible.

For many women, embryo freezing is not even an option. Unless you have a partner or chose to use donor sperm, without a sperm source, you can’t make embryos. The lack of sperm and the ability to make embryos are NOT a bad thing AT ALL! And we definitely don’t recommend using donor sperm just to make embryos and have more information about your egg quality. In these situations, egg freezing is totally the way to go! Additionally, even if you have a partner, egg freezing may be a better option for you. Not to be Debbie Downers, but nearly half of all relationships end in divorce. So be careful about who you mix your gametes with!

If you are even thinking about freezing, be it eggs or embryos, you’re being proactive. You are several steps ahead of the game. It’s like you’re planning your roster months before opening day! Either way you do it, you’re giving yourself options and choice. And that’s really why you did this in the first place. So however you get on the field, you are here to play ball—go, girl, go!

What Are You Wearing to PPROM?

When you hear the word prom, your mind immediately goes to dresses, dancing, and corsages—those awkward high school days when who your prom date was felt as important as who was running for president. And while we would love to relive what we wore and who we wore it with, the PPROM we are here to discuss is premature preterm rupture of membranes (a.k.a. breaking your water before you’re in labor and way before your due date!).

Before we delve into the details of PPROM, let’s take a step back. From the moment of implantation, your plus one spends his or her days and nights swimming in a pool. This pool is in your uterus and is called the amniotic sac. When your water breaks, be it at six months or nine months, it signifies that the amniotic sac has opened and your amniotic fluid (a.k.a. water) is leaking. When this happens at or around your due date, it’s game on. Pack your bags; let’s go have a baby!

And while there is excitement (#babyontheway), there is generally no cause for concern. However, when your water breaks before you have reached the full-term mark (37 weeks), we put on a full-court press to stop things from moving any further. And depending just how early in pregnancy you are, we may pull out all the stops to stop labor from progressing. Preterm delivery can be dangerous: think lung problems, brain problems, GI problems, and beyond. That’s why we will do our very best to stop it.

Because of the what-ifs and the what-cans that often follow premature babies, women with PPROM can anticipate a lot of attention. You, your uterus, and your fetus will take center stage on the labor floor, which will become your new home until the baby is born. And depending on how things go (Do you develop an infection? Does your baby appear to be in distress? Have you reached a safe gestational age for delivery?), the curtain may not fall for several weeks. In short, our goal is to keep you pregnant for as long as we safely can. When it comes to fetal development, days matter. Although the neonatal intensive care units (NICUs) have come a long way, there is no better home for a developing baby than in your womb.

Why your uterus decides to go to PPROM earlier than it should is often unknown. While most cases occur because of an underlying infection, in many cases, we aren’t sure what set the system into motion. However, given that infection is the no. 1 culprit, we will routinely start antibiotics to treat a potential infection and to hold off what might come next (a.k.a. full-blown labor). We will also keep a close eye on your temperature, your white blood cell count, and your baby’s heart rate to make sure that an infection is not arising or, if already present, getting worse. Additionally, if the PPROM occurred at less than about 34 to 36 weeks, your OB/GYN will administer a dose of steroids to help your baby’s lungs reach maturity.

Many of us have had many water-breaking false alarms during pregnancy. The kind when you realize, “Oops, I just peed on myself.” And while it can be hard to distinguish amniotic fluid from urine (for the non-OB/GYNs amongst us), when symptoms like cramping, pressure, and bleeding are present, it is usually the former.

However, the only way to know is to go (we purposely made that rhyme so it sticks in your head!). Going to your OB’s office or the labor floor is the only reliable way to know exactly what that liquid is. And while no one wants to be the boy (or girl) who cried wolf, it is always better to be safe than sorry.

The good news is that most of us won’t show up for the prom early. In fact, only about 3% of all pregnancies in the US are complicated by PPROM. However, women with a previous PPROM are at increased risk for another PPROM. To avoid an encore performance in your next pregnancy, your care might be transferred to a high-risk OB. Such individuals are specifically trained to take care of women with previous pregnancy complications. Furthermore, they may suggest taking weekly progesterone injections, starting at 16 weeks of pregnancy and twice-monthly cervical length checks to reduce the chance of the preterm delivery happening again.

Additionally, if fertility treatments are being used in the future, we strongly recommend that your doctor employ all and any techniques to reduce the risk of multiple gestations. After all, if your uterus had a hard time making it to the end with one, why stress the system with two?

The good news is that while your courtship (a.k.a. pregnancy) may be cut short, the “prom” usually ends on a high note. With early attention, immediate treatment, and a team approach (OB, pediatricians, nurses, and support staff), most babies born following PPROM will do great. And not unlike the prom that they will attend nearly 17 years down the road, while their time in the NICU will be beyond stressful for us as parents and family members, most “kings” and “queens” leave the PPROM none the wiser.

Welcome to parenthood!

7 Tips for Picking a Nanny: Advice from Expert Tammy Gold

Whether you are a new mom or a seasoned mom, searching for a nanny can be a challenge, to say the least! From where to find someone to what questions you should ask at that first meeting to when is the best time to start, the search can be overwhelming. Let’s face it: there is nothing or no one more important than your child. Finding the right person to help you care for your little one can seem nearly impossible.

To help soothe your nanny nerves, we sat down with Certified Parenting Coach, Licensed Therapist, and Founder of Gold Parent Coaching Tammy Gold (www.tammygold.com) to get the seven best tips on how to find a nanny. Here’s what she had to say….

Rule #1: Don’t rush the process of looking for a nanny.

When you’re worried about childcare, it’s extremely hard not to rush, especially if you need coverage immediately. But you must force yourself to fight the initial panicked instinct to hire the first remotely qualified nanny and put her to work right away. To make a good decision, you need data. You want to allow yourself plenty of time and ideally be under as little pressure as possible so that you can go through the entire process carefully, complete the necessary due diligence, and feel great about the person you hire.

Rule #2: Do the work to figure out what you need.

Your nanny will be intimately involved in raising your child, so you want to really hone in on the quirks and nuances of your family, as well as the nanny personality and skill set that you need. You’re the employer, so you get to create the job, and it can be whatever you want it to be. But you need to be absolutely clear about the requirements and expectations from the get-go. Things get complicated when a nanny feels misled, you feel like you’re not getting what you pay for, or you try to change the job and modify the nanny’s responsibilities along the way.

Rule #3: Have realistic expectations.

There will be pros and cons to every candidate, and every nanny will occasionally make mistakes. But that doesn’t mean that she can’t be a wonderful caregiver or that she isn’t the right fit for your family.

Rule #4: Don’t project too far into the future.

When you sit down with a nanny, try not to think, “Is this the person who’s going to care for my child for the next ten years?” Don’t worry about whether this is a life-long match or whether you can see her being at your child’s wedding someday. Most nannies don’t stay forever; they typically stay for a few years and then move on as the family’s needs or their needs change. So, all you have to decide is whether this person is the right caregiver for your child right now and whether she will still be able to meet your needs one to two years down the line.

Rule #5: Remember that, during the nanny interview, your nanny is also interviewing YOU.

Yes, you are choosing to hire a nanny, and yes, as the employer, you are in the driver’s seat. But in the nanny’s mind, she is also deciding whether she should work for you, and any really good nanny will have her pick of jobs. Be aware that, at any given point in the process, she will be asking herself, “How do I feel about this family? Do I like how they handle things? Do they make me feel respected and understood?” You are two equal parties in every sense of the word, and you want to think about it as an equal relationship from the start.

Rule #6: If you like someone, keep the process moving.

Remember that, when nannies are interviewing with you, they are also interviewing with other families. If you like someone, make sure she knows that you’d like to move on to the next step, and give a specific timeframe so she knows what to expect. You want to keep the nanny in the loop so she knows you’re serious and hopefully will not jump to accept another offer.

Rule #7: Keep the faith!

Nanny searches require stamina, and just like job searches or dating, they can have ups and downs. There will be setbacks. A nanny may do everything right and then be terrible in the trial, or your frontrunner may get another offer that you can’t afford to match. You will sometimes feel like you are getting nowhere—and then suddenly, you’ll meet the right nanny and feel that “click.” The key is to be patient and continue with the process. If you stay the course, it does work!

Tap It Back…Add It Back: Hormonal Add-Back Therapy

All you indoor cycle enthusiasts probably got the reference pretty quickly… Tap Backs are not only good for your core and your gluts but for your quads and your arms (and they are sort of fun at the same time). Dancing on a bike is liberating, to say the least, and lets you think, at least for 45 minutes, that you too could be Beyoncé’s next back-up dancer!

Tap backs are not just good for the body; they are good for the soul (no pun intended!). In the same way, add-back hormonal therapy is good for many different organs. With oral progesterone + estrogen, you are hitting many of those key areas and shaping your future.

Let’s take a seat in the saddle and review why you would need add-back therapy and how it does its job. Many GYN pathologies think fibroids, endometriosis, and adenomyosis run on hormones. No hormones usually = no pain/no symptoms. Therefore, our treatment choices for such problems frequently center on taking the hormones away. Our first line of attack usually includes oral contraceptive pills (OCPs). The synthetic estrogen and progesterone in OCPs feeds back on your brain and shuts off your natural production of estrogen and progesterone.  It’s a complicated pathway of events, but this one daily pill is usually very good at putting the brakes on the body’s own hormone production and keeping those pesky symptoms (pain, bleeding) at bay.

However, in certain cases, the OCPs are no match for the pathology pervading your pelvis—in these instances, we need to look into our bag of tricks and pull out something more powerful. Cue GnRH agonists (a.k.a. Lupron). These injectable (and in some forms nasal) medications shut off the brain’s production of the hormones that stimulate ovarian estrogen production. They don’t waste their time with feedback but rather go right to the source and turn off that switch. And while they are good at keeping things dark when this switch has been flipped to OFF by Lupron, it’s like a major blackout occurred in your body.

Everything hormonal goes dark. And while this darkness is good for stopping endometriosis, fibroids, and the like, it is not so good for those organs that desperately depend on estrogen (think bones). Therefore, in order to satisfy both parties (those that like the dark and those that need some light), we give what is called hormonal add-back therapy alongside the Lupron.

Think of the add-back therapy as a flashlight. It shines light on the areas that are really afraid of the dark (a.k.a. the bones). And like all good nightlights, it does its job well—it can keep the bones happy without reducing the efficacy of the Lupron. It also quells those crazy hot flashes that women can get while taking a GnRH agonist (Lupron). You may be making a funny face, thinking this doesn’t really make sense? If endo is fed by estrogen and then the doctor gives estrogen, won’t that make matters worse? You are sort of right and also sort of wrong. Here’s why.

The doses at which you are taking oral add-back therapy are right at the hormone sweet spot. They are just enough to protect your bones and stop the hot flashes but not enough to fuel your disease (endo, fibroids, etc.). As a result, add-back therapy has become all the rage for women taking GnRH agonists (Lupron). By supplying it, we can give Lupron without much stress over the possible negative side effects. Examples of add-back therapy include norethindrone acetate alone or norethindrone acetate + estrogen. Either combo has been shown to work; however, what works for you must be figured out with your doctor. Most of the time, we start add-back right when the agonist is started. While we used to wait a few months before initiating add-back, we now don’t really think there is any benefit to delaying its start.

Whether you are a SoulCycle or a Flywheel girl, an Equinox fan or a Crunch crazy, you know that, while on the bike, you will burn a serious number of calories. Add-back therapy is the lubricant that allows those wheels to keep turning. Without a little juice, over time, the bike will break down, and you will come to a screeching halt. We want to prevent that in your body by giving add-back hormonal therapy alongside a GnRH agonist. It will allow you to keep “cycling” without much pain. Not bad… Now, let’s see you Tap It Back!

We Go Both Ways…From West to East and Everything in Between!

We were both trained in Western medicine—BA to MD to residency to fellowship. We ran on a linear pathway (admittedly, Sheeva way faster than Jaime!) without even as much as a water break. We spent endless hours burning the midnight oil (that’s why we know all the good coffee spots!) studying, memorizing, and analyzing. We went from the classrooms to the wards, from the laboratories to the clinics, and finally from trainees to attendings—always focused on Western medicine. We believed that cures only lurked in pills or scalpels, not herbs and pressure points. We were smart, but we were naïve. We had no idea how wide the world of medicine was.

We have matured a lot over the past several years (as evidenced by our grey hairs!). We have met many talented clinicians and practitioners who practice ALL types of medicine. We have been awed by their knowledge, amazed by their patience, and impressed by their skill. We have learned that what you eat really matters, that meditation is more than humming in a dark room, that yoga is more than stretching, and that acupuncture is more than a bunch of needles. We are humbled by the genius of the many disciplines we never even knew existed 10 years ago! We feel privileged to have formed relationships with those who have exposed us to medicine and healing from all parts of the globe.

We for sure don’t have all the answers (as much as we wish we did!). We know that, although our training was very, very, very long, it didn’t even come close to touching the surface of medicine as a whole. We recognize that medicine is changing faster than the lead car in the Daytona 500 and there is no way to keep up with it alone.

We are not sure if you noticed this by now, but every sentence in this post started with “we.” We did this to prove how important it is for all practitioners, Eastern and Western, mind and body, to work as one—to listen to each other’s voices and opinions and learn from each other. We have no desire to go back to medical school or pull all-nighters in the library, so we are all ears when we meet new practitioners that have new ideas and new treatment strategies. We can’t wait to hear what they have to say!