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!

Variety, Variability, and a Very Good Surgeon: The Many Flavors of Removing the Uterus

As if reaching a decision about if and when you want to get your uterus out is not enough, you now must also decide how much and in which way your uterus will come out. Unbeknownst to many, the uterus can come out from above (a.k.a. abdominal), below (a.k.a. vaginal), or a little of both (laparoscopic assisted or robotic). But it’s not so cut and dry (no pun intended). Imagine you are standing on line at your favorite ice cream shop. In those minutes before you give your order, you run through the options and the pros and cons of the various choices—chocolate with sprinkles, vanilla with chocolate chips, or maybe toffee crunch with nuts. Although whatever gets you to go with chocolate over vanilla is not so memorable and fairly insignificant, what makes you choose a vaginal hysterectomy versus an abdominal hysterectomy or doctor A versus doctor B should be unforgettable. So, as your favorite ice cream scoopers, here’s what’s on the menu—step by step.

Flavor (Is my uterus coming out?)

The first decision that must be made (whether on the ice cream line or in the hysterectomy process) is the most basic one: are you going to remove your uterus? This decision is a big one, and when making it, you must be comfortable and clear on why you are doing what you are doing. Is it because of pain, pressure, bleeding, or cancer? And have you tried medical or non-surgical treatments before moving on to surgery? Whatever the reason there must be a reason and a reason that does not have any other solution. And while we are not knocking vanilla ice cream, your reason for taking out your uterus should not be “vanilla!”

Cone or cup: Are you going to take out all of it (a complete hysterectomy) or a part of the uterus (a.k.a. a supracervical hysterectomy?)

After you decide what flavor you are choosing, you must decide how to eat it. Translate that into your uterus. After you decide if you are going to take your uterus out, you must decide if you want to remove your uterus and cervix (total hysterectomy) or just your uterus (supracervical hysterectomy). There has long been a suggestion that women who take out their cervix will suffer sexual consequences, dysfunction, and urinary incontinence. However, more recent data have debunked these theories, and most women opt to take the cervix out with the uterus to reduce the risk of cervical cancer. And while you have a lot of say in what you are going to leave and what you are going to remove, your doctor will also be a big part of this decision.

Toppings (Is my uterus coming out abdominally, vaginally, laparoscopically, or robotically?)

Even for us GYNs, it’s sometimes hard to believe how many different ways there are to remove the uterus. Long gone are the days of it’s abdominal or bust. Depending on things like the size of the uterus, the pathology (problems) affecting the uterus, the shape of the vagina, the presence of other medical conditions (think things like heart and lung disease), past surgical history (previous abdominal/vaginal surgeries), and the need for concurrent procedures (removing your ovaries as well as your uterus), one way may be recommended over another.

While there are pros and cons to each approach, research shows that, in most cases, the safest way to remove the uterus is vaginally. And while you may not be a candidate for a vaginal hysterectomy (the uterus is too big or you have had 3 C-sections in the past), it’s important to ask your MD why she is recommending a certain route and why you are not a candidate for another. It’s your uterus, and you deserve answers. And remember, the answer should never be because that is what the surgeon is most comfortable with…it should always be what you are most comfortable with.

With a cherry on top (Whom are you selecting as your surgeon?)

Deciding who is going to do the “scooping” (a.k.a. your surgeon) is a big decision. Not all “scoopers” were created equal. Some of us scoop daily, while others scoop no more than once a year. And as you can imagine, the more you do it (otherwise known as operate), the better you are at it. Make sure to ask about the surgeon’s experience, surgical outcome data, and training. It can make a huge difference in how your procedure goes.

While this is no ice-cream parlor and you may not be lining up to get your uterus out, if done in the right way, for the right reasons, and with the right surgeon, you will be enjoying an ice cream cone in no time. A hysterectomy may not be the treat you were dreaming of, but it will likely take care of many of your problems—at least when it comes to your female organs. So start building your perfect “hysterectomy sundae.” It can bring you sweetness and satisfaction for years to come!

The Tubes: More Than Just a Tunnel?

For any of us that drive, either to work or for pleasure, particularly in and around major cities with lots of congestion, getting stuck in traffic is not pleasant. It makes you late, it makes you frustrated, and it makes you anxious (it also eats your gas and costs money!). Where and why traffic arises is usually self-explanatory: an accident, construction, a street closure, or a blocked tunnel. The worse the situation, the more the traffic builds up.

Think of the fallopian tubes, the connection between the uterus and the ovaries, as a tunnel. The fallopian tubes serve as a conduit by which the sperm gets to the ovary/egg and the resultant embryo gets to the uterus. If they are blocked or severely damaged, flow to and from will be severely limited or shut down. In the worst of cases (think Midtown Tunnel during Hurricane Sandy), not only will the sperm be unable to pass, but also the normal tubular fluid will have no way out. The fluid will just sit there and become stagnant; stagnant fluid becomes filled with debris (a.k.a. junk). Even if a sperm or an embryo is able to swim this filthy sea, this cesspool of inflammatory mediators can harm an embryo’s ability to implant and grow. Tubal disease can be toxic to your fertility. It will shut the traffic of your reproductive system down, and without the help of a fertility specialist, everything will be at a standstill.

While tubal disease is not as common as traffic in New York City (all day, every day!), it does cause serious delays for a good percentage of women. Tubal disease is the culprit for about 10–15% of all couples with infertility. Unfortunately, there are not many flashing light “construction ahead” signs when it comes to tubal disease. Most of the time, it goes undiagnosed until a couple has struggled with infertility for some time. And when it comes to tubal disease, the sooner the police come to clear the accident, the sooner the road re-opens; a.k.a. the sooner you realize your tubes are shot, the sooner you can undergo treatment, and the sooner you will get pregnant.

While it may take some time to identify the tubes as a problem, there are certain risk factors for tubal disease that might set the siren off a bit sooner. For example, if you have a history of a sexually transmitted infection, pelvic inflammatory disease, previous tubal surgery, previous abdominal surgery, an ectopic pregnancy, endometriosis, smoking, a previous case of appendicitis, or inflammatory bowel disease, go for a tubal evaluation early. Finding out that your tubes are damaged sooner rather than later will save you a lot of time and frustration. Think of it this way: if you know you have a bad driving record, you should consider taking out extra insurance. You may not need it, but if you do, you will save yourself a lot of money.

A diagnosis of tubal disease is generally made by a test called a hysterosalpingogram (HSG). Now, if you have any friends who have struggled with infertility or have read any blogs, these three letters probably made you gasp. An HSG has become synonymous with “that awful dye test that hurts so badly.” We are here to reassure you that, for most women, the test is quick and fairly painless.

If the tubes are open, the pain should be minimal. It’s when the tube or tubes are blocked that the test can be uncomfortable. Talk to your doctor before you go. Get a recommendation for a radiologist who specializes in these tests (when it comes to HSG, radiologists are not all created equal!), and consider taking some Ibuprofen about 30 minutes prior to the procedure. While an HSG is a pretty good way to pick up tubal problems, it is not uncommon for women to have a false positive result. Basically, the test says you have tubal disease, but you actually don’t. This tends to happen when there appears to be a problem in the proximal portion of the tube (the part that attaches to the uterus) rather than the distal part (the part that is near the ovary).

Nearly 60% of proximal tubal disease picked up on an HSG are false alarms—the tube will appear blocked when it is actually in spasm (clamping down) or is temporarily kinked. There could also be a piece of mucus that is stuck and giving the appearance of a blockage. That is why, if your test report comes back with an “F,” you may not really have flunked. Unfortunately, you need to take the test again (at least it doesn’t require studying!). If your repeat performance is the same, the diagnosis is clear.

There are more ways than just an HSG to interrogate the integrity of your tubal system. In certain cases, tubal disease will be identified in a laparoscopy. Additionally, vaginal ultrasound and MRI can strongly suggest tubal disease. However, unlike an HSG or a laparoscopy, they cannot tell whether your “tunnels” are open or closed. To truly get an accurate traffic report, you have to test drive the system (put fluid or dye in and see if it can come out both sides)!

In addition to the anger and the frustration traffic can cause, it can also be confusing. The obvious is obvious: an accident, construction, or some guy whose truck didn’t fit through the underpass but tried. (We never get that. If it says trucks higher than six feet can’t clear an underpass and your truck is seven, why go for it?). But what about when there is no reason—no accident, no construction, no guy who is vertically challenged? Why then have things slowed down or stopped? It makes no sense!

The same can go for a woman who winds up with tubal disease without any identifiable risk factors. This can be particularly true in cases of proximal tubal obstruction. The causes of this are things you have likely never heard of. (Neither did we before medical school!) They include diseases such as salpingitis isthmica nodsa (say that five times fast), endometriosis, or pelvic inflammatory disease. But unlike that guy who drove his truck under the underpass, let us reiterate that none of these processes are your fault…it’s just bad luck.

Luckily, fixing your tubes is not like fixing potholes on I-95. It won’t take years and years and cost endless amounts of money. After making the diagnosis, treatment plans can usually be implemented immediately with minimal hassle. While some cases will be amenable to surgical correction, the majority will require in-vitro fertilization (IVF). IVF allows you to bypass the tubes (it’s like Google Maps or Waze when trying to get to your favorite weekend spot in the summer!) and therefore is very successful in achieving a pregnancy. Women whose tubes are causing their infertility do quite well with IVF; their eggs are good, their partner’s sperm is good, and their uterus is ready and waiting.

The only catch here is that tubes damaged near the ovary (distal damage) that have filled with fluid (remember the stagnant pond) should be removed before undergoing IVF.  Reason being is that this fluid becomes a soup of inflammatory products that can be toxic to a developing embryo; simply stated, patients who do IVF with a dilated damaged tube (medically termed hydrosalpinx and commonly called “hydro”) in place can have about a 50% reduction in their pregnancy rate. Its presence can negatively affect an embryo’s ability to implant into the uterus. Your doctor will know if and when the tube(s) need to be removed. Trust their advice. They have the road map for your success.

Thinking about your tubes and what they look like (both inside and out) is probably a totally foreign concept. But how to weave in and out of traffic and deal with blockages is definitely not. You can pretty much always get to the other side, no matter how many roads, tunnels, or bridges are closed. It will take more time and will not be the route you planned, but with a little help from your friends (gotta love that navigation system), you will get there. Let your fertility doctor be your navigator; together, we can get you to your destination.