Dr. Sameer Kumar
Obstetrics and Gynecology
The following is an actual conversation between an iCliniq user and a doctor that has been reviewed and published as a Premium Q&A.
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Patient's Query
Hi doctor,
I lost 25 lbs quickly with no effort. I have managed to keep my weight up with a high-calorie diet. I get low-grade fever, chills, night sweats. Nine months back, I had no mass on CT and ultrasound. As I had worsening painful periods took another ultrasound last month, which showed a complex adnexal mass. A Ca-125 result was 28.4 (reference range was 0 to 30). Just over five weeks after the first US, a second ultrasound shows a small complex cyst on the ovary and a previous complex adnexal mass that has grown. In one direction, it is 0.4 inch, and in the other, it is 0.04 inch. So overall, about a 24% increase. It also has septations.
I have no tubes as they were both removed years back. At that time, I ended up with peritonitis and sepsis. My gynecologist said to me it grew 1 mm, but it was 0.4 inch. He said it is probably a scar tissue and fluid trapped from previous surgery. But the previous surgery was three and a half years ago, and this is within the past six to nine months. I have increased feeling like I have to urinate but having trouble. I also have digestive issues, lack of appetite. A bunch of the other problems as well. My doctor wants to leave it and do an IUD or some birth control. But I have a lot of pain in my abdomen and back, and it is pretty debilitating. I have a family history of ovarian and breast cancers. If I removed it, the doctor said I need to be prepared to have a colostomy bag and have complications. I take anxiety medications Tylenol and Motrin at bedtime. Please guide me.
Hello,
Welcome to icliniq.com.
The symptoms that you give, such as fever, chills, low backache, abdominal ache, painful menses, increased frequency of urine, indicate painful intercourse, and all hint towards pelvic inflammatory disease. The presence of a complex adnexal mass near the right ovary (attachments removed to protect the patient's identity), with evident septations but CA-125 (cancer antigen) near normal, is more likely to be a hemorrhagic cyst rather than ovarian cancer. However, you can get ovarian-specific tumor markers done - CEA (carcinoembryonic antigen), AFP (alpha-fetoprotein), beta-hCG (human chorionic gonadotropin), inhibin-B, and CA-19.9 to rule out ovarian cancer. Also, an MRI (magnetic resonance imaging) of the pelvis would be beneficial. A possible presence of continuous or frequent vaginal discharge in the form of infection, thick curdy white, and often foul-smelling cannot be ruled out. Do you have a vaginal infection (mixed vaginitis) as well? This is the most common cause. If left untreated can cause PID (pelvic inflammatory disease). I hope this was helpful. Please get back if you have further queries.
Patient's Query
Hi doctor,
Thank you.
When I was at the ER nine months back with a possible UTI (urine tea-colored), they did the CT and ultrasound, and neither had masses in them. They also ran cultures for PID, and all came back negative, with no infections. I do not have abnormal foul discharge and cannot remember any time having so. (My husband and I have been in a committed relationship for 18 years, and neither have ever looked outside our marriage). When I had my tubes removed three and half years ago and developed sepsis and peritonitis, I was treated with five different IV antibiotics over 12 days, as well as another surgery to clear out my insides from infection. By the time I was released, the infection was gone, and I have been normal till the heavier periods and pain started over the past six months.
Over a year ago, it started with a chronic sore throat, and eight months back, they found a paralyzed vocal cord (first in-person exam of my throat) but could not find cause for it. With the sore throat, I had irritation with breathing in. A neck CT (evaluation of thyroid nodule also found) showed the upper lungs has para-septal bullous emphysema. I have never smoked, and I am 41 years old. Currently, my primary is trying to get me into a geneticist due to a family history of emphysema in non-smokers and aortic aneurysm possible Ehlers-Danlos. With the sore throat, paralyzed vocal cord, and breathing issues, the start of the low-grade fevers, night sweats, etc., nine months back, they biopsied a cellular fibrous histiocytoma that rapidly grew on my neck and around my ear, which was recently removed. I did get checked for COVID antibodies last spring and had none. We are also strictly following social distancing. We have kids schooling from home, and my husband is an engineer working from home, and myself a housewife. We place online orders for groceries, and I wipe everything down before bringing it in. So I am confident I did not have COVID. I am now fully vaccinated for COVID.
Hello,
Welcome back to icliniq.com.
I have read your medical history here and believe that you have a possible developing tube-ovarian complex adnexal mass that is most infectious. However, I am sure after thyroid surgery, it is unlikely to be the cause of low-grade fever with chills at night. Instead, it is usually seen in chronic urinary tract infection or pelvic infection (secondarily, which can cause tubal-ovarian abscess). You would require a high vaginal swab culture and a clinical examination for evaluation of the lower abdomen. If the pain in the abdomen is in both iliac fossa and more in the suprapubic region on deep palpation, then it is likely PID. Also, painful menses or dysmenorrhoea is a known feature of PID and also endometriosis. The gold standard for diagnosing endometriosis remains diagnostic laparoscopy. However, PID can be clinically diagnosed here.
Also, tubal-ovarian abscess of the collection can present with septations but does not have nodules within (signs of malignancy). You do not have solid nodules within the complex cyst. Nevertheless, non-invasive evaluation options remain tumor markers for ovary and an MRI scan for pelvic and abdomen. This would make the picture much clearer. As you are symptomatic and have pain and fever, there has to be an infection, and it needs to have retreated. You would need to visit the hospital and get a high vaginal swab culture, urine culture, MRI scan, and tumor markers done. Once we rule out malignancy, then a two-week course of antibiotics for the PID regimen can be offered to you, and then a repeat USG (ultrasonography) follow-up can be planned for evaluating the size.
I hope this was helpful.
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Obstetrics and Gynecology
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