Dr Peter Chew

03/06/2020

“My ovarian cyst got twisted!!”

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J, a 28-year-old engineer, would never forget the afternoon when she was rushed to the hospital for an emergency surgery.

J had a slight abdominal pain and nausea which started suddenly, shortly after taking her breakfast at a hawker center. “I thought I might have been sensitive to the food I just ate,” she recalled. She was not immediately alarmed. But the pain got progressively worse. She started to vomit and eventually fainted in her office. Her colleagues decided to rush her to the hospital.

J was conscious but in severe pain. Her body temperature was normal. Her pulse rate was 100/min. and her blood pressure 110/70mm Hg. The abdomen felt hard and stiff (rigidity)and was guarded with gentle pressure.

She was given intravenous fluids, anti-nausea treatment and pain medication. An ultrasound examination of the pelvis and a CT (computerized tomography) scan of the abdomen were done immediately. The investigations revealed that she had a 5 cm right ovarian cyst, which had twisted and was cutting off the blood supply to the o***y.

What is ovarian cyst torsion?

The ovaries are held in place in the pelvis by some suspending ligaments. In one of the ligaments, the o***y receives its blood supply.

Torsion occurs when the extra weight of the cyst causes the o***y to twist and rotate around its supporting ligaments. If the twist is minor there may be little or no consequences. However, if the twist is severe enough to ‘kink’ the blood vessels, the blood supply to the o***y may be compromised and may lead to tissue death eventually.

Figure 1


How common is torsion?
Ovarian cyst torsion is generally thought to be uncommon. Studies have shown that around 2%–15% of gynecological surgeries for ovarian masses were done for torsion. Most cases of ovarian torsion occur in the reproductive age group. It is less common before puberty and after menopause.

What are the symptoms and signs?

The symptoms of ovarian cyst torsion are somewhat non-specific. They include:
severe abdominal/pelvic pain
nausea and/or vomiting
fever occasionally

These symptoms usually present suddenly and without warning. If the cyst twists and then untwists, the symptoms may 'come and go', sometimes over hours, days or even weeks. If this occurs, the diagnosis may be challenging since these symptoms may mimic many other conditions.

How is it diagnosed?

A pelvic exam is done to locate areas of pain and tenderness. A pelvic ultrasound is done to view the o***y and its blood flow. A CT scan is usually done to rule out other potential diagnoses, such as:

Appendicitis
Acute pelvic infection
Ectopic pregnancy
Kidney stone

A definitive diagnosis is usually made by direct visualization of the o***y during surgery.

What is the treatment?

Laparoscopic surgery is the method of choice. It is done to ‘untwist’ the o***y and remove the cyst. If the ovarian damage is minimal, the o***y can be salvaged and its functions restored.
If tissue death has occurred, removal of the o***y along with the cyst should be done.

J had a laparoscopic surgery immediately. The o***y and the cyst appeared dark purple, indicating that the ovarian blood supply was compromised. After untwisting the cyst, which wound round the ovarian ligament twice, the o***y returned to its normal colour after a while. The cyst was then removed with conservation of the o***y.

J recovered well after the surgery. Her abdominal pain had disappeared the next day and she was discharged 2 days later.

03/06/2020

Defying All Odds: Cord Prolapse

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Holding her newborn baby who was soundly asleep in her arms, C recounted the dramatic events that happened during labour a week ago. She was still in a daze as to how her boy, at the verge of death, could defy all odds and survive. “You are truly a warrior,” she said.

C, a 36-year-old teacher was in her third pregnancy. At 22 weeks of gestation, she was diagnosed to have gestational diabetes with a slight increase in the amniotic fluid. During the last trimester, her blood pressure was raised and she was admitted for induction of labour at 39 weeks of gestation.

A rare complication occurred during the induced birth. An hour after the foetal membranes were ruptured artificially, the electronic recording of the foetal heart rate (Cardiotocograph CTG) showed a sudden and rapid deceleration to a dangerous level. A va**nal examination revealed that a loop of cord had slipped out of the cervix into the va**na with the foetal head compressing it.

She was immediately put on the head-down-bottom-up (Trendelenburg) position to keep the baby's weight off the cord and was rushed to the operation theatre where an emergency caesarean section was performed. C had a dangerous obstetric complication called umbilical cord prolapse, which occurs in about 0.5% of births.

What is umbilical cord prolapse?

The umbilical cord is a flexible tube-like structure that connects an unborn baby with the mother. It is the lifeline for the baby as it transports nutrients and oxygen to the baby and carries away the baby's waste products. During pregnancy or delivery, an umbilical cord can prolapse when it drops through the opening of the womb ahead of the baby. The cord would be trapped and get compressed against the baby's body during delivery. This would deprive the baby of the oxygen resulting in grave consequences.

What are the risk factors for umbilical cord prolapse?

Cord prolapse is more likely to occur if the following risk factors are present. They include:
Premature rupture of membranes
Polyhydramnios: excessive amniotic fluid surrounding the
foetus
Premature birth
Breech
Multiple pregnancy

What are the signs of umbilical cord prolapse?

If the cord prolapses outside the va**na, the patient may be able to feel or see the cord.
Otherwise, the condition is detected during a va**nal examination. If the baby’s heart rate is being monitored when cord prolapse happens, there would be a rapid and sudden drop in the heart rate.



What are the consequences of umbilical cord prolapse?

Cord prolapse presents a great danger to the foetus. Deprivation of oxygen to the baby may cause brain damage and even result in a stillbirth. It is an obstetric emergency and the baby must be delivered immediately.

How should umbilical cord prolapse be managed?

To reduce the risk of the cord becoming compressed, the patient should be put in the Trendelenburg position. The midwife may insert a hand in to the va**na to lift the baby’s head to stop it compressing the cord and the baby should be delivered urgently, either by assisted delivery or by emergency caesarean section.

When C’s baby was delivered by caesarean section, he was pale, floppy with little response to stimulation. His heart beat was 90 beats per minutes. His breathing was shallow and irregular. After resuscitation for 5 minutes with oxygen, his condition improved with a good Apgar score. He was sent to the neonatal intensive care unit (NICU) for further observation.

Much to C’s relief, her baby was discharged from the NICU two days later and has recovered well since.

19/05/2020

“Doc, My Me**es Smells”

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She looked worried and upset when she stepped into my consultation room. “Doc, my me**es has a fishy smell for the past 2 months.” She said. “Am I having a growth in my va**na?”

T, a 32-year-old housewife had been married for 5 years. Her husband worked in a neighboring country and returned home for a week every 2 to 3 months. She last had s*xual in*******se with him 2 months ago.

On further questioning, T also noticed yellowish, sometimes greenish va**nal discharge on and off for the past 6 months. The discharge was accompanied by occasional itchiness and burning sensation around her v***a.

On examination, her v***a was inflamed and red. The va**nal discharge was creamy yellow and foul-smelling. The cervix was angry looking with red hemorrhagic spots. A microscopic examination of the va**nal discharge demonstrated the presence of the parasite, trichomonas va**nalis as shown in Figure 1 below.

Figure 1

T was suffering from trichomoniasis, a disease caused by the micro-organism, Trichomonas va**nalis. The parasite is approximately the size of a human white blood cell. The fishy smell in the va**nal discharge and the me**es is due to the presence of a chemical compound known as trimethylamine.

How common is trichomoniasis?

Trichomoniasis is one of the common s*xually transmitted disease (STD). It occurs more often in women than in men.

Risks factors of the infection include:

Multiple s*xual partners

S*x workers

Drug abuse

Older women

Poverty

How is it transmitted?

The parasite lives in the semen and va**nal fluids. It is transmitted between couple during unprotected va**nal s*x. In women, the most commonly infected area is the lower ge***al tract (v***a, va**na and cervix). Other body parts, like the hands, mouth, or a**s are usually spared. Occasionally, the infection can be spread by sharing s*x toys. Very rarely, it can be transmitted through objects like wet towels and toilet seats.



What are the symptoms of trichomoniasis?

Only about 30% of infected patients have symptoms. It is unclear why the rest remain asymptomatic. Probably this is related to the person’s age and overall health.

The symptoms vary and can occur sporadically. They can present as a mild irritation or severe infection. The incubation period ranges from 5 to 28 days or longer. If untreated, the infection can last for months or years.

For women, the common symptoms are:

White, yellowish, or greenish with an unusual fishy smell.

Itching, burning, redness or soreness of the ge***als;

Discomfort with urination

Pain during s*xual in*******se.

Urinary frequency

Lower abdominal pain

What are the complications of trichomoniasis?

Trichomoniasis increases the risks of getting or spreading other s*xually transmitted infections such as chlamydia and gonorrhea. Pelvic inflammatory disease and infertility may result. If it occurs during pregnancy, there is an increased incidence of premature birth ,intrauterine growth restriction (IUGR) and baby with low birth weight.

What is the treatment for trichomoniasis?

Trichomoniasis can be easily treated with medication. To avoid getting reinfection, both s*xual partners should be treated at the same time. It is advisable to have a review 3 months later to make sure the infection is completely cleared.

T was treated with medication for 5 days. She noticed drastic improvement in her symptoms the next day and her me**es was not smelly on her next cycle. However, reinfection occurred as her husband refused to be treated as he was asymptomatic. After much counseling and persuasion, he finally agreed to take the medication together with T who had remained symptom free since.

19/05/2020

A Miracle Baby: Grappling with Repeated Miscarriages

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Never did she expect that starting a family was such a challenge. She had had 3 miscarriages for the past 4 years.

Y, aged 35, came from a neighboring country. For her first pregnancy, she conceived within 6 months of her marriage. She thought that everything would be smooth-sailing. Unfortunately, she had a miscarriage at about 10 weeks of gestation. She felt upset and grieved over her loss for a while.

It took her another year to conceive the second time. The pregnancy progressed smoothly until the fetal heart stopped beating at 12 weeks of gestation. She was devastated and suffered a short spell of depression. She had some blood tests done by her local gynecologist, who told her that all the results were normal and the miscarriage was due to “bad luck”.

She moved with her husband to another town due to his work commitments. She was pregnant soon after. Again, mishap happened at around 16 weeks of gestation. This time, she was told that the miscarriage was due to an abnormal wedge of tissue which was found to divide the upper part of her uterine cavity.

“Doc, can you please confirm this anomaly and help me solve the problem?” she asked.
Y had a uterine septum which was confirmed by a magnetic resonance imaging (MRI).

A uterine septum occurs when a full or partial wall separates the uterus. It is a structural abnormality and is formed during Y’s development as a fetus.

Cause of the septum:
During embryonic development, the uterus starts out as two small tubular structures. As the fetus develops, each structure moves downwards and towards the middle of the body where they fuse together to form a single organ. Normally, the wall where the two tubes join in the middle will break down completely resulting in a single triangular shaped uterine cavity (fig 1). If the wall between the two tubes does not disintegrate completely, a septum will form (fig 2).

Figure 1

Figure 2

Prevalence:
About one in 10 to 15 women with repeated miscarriages has a uterine septum.

Symptoms:
Uterine septums increase the risk of a miscarriage by two to four times. It is suggested that if the foetus is implanted on the septum, the blood supply to the foetus may be compromised resulting in pregnancy loss.

Besides miscarriages, uterine septum may increase the risk for:
· Preterm birth
· Abnormal foetal position e.g. breech
· Intrauterine growth restriction
· Premature detachment of placenta: Placenta abruption
· Stillbirths and neonatal deaths in the first week of life

Diagnosis:
Uterine septums are usually detected during an ultrasound examination, hysterosalpingogram (HSG) or magnetic resonance imaging (MRI). More recently, a modified ultrasound procedure, called sonohysterogram is used to provide better images and measurements of the septum. It involves instilling saline into the uterus and then looking at it with an ultrasound.

Treatment:
The septum can be removed with a simple surgical procedure using a hysteroscope. The uterus is distended with saline solution. The lighted telescope is inserted into the va**na, through the cervix and into the uterus. The septum is then incised. The procedure is usually done under general anesthesia.

Outcome:
After removal of the septum, the patient is advised to wait for two to three menstrual cycles for healing to take place before trying to conceive. About 50 to 80 percent of women will go on to have an uneventful pregnancy.

Y had a successful removal of the septum. She returned for review six months after surgery and was pregnant the following month. The antenatal period went smoothly without complication and she delivered a healthy male baby weighing 3.2 kg by Caesarean section.

When I saw her the next day after delivery, she looked at her baby in her arms and said “ Doc, it’s so surreal. I still can't believe that I have a baby! I look at him in wonder and will never forget the long and tough path I have travelled to bring him safely into the world. I am so lucky to have my little miracle baby”.

19/04/2020

COVID-19 and pregnancy

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She sighed a big sigh of relief when her COVID-19 tests were negative. M, 29, pregnant with a pair of twins was at 30 weeks of gestation. She had been having fever and cough for 2 days before she was admitted to the wwwward for observation.

For expectant mothers, the deadly virus has caused much stress and anxiety. It also raised many unanswered questions.

Effects on the mother:

Current data indicates that pregnant mums do not have a greater chance of getting sick from COVID-19 than the general public. There is also no evidence to suggest that infected expecting mums have more serious complications than non-pregnant women. In an analysis of 147 women, only 8 percent had severe disease and 1 percent were in critical condition, according to a report published on February 28 by the World Health Organization.

At present, there is no data to show an increased risk of miscarriage. Though there have been some babies born prematurely, it is unclear whether it is due to the virus.

Effects on the baby:

Available evidence has suggested that the virus is unlikely to cross the placenta and infect the fetus. Babies born to women with the infection seemed to be free from the virus and appeared healthy at birth according to a study published in Lancet in February 2020. After birth, the newborn is susceptible to person-to-person spread. Researchers have reported 33 babies with COVID-19 infection shortly after birth; only three had mild symptoms and signs of the illness.

Breast feeding:

Current evidence suggests that breast milk does not contain the virus. The Royal College of Obstetricians and Gynaecologists (RCOG) advises that breast feeding is permissible if the baby is well. The concern is whether an infected mother can transmit the virus through respiratory droplets during the period of breastfeeding.

American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine have the following suggestions:

· Mothers with confirmed COVID-19 should take all possible precautions including washing her hands before touching the infant and wearing a face mask, if possible, while breastfeeding.

· If breast milk is expressed with a manual or electric breast pump, the mother should wash her hands before touching any pump or bottle parts and follow recommendations for proper pump cleaning after each use. If possible, consider having someone who is well feed the expressed breast milk to the infant.

As very little is known about COVID-19, there are currently no recommendations specific to pregnant women regarding the evaluation or management of COVID-19 according to obstetrics fraternities (ACOG and RCOG).

Prevention:

As the immune system in the body does change during pregnancy and expectant mums infected with viruses from the same family as COVID-19 (e.g. SARS) can become more seriously ill, it is important for expectant mums to try to protect themselves by:

· Avoiding people who are sick or who have been exposed to the virus

· Cleaning their hands often using soap and water or alcohol-based hand sanitizer

· Cleaning and disinfecting frequently touched surfaces daily

· Wearing a facemask and avoid touching the face and eyes

· Social distancing

· Any other measures recommended by the local government

07/04/2020

https://www.alife.org.sg/post/a-mother-s-not-so-sweet-story-pregnancy-diabetes

M was upset and looked at me in disbelief when I told her the not-so-sweet news. She had failed her glucose tolerance test (GTT) and had been suffering from gestational diabetes. M, aged 34, and a first-time mum was at 24 weeks of gestation. “Doc, I have a sweet tooth.” She confessed. “I would...

10/03/2020

Is coffee dangerous in pregnancy?

G looked tense. Her face was creased with anxiety.

“Doc, I am a coffee addict. I can’t work without drinking three to four mugs of coffee a day. I am in my first trimester now and my friend told me that I may have premature birth if I continue drinking the beverage. Is it true?” She said apprehensively. "I am also in a dilemma. I will have terrible migraines when I stop drinking coffee. What should I do? "

Like G, many pregnant mums are in a quandary regarding the negative effects of coffee on their health as well as the developing foetus.

Coffee contains caffeine which is a well-known stimulant that can cause an increase in maternal blood pressure and heart rate. Caffeine can reduce iron absorption from food. It is also a diuretic that may induce loss of body fluid leading to dehydration. All these negative effects on health have led obstetricians to advise pregnant mum to reduce the consumption of coffee.

Caffeine has a negative influence on foetal growth too. Studies have shown that it can enter foetal circulation via the placenta. Its levels remain longer and higher in the foetus due to immaturity of the foetal liver which cannot break down caffeine as quickly as in the adult.

A number of animal studies have shown that caffeine can cause birth defects, premature labour, preterm delivery, and increase the risk of having low-birth weight offsprings.

However, no conclusive evidence has been found in the human.

Whether caffeine causes miscarriage remains controversial. In one study, women who consume 200mg or more of caffeine a day are twice as likely to have a miscarriage compared to those who do not drink coffee. In another study, no such increased risk has been found.

With regards to migraine, I told G that it was due to caffeine withdrawal. She should gradually wean herself off coffee, by sipping smaller amounts of the beverage slowly throughout the day. If the headache still persists and complete abstinence is not possible, a small cup of coffee with less than 200mg of caffeine a day is permissible.

G tried to wean off coffee slowly by drinking decaffeinated coffee and tea. She succeeded in stopping drinking coffee after a few weeks. A healthy baby girl weighing 3 kg was delivered normally at term.

“Doc. Thanks for helping me kick the habit of drinking coffee,” she smiled as she told me during her postnatal visit.

“I also save a lot of money from buying expensive coffee,” quipped her husband.

08/03/2020

A close encounter with CMV infection during pregnancy

She was distraught when her blood tests confirmed that she had been infected with CMV- the cytomegalovirus. K, a 28-year-old kindergarten teacher and a first-time mum was at her 18 weeks of pregnancy. She had a mild fever and sore throat about 2 weeks ago. There were some swollen lymph nodes on her neck.

“Doc, will CMV affect my baby?” She asked.” I read in the internet that it can cause blindness, hearing loss and mental retardation in my child.” I told her that she had about a 40 % chance of transmitting CMV to the baby. Of the babies that become infected, only 10% will show signs of conge***al CMV with multiple disabilities.

Cytomegalovirus (CMV) is a very common virus that can infect almost everyone. The primary (first time) infection usually occurs in children and less often, in adults, as in K’s case. It is estimated that between 60 to 90 percent of all adults would have had the infection. It belongs to the same family of viruses that causes chickenpox and herpes. Once infected, the virus stays in the body for life. Most people do not know they have had CMV because it rarely causes symptoms. If symptoms do occur, they include sore throat, swollen tender lymph nodes, mild fever, fatigue and feeling unwell.

CMV is transmitted through infected bodily fluids such as blood, saliva, urine, semen and breast milk. Pregnant mothers can get the primary infection via s*xual in*******se or through contact with children. CMV is the most common virus that passes from mothers to babies during pregnancy. About 1 to 4 in 100 women have CMV during pregnancy. Majority (85-95%) of the babies born with CMV do not have health issues. But in the remainder, serious birth defects can occur. They include:

Microcephaly, in which the baby’s head is smaller than normal. This may result in mental retardation.

Enlargement of the liver and spleen.

Problems with the vision and hearing.

Seizures.

In some babies who have no symptoms at birth, varying degrees of hearing, mental or coordination problems may develop later in life. Thus, long term follow-up of the baby is of utmost importance.

K asked me in what way she could find out whether her baby was affected with the virus. The only way, I said was by a procedure called amniocentesis in which a long needle is introduced into the uterus to withdraw some amniotic fluid which surrounds the baby. Virus could then be cultured from the fluid.

After prolonged discussion with her spouse and family, K decided to continue with the pregnancy without any intervention. A fetal anomaly scan at 20 weeks showed that the brain, heart and abdominal organs were normal. The pregnancy progressed smoothly and the baby’s brain MRI scan at 36 weeks gestation did not show any abnormality. K finally delivered a healthy baby boy at 39 weeks of gestation. She had a sigh of relief when the urine and blood of the baby were tested negative for CMV.

“What a close encounter with CMV!” she exclaimed.

06/03/2020

“I have to change menstrual pad every hour!”

F,40, a mother of two walked into my consultation room with a wobbly gait. Her face looked as white as a sheet. She had to pause frequently to catch some breaths while talking.

“Doc, I have been having heavy periods with clots for a year. But it is manageable as the bleeding would stop after 5 days. But for this month, it is terrible. I have to change the menstrual pad every hour and the bleeding does not seem to stop. I have bled for the past 10 days and I feel very week and giddy now.”

F’s pulses were rapid, weak and thready at 112 /min. Her blood pressure was low at 80/50mmHg. Fresh blood was oozing out from the va**na. Her uterus and ovaries were normal. Ultrasound examination of the pelvis did not reveal any fibroid or ovarian cyst. She was anemic with a low hemoglobin of 6.7g/dL (normal range 11.5-13.5g/dL). She was admitted to hospital straight away and was transfused with blood. When her condition was stable, a hysteroscopy was performed. This is a procedure in which a thin telescope is inserted through the cervix into the uterus to examine its cavity. The tissue lining the uterus (endometrium) was sampled for microscopic examination. F’s heavy bleeding was due to the shedding of a thickened endometrium from hormonal imbalance.

Many women of reproductive age have heavy menstrual bleeding but a large number do not seek treatment until severe anemia sets in, causing symptoms like breathlessness and giddiness.

Hormonal imbalance is one of the common causes of heavy periods. In a normal menstrual cycle, there is a balance between the hormones secreted by the o***y. These hormones regulate the endometrium, which is shed during menstruation. If hormonal imbalance occurs (which may be due to the o***y not producing and/or releasing the egg), the endometrium grows thicker and finally sheds by way of heavy bleeding.

Other common causes of heavy me**es include uterine polyps , fibroid, ovarian cyst, endometriosis and pelvic infection. Medications are usually given first to treat heavy menstrual bleeding. They include hormones, oral contraceptive pills, clot promoters (tranexamic acid) and hormone manipulators (Gonadotropin releasing hormone, GnRH agonists)

Other modes of treatment include:

Insertion of hormonal intrauterine device (IUD) commonly known as Mirena. This is a hormone impregnated IUD which releases a hormone to thin the endometrium and reduces menstrual flow,

Endometrial ablation in which the endometrium is destroyed with heat using hysteroscope or other devices,

Surgery: This includes removal of uterine fibroid(myomectomy), polyp (polypectomy) ovarian cyst (ovarian cystectomy) or the uterus (hysterectomy).

F’s pulses were rapid, weak and thready at 112 /min. Her blood pressure was low at 80/50mmHg. Fresh blood was oozing out from the va**na. Her uterus and ovaries were normal. Ultrasound examination of the pelvis did not reveal any fibroid or ovarian cyst. She was anemic with a low haemoglobin of 6.7g/dL (normal range 11.5-13.5g/dL). She was admitted to hospital straight away and was transfused with blood. When her condition was stable, a hysteroscopy was performed. This is a procedure in which a thin telescope is inserted through the cervix into the uterus to examine its cavity. The tissue lining the uterus (endometrium) was sampled for microscopic examination. F’s heavy bleeding was due to the shedding of a thickened endometrium from hormonal imbalance.

F had the procedure done 8 months ago. Her menstrual flow had reduced significantly. Her hemoglobin returned to normal and she was happy with the outcome.

06/03/2020

Ovarian Cyst Gone!

She looked anxiously on the monitor screen while I scanned her with the ultrasound machine.

“Doc, is the cyst still there?” She asked.

“No, it’s gone” I replied.

“Thank God!” she exclaimed joyfully.

M, 30, experienced some niggling pain on the right side of her lower abdomen 2 weeks ago. She saw me a week later when the pain started to get worse. A va**nal ultrasound scan then revealed a 3 cm cyst in her right o***y. It was filled with clear fluid with no solid components. The blood tumour marker test CA125 was normal. I told her that it was probably a functional cyst. As it was around the second half of her menstrual cycle, I told her to have a re-scan soon after her me**es. The cyst has since vanished on her second scan.

What is a functional cyst?

A functional ovarian cyst is a sac that forms on the surface of the o***y during or after ovulation. It holds a maturing egg. Usually the sac empties itself after the egg is released. However, if there is disruption in the way the o***y produces or releases an egg, a functional cyst may develop.

There are two types of functional cyst, the follicular and luteal cyst.

· Follicular cyst: The cyst is formed in a follicle where the egg is not released properly during ovulation and fluid rapidly accumulates and causes a swelling.

· Corpus luteum cyst: The cyst develops in the corpus luteum, which is the tissue that fills an empty follicle once it has released the egg during ovulation. The cyst may bleed and cause pain.

Functional ovarian cysts can occur at any age but are much more common in women of reproductive age. They are rare after menopause.

They are also different from other abnormal ovarian cysts or growth such as cancer as they usually subside without any treatment. But occasionally, the cyst can expand rapidly, become large and cause complications such as bleeding or get infected, twisted or rupture.

What are the symptoms?

Most functional ovarian cysts do not cause symptoms. The larger the cyst is, the more likely it may cause symptoms, which include:

· Lower abdominal pain which is usually mild.

· Delayed menstrual period.

· Irregular va**nal bleeding.

· Pain during or after s*x.

· Frequent urination if the cyst is big and is pressing on the bladder

· Severe abdominal pain if the cyst develops complications

How is it diagnosed?

Functional cysts are diagnosed by pelvic ultrasound. The cyst will reduce in size or disappear around menstruation as in M’s case. If the cyst is big, it may take one or two cycles to resolve.

M was treated conservatively with medications for pain relief and heat pads to sooth her tense muscles and anxiety. The pain subsided with the dissolution of her cyst. She was monitored for another two menstrual cycles with no sign of recurrence. She has remained well since.