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Liz hurts her back….

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Liz hurt her back, so decided to come to see us here at the clinic. Andrew examined her and found something interesting on ultrasound examination: a simple ovarian cyst, nearly the size of a tennis ball. Ovarian cysts are common and can sometimes cause back pain, amongst other symptoms. Often they simply disappear with the passage of time. I have done a brief summary of ovarian cyst issues below:

What are ovarian cysts?

They are fluid-filled sacs within the ovary. They can be divided in to two types: functional cysts (that are related to ovulation) and organic cysts that are more structural.

Why are we interested in them?

Chiropractors are interested in them because they can cause back pain [1] [2]. A small percentage of them can occasionally turn cancerous, more commonly in post-menopausal women [3].

Who gets them?

They occur in women of all ages. They are more common before the menopause [4], but the small percentage that can turn malignant tend to do so post-menopause [5].

What symptoms do they cause?

Mostly none, but they can cause a variety of symptoms, including back pain. The mechanism for this is unclear, but one possible mechanism is the hydronephrosis caused by an ovarian cyst compressing the ipsilateral ureter [6]. This may explain the flank tenderness sometimes found when examining these patients. They have occasionally been reported to cause sciatica [7]. More common symptoms include abdominal pain or bloating, or a feeling of fullness.  Normally, symptoms are not serious, but can be particularly bad if the cyst ruptures. Ovarian cysts may also compress the bladder and cause urinary urgency and can compress the bowel, compromising emptying.

Are they serious?

The concern is whether the cyst is malignant (cancerous) or could possibly turn malignant. Previous guidance [8] has suggested that cysts are monitored periodically to ascertain whether changes are occurring. There has been a feeling that large cysts are more likely to turn malignant than small cysts[9], but this seems not to be the case [10], and there does not seem to be a significant risk of simple ovarian cysts turning malignant. The risk seems to lie with cysts that are more complex.

Multilocular cysts are more likely to be malignant than unilocular cysts [11].

Cysts with solid parts in them are more likely to be malignant than clear cysts [12].

Cysts with papillary formations are more likely to be malignant [13].

The echogenicity of the cyst is not related to malignancy [12], nor is the presence of septae [11].

Bilateral cysts are more likely to be malignant than unilateral cysts [14].

Ovarian cysts that are causing symptoms are of more concern than cysts that are not causing symptoms [2]. This is of concern for the chiropractor, because one of the symptoms of an ovarian cyst is back pain. However, it is quite possible that for some patients the back pain is mechanical and unrelated to the cyst, whilst for others the cyst may play a role in the back pain. No doubt this will be an area for future research.

A CA-125 blood test can be useful to differentiate benign cysts from malignant cysts, but the test can produce results that are falsely negative and falsely positive [15] [16] [17] .

What happens to ovarian cysts?

In women who are who are premenopausal with normal blood tests and a cyst size of <6cm, it has been shown [18] [19] that in 50% of the cysts are gone within 6 months and 73% of them gone within 75 months of diagnosis. In postmenopausal women with functional cysts, these too will often disappear within a few months of diagnosis, especially if the woman is less than 60yrs of age [20]

What is the best treatment for them?

Most ovarian cysts do not require any treatment, and simply regress, as described earlier. If they are large enough, then the suggestion has been that they should simply be monitored periodically[21] [22], but the benefits of this have been questioned [23].

The role of aspiration of benign ovarian cysts has been shown to be of benefit in one study [24] but another study [25] suggests the opposite.  It is to be avoided on any cyst that may be malignant [26].

The evidence for any role that HRT may play in ovarian cyst treatment is conflicting [27, 28]. Oral contraceptive medication has been shown to be more helpful [29], but this has to be balanced by the potential other risks of this type of prescription

Ovarian cysts that are considered more likely (as described above) to become malignant, may be considered for surgical removal.

Which is the best type of scan: transabdominal, or internal?

In the clinic here, Andrew will only do TA (transabdominal or external) scanning of the abdomen and pelvis as part of our examination of patients with low back pain. Internal scanning would not be appropriate. However, patients who are referred to hospital for ultrasound scanning will generally have an internal (transvaginal) scan, because the scanning probe can get closer to the ovary and produce a clearer picture. But is internal scanning actually better at looking at the ovary? Whilst it seems intuitively that this should be the case, I can find little published literature that investigates this. One study [30], admittedly an older one, showed no difference in the diagnosis of polycystic ovaries by transabdominal scanning compared to internal scanning.

1.         Chamberlain, G.V., Backache–II. Br Med J, 1971. 2(5754): p. 159-60.

2.         Olson, S.H., et al., Symptoms of ovarian cancer. Obstet Gynecol, 2001. 98(2): p. 212-7.

3.         Okugawa, K., et al., Relationship between age, histological type, and size of ovarian tumors. Int J Gynaecol Obstet, 2001. 74(1): p. 45-50.

4.         Mimoun, C., et al., [Epidemiology of presumed benign ovarian tumors]. J Gynecol Obstet Biol Reprod (Paris), 2013. 42(8): p. 722-9.

5.         Noone, A., et al. Seer Cancer Statistics Review 1975-2015. 2017; Available from: https://seer.cancer.gov/csr/1975_2015/.

6.         Lameire, N., W. Van Biesen, and R. Vanholder, Acute renal failure. Lancet, 2005. 365(9457): p. 417-30.

7.         Ahmad, M., A. Kumar, and S. Thomson, The unique case of foot drop secondary to a large ovarian cyst. Br J Neurosurg, 2014. 28(4): p. 549-51.

8.         Levine, D., et al., Management of asymptomatic ovarian and other adnexal cysts imaged at US Society of Radiologists in Ultrasound consensus conference statement. Ultrasound Q, 2010. 26(3): p. 121-31.

9.         Reimer, T., et al., Differential diagnosis of peri- and postmenopausal ovarian cysts. Maturitas, 1999. 31(2): p. 123-32.

10.       Smith-Bindman, R., et al., Risk of Malignant Ovarian Cancer Based on Ultrasonography Findings in a Large Unselected Population. JAMA Intern Med, 2019. 179(1): p. 71-77.

11.       Granberg, S., M. Wikland, and I. Jansson, Macroscopic characterization of ovarian tumors and the relation to the histological diagnosis: criteria to be used for ultrasound evaluation. Gynecol Oncol, 1989. 35(2): p. 139-44.

12.       Osmers, R.G., et al., Evaluation of ovarian tumors in postmenopausal women by transvaginal sonography. Eur J Obstet Gynecol Reprod Biol, 1998. 77(1): p. 81-8.

13.       Ekerhovd, E., et al., Preoperative assessment of unilocular adnexal cysts by transvaginal ultrasonography: a comparison between ultrasonographic morphologic imaging and histopathologic diagnosis. Am J Obstet Gynecol, 2001. 184(2): p. 48-54.

14.       Minaretzis, D., et al., Ovarian tumors: prediction of the probability of malignancy by using patient’s age and tumor morphologic features with a logistic model. Gynecol Obstet Invest, 1994. 38(2): p. 140-4.

15.       Davies, A.P., et al., The adnexal mass: benign or malignant? Evaluation of a risk of malignancy index. Br J Obstet Gynaecol, 1993. 100(10): p. 927-31.

16.       Einhorn, N., et al., Prospective evaluation of serum CA 125 levels for early detection of ovarian cancer. Obstet Gynecol, 1992. 80(1): p. 14-8.

17.       Buys, S.S., et al., Ovarian cancer screening in the Prostate, Lung, Colorectal and Ovarian (PLCO) cancer screening trial: findings from the initial screen of a randomized trial. Am J Obstet Gynecol, 2005. 193(5): p. 1630-9.

18.       Sasaki, H., et al., Follow up of women with simple ovarian cysts detected by transvaginal sonography in the Tokyo metropolitan area. Br J Obstet Gynaecol, 1999. 106(5): p. 415-20.

19.       Sarkar, M. and M.G. Wolf, Simple ovarian cysts in postmenopausal women: scope of conservative management. Eur J Obstet Gynecol Reprod Biol, 2012. 162(1): p. 75-8.

20.       Levine, D., et al., Simple adnexal cysts: the natural history in postmenopausal women. Radiology, 1992. 184(3): p. 653-9.

21.       Gynecologists, A.C.o.O.a., ACOG Practice Bulletin. Management of adnexal masses. Obstet Gynecol, 2007. 110(1): p. 201-14.

22.       Greenlee, R.T., et al., Prevalence, incidence, and natural history of simple ovarian cysts among women >55 years old in a large cancer screening trial. Am J Obstet Gynecol, 2010. 202(4): p. 373.e1-9.

23.       Valentin, L. and D. Akrawi, The natural history of adnexal cysts incidentally detected at transvaginal ultrasound examination in postmenopausal women. Ultrasound Obstet Gynecol, 2002. 20(2): p. 174-80.

24.       Koutlaki, N., et al., Transvaginal aspiration of ovarian cysts: our experience over 121 cases. Minim Invasive Ther Allied Technol, 2011. 20(3): p. 155-9.

25.       Zanetta, G., et al., Role of puncture and aspiration in expectant management of simple ovarian cysts: a randomised study. BMJ, 1996. 313(7065): p. 1110-3.

26.       Vergote, I., et al., Prognostic importance of degree of differentiation and cyst rupture in stage I invasive epithelial ovarian carcinoma. Lancet, 2001. 357(9251): p. 176-82.

27.       Bar-Hava, I., et al., Ovarian cysts and cyclic hormone replacement therapy: is there an association? Acta Obstet Gynecol Scand, 1997. 76(6): p. 563-6.

28.       Modesitt, S.C., et al., Risk of malignancy in unilocular ovarian cystic tumors less than 10 centimeters in diameter. Obstet Gynecol, 2003. 102(3): p. 594-9.

29.       Lanes, S.F., et al., Oral contraceptive type and functional ovarian cysts. Am J Obstet Gynecol, 1992. 166(3): p. 956-61.

30.       Farquhar, C.M., et al., Transabdominal versus transvaginal ultrasound in the diagnosis of polycystic ovaries in a population of randomly selected women. Ultrasound Obstet Gynecol, 1994. 4(1): p. 54-9.

A 65yr-old lady with a funny walk….

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Late last autumn, the GF found an injured hedgehog in her garden. It was missing its left back leg.The reason for this wasn’t clear: a rat bite maybe, or injured by a strimmer in someone’s garden, or perhaps it had got tangled in some plastic netting and got its leg trapped? It was never clear what had happened. Anyway the leg was infected, and stinking (yuk)! This hog was not going to last the winter. So she put the hog in the straw and newspaper-filled rabbit run with water and some food with some antibiotic in it. She’s a vet btw. She kept the little hog fed through the winter, and gradually the wound healed. Of course, the leg didn’t regrow…. so now this was a three-legged hedgehog. The other day it was time to release the hog back into the wild. You can see the hog in the video, scuttling off with a very lop-sided gait, thanks to the missing leg.

In the clinic we see all sorts of lop-sidedness, and you can see this when you are out and about in town watching people go about their business. Look at the lady in the above video swaying from side to side as she walks. This is a typical gait of someone who has wear and tear in both of their hips. She probably needs both of her hips replacing, really. The side to side sway put a lot of load onto the spine and pelvis, quite commonly resulting in the low back pain that brings people in to see us in the clinic. It’s great to see how improving flexibility and strength helps people to function with less pain and continue to do the things that they like to do.

Hopefully our hop-along hedgehog will continue to explore the back gardens of the neighbourhood. We haven’t seen him back in the garden yet, but there are regular visits by other hogs. For more information about how to make your garden more hedgehog friendly, visit the British Hedgehog Preservation Society’s website. Our hedgehogs need all the help that they can get!

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