Ep. 97: Ovarian Cysts, with Dr. Naomi Whittaker, MD, CFCMC
Caitlin:
Welcome to the Woven Well Podcast. I'm your host, Caitlin Estes. I'm a certified fertility care practitioner with a master of divinity degree. Each episode will cover a topic that helps educate and empower you and your fertility, while honoring the deep connection your fertility has with your faith. Let's get started. Welcome back to the Woven Well Podcast. Today I'm excited to introduce Dr. Naomi Whittaker. Dr. Whittaker is a Pennsylvania-based board certified OBGYN and fellowship-trained surgeon who specializes in the Creighton model fertility care system and NaPro technology, which works cooperatively with a woman's body to treat the underlying cause of gynecologic issues and infertility, such as endometriosis and PCOS. She has dedicated her practice to women's restorative, reproductive medicine, compassionate healthcare, and education, and we are thrilled to have her on the show today. Dr. Whittaker, welcome.
Dr. Whittaker:
Thanks so much for having me. I'm so excited to be here.
Caitlin:
Me too, me too. So, as I mentioned, you specialize in the Creighton model system and NaPro technology. Most of our listeners are extremely familiar with both topics as we talk about them almost weekly on our show. But I'd love to hear from you what you feel like makes these approaches different than traditional OBGYN care.
Dr. Whittaker:
Absolutely. So I have something special, a really special tool, which is the Creighton model chart, which thank you for what you do in teaching women how to scientifically and objectively chart their cycles and write down what's going on in a reproducible way, which makes it very scientific. So we can study it, we can run tests based on it, and we can use treatments based on that cycle. So, most physicians are blind to what's going on on any given day in a cycle, which is different for each woman. And so I have a special tool, I have extra, you know, everything with medicine is based on what tools you have to offer. And so I have the tool of the Creighton chart, a special language that I can interpret for testing and treatment. And so, you know, my options are vast based on that. I'm not limited to, and I don't do IUI, IVF, which overrides the cycle. I'm able to see what's going on and work with that woman's body in an individual way.
Caitlin:
I love it, and we know it makes such an incredible difference. And even to the patients who are able to do all this work, learn what's going on in their body, really connect with how God has designed their body, and then bring that in to you, have an equal seat at the table where their experiences matter as well and you are guiding them, giving them that personalized, individualized treatment. They're not just another number, but they're a patient that you know and care about deeply. So we are very much appreciative of that as well. We see how these differences play out in real life. And so our topic today, for instance, is ovarian cysts and it's generally understood in women's health that the only thing that you can do to reduce or improve ovarian cysts is to take hormonal contraception of some kind. But we're going to talk today about NaPro technology's approach to these ovarian cysts. So let's start off, if we could, by sharing with us what are ovarian cysts.
Dr. Whittaker:
Cysts are a part of the ovary that include a sac-like structure. And there are kinds that should be there and there are kinds that shouldn't be there. The whole point of an ovary is to have eggs that are released in follicles or in cysts. So certain cysts are healthy and you want to form one, sometimes two, cysts a month. If we can ultrasound on cycle day three, we see multiple follicles that the body is choosing from. And so it's going to pick the best quality follicle. And so that one over time is going to dominate and grow and we want to see it reach around two to three centimeters and collapse by 0.7. And so it really should range at its peak somewhere between, you know, 1.9 to two to three centimeters and collapse by 0.7. So it shouldn't ever really be bigger than three centimeters at its peak approximately, give or take a few millimeters.
Dr. Whittaker:
So that's a normal healthy cyst. So anything outside of that can be abnormal. And so those appear simple and simple cyst means it's fluid filled. So on ultrasound it looks black and so there aren't walls in it. There aren't weird little nodules in it. It doesn't have debris in it. When it has any of those things, it's called complex. And so the only other really simple cyst other than a follicle or a normal ovulation would be a paratubal cyst, which isn't part of the ovary, but it may look like that on ultrasound. So that's not really a cyst, but it's something that looks simple that is next to the ovary, that on ultrasound may be confused with a cyst. And so if you see it's staying for a long time and not going away, you may consider it's a paratubal cyst. So the other group is complex cysts and so these can be benign or cancerous.
Dr. Whittaker:
The things that can increase level of suspicion of cancer would be the more complex it is. So the more little lesions inside, little nodules, septations. So it looks like they have different compartments. This doesn't happen very often. Ovarian cancer is rare. One in 70 women get ovarian cancer in their lifetime. When someone sees something abnormal in ultrasound, we tend to watch it. And so if it changes as in it goes away, it's not likely cancer. If otherwise if it's persistent we may get tumor markers to raise or lower the suspicion of cancer. But really if you think it's cancer, you really want to see an oncologist. Because you don't want a non oncologist to do surgery because it can spread ovarian cancer. So it's rare, but it's very serious. It's a very scary cancer. So that's always on our radar whether we tell you or not, we're always screening for that. But more often it's a benign tumor, like something called a cyst adenoma or a dermoid, and that one has a classic appearance. It can have hard components in it and that's also benign, but those are pretty rare. Now, more commonly would be blood-filled cysts as far as under the complex type of cyst.
Dr. Whittaker:
And so you have, blood filled could be like a old abnormal ovulation from like an LUF luteinizing ruptured follicles. So instead of collapsing when some, a woman is attempting to ovulate, she has an unhealthy ovulation event and instead of collapsing, that cyst or follicle fills with blood and can become large. Another thing that can happen is after a woman ovulates, she's supposed to create a corpus luteum, which is a smaller, that shriveled part after it collapses is called the corpus luteum. Usually that should just have a simple appearance on ultrasound, but sometimes that can fill with blood or bleed. And another type of a blood-filled cyst would be an endometrioma. So a ball of blood collection in the ovary. And the first two I mentioned, LUF and corpus luteum, those resolve over time. So we usually watch. So if we're watching and repeat your scan, we might get progesterone to kind of see if we help it reabsorb. If it doesn't respond, if it's staying the same or growing, especially three months down the road, six months, you know. If it's persistent even over years or growing and especially if someone has pain, we highly suspect an endometrioma. And so that's related to more advanced endometriosis, usually stage four at that point. By the time it's visualized on ultrasound, it's pretty advanced.
Caitlin:
And you just made a great point or mentioned something really important, which is pain. So we know that there are cysts that can get so large that the pain is pretty intense. If you're a woman out there listening who has dealt with this, then you know what I'm talking about. There's, this is no joke, you know, it really is a very painful experience and the pain alone is a valid reason for wanting to reduce the risks of cysts. But you've described a lot of different types of cysts, which is so helpful. And some of them you mentioned the possibility of ovarian cancer, want to be mindful of that. Are there any other reproductive health concerns or issues? Or is there any point in which you become concerned as a medical professional if you see that a woman has cysts on her ultrasounds?
Dr. Whittaker:
Well, like I said, any cyst over a certain size or severe pain, that's not normal. So to see a professional, and again, none of this is medical advice. If you're dealing with this, you need to talk to your doctor because I can't cover everything today. But severe pain, you know, where it's interfering with your day-to-day activity or cysts greater than especially four or five centimeters can be very abnormal. Probably over three are starting to get close to abnormal as well.
Caitlin:
Yeah. Would any of those types of cysts affect a woman's ability to conceive?
Dr. Whittaker:
Persistent cysts or endometriomas indicate a problem and can affect future ovulation and multiple follicles, right? With PCOS.
Caitlin:
So what can we do? You know, I know from years in the field that women who are told that they have ovarian cysts are given one option and one option only, which is hormonal contraception. But not only do we know that hormonal contraception of any kind has unwanted side effects and whole body health implications, but it certainly doesn't help women who are open to conception. So love to hear, you know, kind of here's, here runs the gamut here of the options for treatment for a woman with ovarian cysts.
Dr. Whittaker:
Yeah, so I mean, I don't think there's data to show that OC birth control reduces cyst form. Like is it actual good treatment for cysts? It's something that they throw everyone on because there's data to show endometriomas are less likely to recur when you shut down the brain. So endometriomas may be reduced with birth control. Now, if you have IUDs, those can increase cysts. So it kind of depends also on what you're taking. But in general you're not ovulating, so you're shutting everything down. So theoretically that's what their goal is and that's the one tool that they're very comfortable with. So that's usually the first line. Now because we have this charting, we get to have a little more fun and do things a little differently and offer other alternatives, especially in women actively trying to conceive, or women that don't want to be on the pill for whatever reason.
Dr. Whittaker:
Many times it's because they're young and you know, especially as an adolescent they may not want to get something so invasive. So, typically we like to have them charting because then we can work cooperatively with their cycle. And depending on the severity will help guide the aggressiveness of our treatment, which is progesterone. So progesterone is what the corpus luteum should be making. So after you ovulate, your body creates progesterone, which is anti-inflammatory, and it's the body's way of healing. And high progesterone is normal after ovulation. And so we mimic a healthy ovulation, so the body reabsorbs that cyst. So depending on the size of the follicle, typically we and access to shots of progesterone. Now if someone's in a lot of pain, if their cyst is really big, if they want to be aggressive and they don't want to wait a few months, I mean it still can happen. But if they really want to try to get this cyst shrink, you know, shrunken faster, they'll probably more opt for the shot. Otherwise, we can be aggressive with the pill either orally or vaginally or both
Caitlin:
The progesterone pill,
Dr. Whittaker:
Yes, we like to time it after ovulation for 10 days typically.
Caitlin:
Yeah, and I love that, you know, it's hard not to be in a restorative mindset and not love progesterone because it does.
Dr. Whittaker:
Oh my gosh,
Caitlin:
So many incredible things for us.
Dr. Whittaker:
Yes.
Caitlin:
So I love that it is so often the answer for, even for women with ovarian cysts, you know, we feel like there are no options. There's nothing out there that we can do. But there is, and it's of course it's progesterone, which I love so much. But if progesterone is unsuccessful or if maybe it's a cyst that is of higher concern or something, would you recommend surgery? Is that the next option?
Dr. Whittaker:
Again, it depends on what we think it is.
Caitlin:
That's a good point.
Dr. Whittaker:
But typically if it's persistent, some kind of surgical intervention is usually needed, either by oncology or gynecology.
Caitlin:
Now I have clients who experience what they believe is very intense ovulation pain. So I've got some clients who they may even pass out or get physically sick or they're curled up in a ball, you know, on the bathroom floor around the time of ovulation. And so I would love to hear from you, is that related to an ovarian cyst?
Dr. Whittaker:
Yeah, that's a good question. We don't always know for sure. I don't think severe pain is ever normal. I don't think that's a normal ovulation event. I would, you know, that's when estrogen is the highest in the whole cycle. And estrogen can cause inflammation when, especially without progesterone to keep it in check, which it's not around yet. And very high amounts around ovulation. And so you know that that's the body's way of trying to trigger that follicle to release by having that high estrogen. But it can cause inflammation, it can cause cyst formation. So, you know, women with endometriosis can have flares around ovulation, for example. And or a cyst. You know, the two most common things I think of when someone has debilitating pain around ovulation is well, I mean something serious can happen. I've seen someone have a cyst rupture, right?
Dr. Whittaker:
So if you're crippled on the floor, really consider going to, you know, you probably want to go to the ER or call your doctor or both, because I have seen cysts rupture and cause bleeding and an emergency. Again, that's rare, but you know, if that's your body saying something is very wrong, if you are, those symptoms are ER symptoms. So your body will alert you that it thinks it's dying. If you're need to pass out, throw up, can't function, can't move. So to take that, listen to your body, take it seriously, it's telling you something and seek medical attention. But the other thing is if a cyst is there that, you know, if a cyst is very large, like you'd be form an LUF and it's five centimeters, now that can cause pain as well.
Caitlin:
Even how you answered that question shows that there are a variety of things that are at play at any moment and that we need to be considering that full picture. I love that you encourage women to go to the ER because it is so abnormal to have those types of symptoms. Now unfortunately, a lot of women may go to the ER or they may go to their local doctor and just be told there's nothing we can do. Or, you know, you're not on hormonal contraception and that's what we've told you to do, but you are giving us a glimpse at a different option. And so I just want to state, acknowledge how much that means to me. And it does to listeners as well, because there are medical professionals out there who care about the why of what you're experiencing and want to get to the root cause of that in order to help your overall life, your quality of life to be so much better. So I appreciate you bringing up what's normal and then what's abnormal, the possibility of maybe endometriosis or other things and that it's worth exploring. So thank you so much for being on the show. Thank you for giving such an incredible amount of helpful information, very practical, and I know that listeners will be very grateful to hear all of it.
Dr. Whittaker:
Good. I hope it's helpful. And again, if you have any questions, go to the doctor, ask them about your case. Because there's no way we can go over this really complicated subject, but I do like to try to simplify it just so you kind of understand what your doctor is thinking, at least when these symptoms present. Or at least, you know, if you don't feel supported by one, get a second opinion as well. And yeah, if you go to the ER and the worst, let's say you're on the floor debilitated, you go to the ER and the worst thing they do is send you home. That's a good thing. It's better than the alternative of, well, you stay home and it, it turns catastrophic. So, and hopefully as you get help those episodes go, you know, decrease in frequency. But yeah, being on the floor is never a good normal thing. That's not, that's not a normal part of being a woman.
Caitlin:
Absolutely.
Dr. Whittaker:
Thanks for bringing awareness on this topic. I've been wanting to go over it. They are preventable. Post-peak progesterone support, even before the next cycle can help the health of the next cycle, the next ovulation to hopefully prevent cysts. There are people with more complicated issues, but those are pretty rare. Progesterone's going to help most women. Like you said, it's, if we had to only have one thing to prescribe ever, that that would be the one thing I would choose.
Caitlin:
Yes. I love it. Well, listeners, I'm glad to be able to introduce doctors like Dr. Whittaker. As a certified fertility care practitioner, I know that we could not serve women and couples the way that we do without the education, compassion, and care of restorative medical professionals. Here at Woven Well, we consistently bring you resources like this on a regular basis. We provide education and a sense of community that empowers women to make informed fertility decisions while honoring the deep connection between fertility and faith. Women's health is full of challenges, but we hope to engage them with prudence, faith, and courage. In addition to the Woven Well podcast, we have lots of completely free resources for you. We'd love to give you easy access through our monthly newsletter, which you can join at wovenfertility.com or through the link in the show notes. As always, thanks so much for listening as we continue to explore together what it means to be woven well.