How best to convince one's doctor to do a procedure now rather than wait a month?

October 31, 2008 6:52 PM

Thursday I went to the ER with sudden sharp pains, which turned out to be a large ovarian cyst. The Dr said I might need emergency surgery to remove it. After getting some tests back he wants to "wait and see" about a month before approving their removal. I'm still in a lot of pain and want to try convince him to please just take them out... but not sure how I can talk him into it.

In short, what can I do to help him understand that:
1. when the percocet wears off, it still hurts as much as it did when I went to the ER (ie, very very much)
2. I am not very excited about being on percocet for longer than a few days, given it's addictive nature
3. Regular ibuprofen doesn't work for the pain, even at higher dosages

I'm also hoping this will happen so I can kill two birds with one stone. If I'm going to be under some sedation for the laparoscopic procedure, I want to have them remove my IUD at the same time- having it inserted was just awful and I don't want to be awake when they take it out if I can help it. The threads are not down in the os at all, they'd have to work a lot to extract it. The IUD is probably what triggered the cysts in the first place, and I want it taken out post haste b/c I already have some larger follicles in my other ovary.

Please note I'm not asking for medical advice. I just want some insight into how I should present my concerns to him in a way that will be more effective than "because I say so." He's not my regular Ob/Gyn, he was who I got assigned to via the ER.

posted by wowbobwow to health & fitness (21 comments total)

Forgot one important detail: this is a Kaiser Permanente place. Getting a 'second opinion' from another provider means I'd have to pay all out of pocket. I talked to my regular doctor and she has no say in this treatment plan and can only give the ob/gyn her opinion.
posted by wowbobwow at 7:02 PM on October 31, 2008

Call your regular OB/Gyn and ask for an emergency appointment. Tell him/her what you told us. The ER doctor doesn't have the last say in this, and your own doctor may be a whole lot more understanding about your wishes.
posted by brain cloud at 7:04 PM on October 31, 2008 [1 favorite has favorites]

my 2 cents: I'm not sure what a kaiser permanente place is but having had several large and even a few enormous cysts--there are a few different ways to treat them and surgery has not always been the greatest no matter how "easy" the surgeon says it will be(and the surgeon usually says that it will be easy.)

and if you're in that much pain all the time you definitely should consider a second opinion as that kind of pain was not my experience--I would have intermittent sharp overwhelming pains but mostly just a dull ache which didn't need medication. other complications caused me alot of constant pain but not large cysts.
posted by beckish at 8:04 PM on October 31, 2008

I'd say that the key factor is probably your ability to function. What does this condition prevent you from doing? If the pain is so severe that you can't do anything but curl up into a ball, then say so. If you can get up and walk around, but you won't be able to do your job, tell him that. etc. Tell him the things you won't be able to do until this is fixed.
posted by winston at 8:11 PM on October 31, 2008

I think you need to make it clear to your regular obgyn how much pain you're in. Most cysts caused by mirena (if that's the IUD you have) do go away on their own in a month or so, so the ER doctor is probably trying to spare you the pain and hassle of surgery.
posted by selfmedicating at 8:35 PM on October 31, 2008 [1 favorite has favorites]

You don't want surgery unless you have, have, have to have it. If you're worried about percocet now, what do you think you'll be taking after surgery?

That being said, talk to your regular doc about this situation and make sure you get referred to someone outside of the emergency department.

Good luck!
posted by herrtodd at 8:51 PM on October 31, 2008

Communicate your pain levels to your providers explicitly (all of them, ER, PCP, OBGYN). I can understand the POV that in most cases the patient nor the provider wish to rush into a surgical procedure, but many MDs/DOs/NPs unfortunately do not treat/assess pain adequately (for various reasons). Winston is correct, if you can address your functional decline in relation to the pain severity it will allow for a more detailed assessment and can hopefully accelerate your timeline to resolution. What exactly did the provider tell you he was hoping to observe over the course of one month?
posted by Asherah at 9:06 PM on October 31, 2008

If the pain continues to be severe, go back to the ER and insist on treatment, because it could be something other than a ruptured cyst. Continued severe pain doesn't match my experience with ovarian cysts.

I had several cysts rupture. It was never pleasant, but the pain from even the biggest one (tennis ball size) was mostly gone in 1-2 days, with lingering twinges for a few more days. The first several hours were very bad--unable to stand up straight, unable to drive, etc. I took pain meds but didn't need them after 1-2 days.

If an ultrasound showed a cyst, we would wait 1 month, and then do another ultrasound. The first cyst would be gone by the time of the second ultrasound, though there would often be another one somewhere else.

I wasn't told that emergency surgery could be necessary for cysts, although I did eventually have my ovaries removed, which we scheduled months in advance.

I don't understand how your regular doctor could have no say in this. You should be able to make an appointment with your regular gyn, bring the test results from the ER, and have her take over. I'm on a narrow insurance plan that restricts me to certain docs, but I've never had trouble shifting what started as an emergency to my regular doctor.
posted by PatoPata at 9:06 PM on October 31, 2008

I can even tell you something to ask your doctor to check for.

If the pain is constant and ongoing, ask your doctor to see if it's something called ovarian torsion. This is relatively rare -- women only have a 3% chance of this happening -- and it can be triggered by a cyst. Basically, what happens is your ovary just spins around and tangles itself up, potentially cutting off its blood supply and causing all sorts of other mayhem.

And -- speaking from personal experience -- it HURTS LIKE A SONUVABITCH.

It is rare, so it can take them a while to diagnose it (when it happened to me, it took nine hours to diagnose, even though doctors were constantly testing me -- I had something like 4 pelvic exams, 2 x-rays, 6 abdominal palpitations, and all sorts of other constant tests), but once they finally figure out that that's what's happening, they tend to bustle you into surgery fairly quickly. If it's only a slight case, they immediatley operate to put it back in the right place, and if it's more severe, they operate to take it out.

I am not a doctor, and I'm not entirely convinced this is what you have, but if you are in constant, steady, if-I-stand-up-it-hurts-so-bad-it-makes-me-puke-and-pass-out pain, this is definitely not something to fuck around with, and that could be one thing. (That's just how bad the pain was in my case...)

Good luck.
posted by EmpressCallipygos at 9:37 PM on October 31, 2008

Your doctor wants to wait because often ovarian cysts take care of themselves, naturally shrinking over the course of your menstrual cycle. Or they rupture, which hurts like hell and requires an ER visit but is usually not life-threatening. Unless they get extremely large and risk undergoing ovarian torsion (linked by EmpressCallipygos above), it's been my understanding from my doctors that they're reluctant to perform surgery. So I'm betting that the tests you speak of are an ultrasound or something similar, which indicate the cysts are small enough that they're probably not worth worrying about (from the doctor's point of view, anyway).

Which absolutely SUCKS, because I've been in that position. A cyst that was extremely painful, but doctors wouldn't operate because there was no ovarian torsion and the cyst wasn't large enough to risk ovarian torsion. The doctor preferred to wait for it to shrink or rupture.

I, unlike other posters, had constant pain. My OB-gyn said that was from the cyst leaking. Sometimes they leak fluid into your cavity, which hurts like a motherfucker but is, again, not life threatening so the goddamn bastards won't operate.

My point is, I feel your pain, I do. But doctors don't like to perform surgeries that they feel are unnecessary, or whose risks seem to outweigh the benefits. General anesthesia can be pretty risky, and even if we the patients are willing to accept that risk to make the pain stop that doesn't make the insurance company or doctor necessarily want to cooperate.

I had the same worries as you about taking Percocet. See if you can get a prescription for Naproxen, which is prescription-strength ibuprofen. It helped me a bit, and then I'd take Percocet when I couldn't tough it out any longer or needed to sleep.

Things will get better in a week or two. It will be a shitty, shitty week or two, and I am so sorry you have to go through this--I could not believe it either that the accepted medical treatment for an ovarian cyst is to let it sit and/or rupture!

Do please give your doctor a scale of the pain, and ask him exactly his rationale for not performing the surgery though. Hearing him talk about it may make you feel better, or at least give you a better base for going to your insurance company and saying "This man is letting my innards DIE."
posted by schroedinger at 11:23 PM on October 31, 2008 [1 favorite has favorites]

Naproxen is not prescription-strength ibuprofen -- they're separate drugs, although they're relatively similar (both in the NSAID class). They're both available in higher, prescription-only strengths, which are otherwise identical to the OTC versions.

IANAD, but it's also my understanding that opiates like Percocet aren't typically addictive if they're actually used for treatment of severe pain. Tolerance can occur, but that's a different beast entirely. Your doctor or pharmacist should be able to shed some more-informed light on this.
posted by neckro23 at 12:32 AM on November 1, 2008 [1 favorite has favorites]

in my experience with Kaiser you need to tell them exactly what you want, and be firm about it.
posted by Jason and Laszlo at 8:04 AM on November 1, 2008

My mother was once diagnosed with a cyst by a student health services doctor. It turned out to be an ectopic pregnancy. Please go see your regular doc.
posted by snuffleupagus at 8:39 AM on November 1, 2008

Seconding EmpressCallipygos' input on ovarian torsion. From personal experience, I can tell you that it is fucking excruciating. In my case, it was constant pain, and I was unable to stand up or stop crying. The upside is that if you do end up having surgery, your pain may be reduced so much that you won't need to continue with the Percocet (YMMV, of course.)

I would try to get to your regular OB/GYN as soon as you can. You may need to be obnoxiously stubborn in order to get them to listen to you. You may need to point out that if this is an ovarian torsion, you don't want to lose your ovary.

I'm so sorry you're in pain.
posted by corey flood at 10:57 AM on November 1, 2008

Thanks everyone, I'm hearing lots of good stuff here. I am fairly sure it's not ovarian torsion based on what we saw in the sonograms. I've started taking both percocet and motrin 800mg at the same time and it seems to be helping, but when it wears off, bam, right back to the fuck-everything-this-hurts-too-much feeling. I'm currently waiting to hear back from them about possibly getting me in today. At the very least, if they still refuse to do the removal I can request more pain killers. I am very worried about having to drive to work while on them, and having to take them every three hours! I'll definitely have to try being more assertive.
posted by wowbobwow at 12:35 PM on November 1, 2008

Your doctors are going to weigh risks vs. benefits of surgery. As a veteran of years of ovarian cysts, I can tell you that mine were painful, yes; when one ruptured, it was the most painful thing that's ever happened to me (besides childbirth); and they always went away. Unless a cyst is very very large and occupying a very big space in your body, they are not going to opt for surgery because the risks of anesthesia and infection outweigh the benefit of the surgery. You could probably find a doctor who would do the surgery for you, but you'd probably have to doctor-shop for a while. Given that cysts can be managed quite well with hormones, and given that it is not practical to open someone up every time a cyst forms, the usual MO is to just watch and wait, with periodic ultrasounds to monitor the growth.

You seem concerned about having to take pain medication, and that is a valid concern. I suggest you talk with your treating physician about an alternative to Percoset. There are some very good alternatives out there. I have had great success for all sorts of pain with Ultracet. Also there are specific medications for menstrual cramps if ibuprofen isn't cutting it. I tried Ponstel and was happy with the results.

Good luck. I hope you feel better soon.
posted by FergieBelle at 4:55 PM on November 1, 2008

In my experience with Kaiser gynecology and chronic pelvic pain, I got so frustrated that I started sobbing, and the doctor insisted that I have a psych eval ("so tearful").

Kaiser is good at health promotion education and preventative care, but the sort of thing you are talking about here is what they'd prefer to defer until you are at death's door (either physically, or, frankly, from suicide because you can't take it).

You absolutely must be firm. I've found that they tend not to be particularly bright, either, for people with so much higher education, and you absolutely have to tell them what you EXPECT them to do.
posted by jgirl at 6:27 PM on November 1, 2008

I have felt your pain. When I was 21, I had a softball-sized cyst on my ovary and I couldn't sit, I could barely lie down, and I wept nearly constantly (though rhythmic moaning helped). Three data points:
1. I was mis-diagnosed thrice ("..vaginal tear..." "...PID..." and something else). Seconding snuffleupagus: make sure you've got the right diagnosis.
2. Cannabis REALLY helped with the pain.
3. Doc scheduled surgery and AFTER my surgical prep that morning, just as I was being wheeled out, surg was cancelled because the doc (this was a VA hosp in Tampa) discovered via sonogram that the cyst was shrinking due to injections of depo-provera (which, back in '85(?) had not been approved of for use as birth control). More treatments, cyst go bye-bye.
Never a problem since, though I am convinced that that ovary no longer produces eggies.

WRT to your situation, there are numerous books detailing the problems with doctor-patient communication. Talk to YOUR doc. Lay out your points. Get a response on each point.
posted by Jezebella at 6:24 AM on November 2, 2008

Sorry about the Naproxen-ibuprofen mixup, it's what my doctor told me. I guess they were just trying to assure me it wasn't addictive.
posted by schroedinger at 4:53 PM on November 2, 2008

Update/conclusion- Ok, so the pain did eventually ebb on its own, within 3 days of me posting the question here. I did have them remove the Mirena and they gave me the pill which is working well already. I'm going to have to say I'm glad the Dr's didn't take my sage advice about how to do their jobs. However, I will be holding on to my leftover painkillers 'just in case.' Thank-you, hive mind!
posted by wowbobwow at 10:10 AM on November 12, 2008

Glad you're feeling better! And definitely keep those painkillers on hand, I found for months afterwards I'd get reoccurring pains mid-cycle (my theory is the cyst area was just acting up).
posted by schroedinger at 10:24 AM on November 13, 2008