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Pelvic pain, normal ULTRASOUND with RAISED HCG. Cause?

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I am a 36 year old female. I do not have a history of previous pregnancies. My LMP was August 28. After my LMP in August, I had some significant pelvic pain which prompted me to see my GP. On Sept 19, a TV and abdominal US were performed.
Transabdominal pelvic ultrasound was initially performed
The uterus measures 7.2 x 2.6 x 4.1 cm.
The uterus appears normal in size and contour.
The endometrial thickness appears uniform and normal measuring 7 mm.

Transvaginal ultrasound was then performed for better visualization of the
ovaries and adnexa.
The right ovary measures 3.9 x 3.7 x 3.1 cm.
The left ovary measures 3 x 2.8 x 1.6 cm.
Right ovary demonstrates a 1.5 x 1.2 x 1.5 cm hypoechoic mass likely
representing a cyst..
Color and spectral doppler flow analysis was performed. Normal flow was present

No adnexal mass or free pelvic fluid identified.

My GP suspected this was a cyst and to watch and see.

In the beginning of October, my period was late and a home pregnancy test was positive. My pelvic pain was significantly worse, so I saw a gynecologist on 10/3/14. My HCG was 835. Because of the severity of my pelvic pain, she performed a repeat ultrasound and also an abdominal CT with contrast.
CT:
CT Abdomen

The visualized lung bases are clear. There is no pericardial or pleural
effusion.

The liver, spleen, gallbladder, pancreas, adrenal glands, and kidneys are
unremarkable without focal abnormality. The small bowel has a normal
appearance. No free air is seen.

CT Pelvis

Scant free fluid is present. Uterus is within normal limits in size and
appearance. There is some diminished enhancement centrally, nonspecific. The
bilateral adnexa are visualized and contain hypodense cystic-appearing foci. The
right ovary appears to contain a more discrete, peripherally enhancing, somewhat
crenulated morphology cystic appearing lesion measuring 2.7 x 1.5 x 1.5 cm in
size, perhaps representing a recently ruptured cyst although nonspecific.

The appendix has a normal appearance. No right lower quadrant inflammatory
stranding is seen. No abnormal fluid collection or free fluid is seen. The
bladder is normal in appearance. The colon is normal in appearance.

Mild depression of the L1 superior endplate is present without retropulsion or
acute fracture line . (6 nonrib-bearing lumbar type vertebral bodies are
present.]

The transvaginal ultrasound was as follows:
Findings: Normal appearing uterus with trilaminar endometrium
noted. Small hypoechoic area noted. No distinct fetal pole or
yolk sac seen.
Right ovary: 4.79x3.69x4.15 cm. 3 separate cysts noted:
(2.15x1.87); (0.84x1.27cm); (0.87x1.56 cm-complex)
Left ovary: not well visualized.

On October 8, my pelvic pain worsened and I began to bleed heavily with large clots. Bleeding persisted through October 15. We believed this was a miscarriage.

On 10/10/14: my HCG was 735.
On 10/14/14: beta HCG was 749
On 10/16/14: beta HCG 748

On 10/17, she RX Misoprostol for failed pregnancy. I took 400 micrograms vaginally and repeated at 4 and 8 hours.

I have not had any bleeding or extra cramping.

I am concerned as I have a family history of breast, ovarian and cervical cancer on both sides of my family and am awaiting results of BRCA and Lynch testing. 2 of my family members are/were positive for BRCA1.

I have elected to proceed with a hysterectomy, but my gynecologist will not perform the surgery unless my HCG levels fall to <5.

I will also mention that I have had a history of significant fatigue, night sweats, diarrhea and an increase in urinary frequency for about the past 6 months.

Any help or insight you can offer on my persistant HCG levels and symptoms would be most appreciated.

Category: OBGYN

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Category: Infertility Specialist
 29 Doctors Online

Hello,
Thanks for posting your query at DoctorSpring.com
With positive B HCG levels and adnexal lesions in the ovaries, there is a strong possibility of ectopic pregnancy also.
Only serial B HCG levels would show if this is the case.
None of the scans have however raised this suspicion so far, and the heavy bleeding with clots is in favour of a miscarriage.
Also, there is no history of any fainting or acute pain.
Please have repeat B HCG levels after 4 days and a repeat scan after a week, that will clarify the diagnosis.
The cyst can only be evaluated after the pregnancy scenario is cleared.
These could be corpus luteal cysts ( normal ) or physiological pregnancy related cysts.
Blood work to evaluate a malignant component too is best done once B HCG levels normalize.
Chances of this being a malignant lesion are remote, given your age and clinical symptoms.
All the best
Please feel free to discuss further.
Regards.


Dr. Aarti Vazirani
Category: Infertility Specialist
Experience: 
Residency: Obstetrics & Gynecolog, BJMC,Civil hospital, Ahmedabad, 2008
Post Graduate: MS (Obstetrics & Gynecology), B.J. Medical College, Ahmedabad, 2008
Medical School: MBBS, B.J. Medical College, Ahmedabad, 2004
Dr. Aarti Vazirani and 4 other Medical Specialists are ready to help you

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