Speaking of Women's Health
The Speaking of Women's Health Podcast is excited to bring you credible women's health information from host and Executive Director, Dr. Holly L. Thacker. Dr. Thacker will interview guest clinicians discussing relevant women's health topics and the latest news and tips.
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Speaking of Women's Health
Understanding Pelvic Ultrasounds And Ovarian Cysts
We explain how pelvic ultrasound, saline infusion sonography and ORADS scoring turn confusing reports into clear next steps for cysts, bleeding, and polyps. We share when to watch, when to act and why expert interpretation reduces anxiety and unnecessary tests.
• Types of pelvic ultrasound and when each is used
• How saline infusion sonography reveals cavity lesions
• Benefits of gynecologic imagers vs general radiology
• Why image quality and timing affect accuracy
• Preparing for scans, full bladder and cycle days
• Ovarian cyst basics and common myths
• ORADS scoring and what each level implies
• Postmenopausal bleeding thresholds and actions
• When hysteroscopy is the gold standard
• Managing cervical stenosis and procedural comfort
• New tech: HyCoSy for tubal patency
• Shared decision-making and practical follow-up
Welcome to the Speaking of Women's Health podcast. I'm your host, Dr. Holly Thacker, and I'm glad to be back in the Sunflower House to talk with an excellent guest, a wonderful colleague and friend, an expert physician, uh gynecologist who's been on our Speaking of Podcast before, and that is Dr. Sharon Sutherland. And we've talked about PAP smears and cervical cancer screening in the past. If you didn't hear that one, definitely go back and listen to that, ladies. But today we're going to talk about pelvic ultrasounds and ovarian cyst, what women need to know, what to expect, and how the tools that we have in imaging help guide our care. But before we dive into this interview, let me share a little bit about Dr. Sutherland. She completed medical school and her residency at the Ohio State. She's a big Buckeye fan, and her husband, too. She earned a Master's of Public Health at Columbia University, and she's been on staff at the Cleveland Clinic for 20 years. And she sees women at Maine Campus, and she operates at several locations. And she also does procedures and consults in our Center for Specialized Women's Health. Her clinical focus is a referral practice, and she's involved in the diagnosis and treatment of precancers of the cervix and abnormal menstrual and vaginal bleeding, which is unfortunately a pretty common occurrence amongst midlife women. She is the director of gynecologic imaging for our OBGYN Institute at Cleveland Clinic, and she's also in charge of the Center for Prevention of Cervical Cancer, which is a team of 14 specialists that drive excellence in the care and treatment of women with precursor lesions. In addition to all that work, she serves as a medical director for supply chain and she co-chairs our Enterprise Reprocessing Governance Council, and she oversees compliance with clinician perform microscopy for all specialties at the main campus. Welcome, Dr. Sutherland.
SPEAKER_00:Oh, thank you so much, Dr. Thacker. It's a pleasure to be here today.
SPEAKER_01:Well, I just so appreciate the uh care of our mutual patients, and you've really uh pushed this field forward. Uh, you're an excellent mentor. You also help train our specialized women's uh health fellows, and um, mainly this podcast is for lay women, but we do have a lot of physicians who tune in too and nurse practitioners. So let's just start. Uh, can you explain to us what a pelvic ultrasound is and what types of ultrasounds there are?
SPEAKER_00:So, for many women, they may have had an ultrasound, for example, during pregnancy. But when we think about gynecologic indications, uh, usually we'll do a transabdominal ultrasound. That might be much like what women had during pregnancy, where the gel goes on the abdomen, the transducers on the outside of the abdomen, usually in the area above your bladder. And that can take some images. However, the best images for female pelvic organs when we're not pregnant is the transvaginal ultrasound. That transducer is uh covered with a sterile sleeve and it's actually inserted in the vagina, much like inserting a speculum. And we can take good images of the uterus, the ovaries, the um fallopian tubes, you know, doing it that way.
SPEAKER_01:And so a lot of women are probably used to, if they've ever had a pregnancy, getting the obstetrical ultrasounds and certainly radiologists do ultrasounds, but what I think is is very unique and adds extra assessment and care is having a gynecologist do this. And do you want to talk a little bit about the differences and uh clinicians can order that specifically with a gynecologist who specializes in ultrasound, and just tell us a little bit about the training for that too.
SPEAKER_00:So we are specialists under the American Institute of Ultrasound Medicine. This is uh something that in our institute, the gynecologists who do ultrasound have to do about 300 hours of uh on-site training doing ultrasounds and also doing a lot of didactics. So if you imagine, you know, reading about information and taking tests so that we maintain our certification. Our sonographers are also trained so that everybody has a good standard, you know, a baseline around getting the good images, that's where it starts. But then the second thing is interpretation of those images. When we think about the differences between our team and radiology, a radiologic ultrasound tech might do radiology pictures of the thyroid, they might be doing pictures of the breast, they might be doing pictures of the gallbladder. So when we think about being able to develop excellence when you're only focused on one body area over and over, day after day, we actually improve our skills. So I think that's really the biggest benefit of doing the ultrasounds in gynecology. The other issue is that because uh all of us are surgeons, OBGYNs who read these, we can give more directed advice around next steps for the patient. That might actually be put out, spelled out in the report, or sometimes we'll do it as a back-end staff message where we'll message the provider that ordered the ultrasound to say, hey, I'm seeing this, this is what I recommend is next steps. So it's almost like a mini consultation based on the images.
SPEAKER_01:And also the other thing is a radiologist generally don't do saline infusion sonography, do they? Where the speculum is placed and a catheter is put inside the cervix to give us a three-dimensional look of the cervix. And obviously, a gynecologist who's used to doing pelvic exams and you know putting speculums in to open up the vagina to look at the cervix is something that they do every day, whereas a radiologist doesn't do that.
SPEAKER_00:Correct. So when we think about saline infusion sonography, the real value of that is to look for any kind of surgical lesions that might be contributing to abnormal bleeding. So in general, when we think of abnormal bleeding, it could be medical, it could be hormonal, side effective medications, infection, those types of things, or it could be something like a fibroid, a polyp, another, you know, unfortunately a cancer. So when we do a saline infusion sonogram, we insert the speculum, we put antiseptic on the cervix, pass a tiny catheter into the lining of the uterus, we remove the speculum, and then the sonographer will insert that transvaginal probe. So while the sonographer is taking pictures, we infuse a small amount of saline, and then we can actually see dynamically that cavity open. If the cavity is normal, it'll just look like an empty cavity, smooth, thin, all the way around. Sometimes it will reveal that there is a polyp, a fibroid, or another abnormality that's causing the abnormal bleeding. So it can help us steer management so we can help guide the patient about what is the true cause so they can get a resolution of their symptoms.
SPEAKER_01:You know, your point that you made about the sonography text uh reminded me a lot about my relationship as a bone densitometrist who uh reads bone densities and works with bone density text. In a lot of community settings, the radiology technician is a jack of all trades. They may do plane x-rays, they may do a bone density, they may be pulled into, you know, MRI or other types of scanning. Whereas, like at our center, the technologists only do bone density. And so they're more expert at the precision, which is very important for being able to look at things over time to know if there's a difference. So, you know, sometimes some of our listeners, they may be in other countries or rural areas and they can just get the imaging that they need. But I know a lot of times when people come and the diagnosis isn't clear or they're having problems, but they've had their imaging done elsewhere, uh, sometimes it's not exactly up to snuff about what at a big tertiary care referral center we would do. I wondered if you had any uh points about that.
SPEAKER_00:So, whenever we have consults in that situation, the reports are helpful, but to look at the images is very important. So, in other words, the report may sound like there's nothing, you know, going on, but then when we look at the images, sometimes they're just suboptimal. And a lot of it has to do with equipment. Um, just like most medical equipment, good ultrasound machines are very expensive. The technology is always changing. So for facilities to be able to continue to invest in better and better equipment, that can be a challenge. And then that's a skill set of the sonographers who's capturing the images. So if we do get enough information on that outside imaging, it doesn't mean it has to be repeated, but you're correct. Where sometimes to really give the patient the best uh consultative advice, doing another imaging study can be helpful.
SPEAKER_01:Yes, and and that's what I emphasize to my patients. They'll just sometimes bring the bone density report, but not the images. And looking at the images is how we interpret and also get an idea about the quality of the technicality of the test. Now, how should a woman prepare for a pelvic uh ultrasound? And behind the scenes, what steps do clinicians take to ensure accurate imaging?
SPEAKER_00:So, for preparation, typically they'll advise that you come in with a full bladder. The reason for that is on the transabdominal images, that full bladder creates an acoustic window. So that helps us to be able to see through that fluid in the bladder into the pelvic organs. For some patients, a transabdominal scan only is appropriate. Perhaps they've had prior vaginal procedures that would make it uncomfortable for them to have that transabdominal probe inserted, mobility issues, younger patients who are not sexually active. So sometimes that's really the big thing. Come with a full bladder. Obviously, if the bladder is too full, then they'll tell you to go and empty it. Usually what we'll do is we'll do the transabdominal images, have the patient empty her bladder, and then come back and do the transvaginal images with the empty bladder. For the saline infusion, a lot of it depends on what the patient's reproductive status is. Because this is an invasive test, we want to make certain that we aren't doing putting any instruments in the lining of the uterus if there's a possibility that the patient's pregnant. So usually there'll be a pregnancy test that's done, and then also we pay attention to the menstrual timing. The best pictures are between the end of the period around day six through day 11. If we were to do the test a few days before the period, the lining of the uterus is sometimes very thickened, fluffy, irregular, and we might misinterpret those images to say that there's a polyp when there really isn't. So the timing is important when women schedule this test.
SPEAKER_01:Yes, that that's just all excellent points. And um a lot of women sometimes might be annoyed that they have to get a pregnancy test if they say that they're not pregnant, but it's it's very important to ascertain this. And as a menopause specialist, I always like to talk to my trainees that you can't just go on a woman's age. I mean, I literally have someone in my practice who's 61 and a half who is still ovulating. I mean, it's way outside the norm. Um, but you just can't go based on age in terms of the diagnosis of menopause. And a lot of these women, even if they're in perimenopause and then they're diagnosed with menopause, sometimes when we give them hormone therapy, whatever little last terra, that ovary kicks in, and then there's more bleeding. Um, I've just been impressed as a physician who orders a lot of ultrasounds, is just the progress in being able to delineate things much better than in the past, and how the incidence of fibroids probably hasn't necessarily gone up, but the diagnosis has. And the same thing with cyst and finding other little ditzels that sometimes make women very anxious.
SPEAKER_00:Yeah, so we're finding now that fibroids occur in about 50% of women, and a lot of people don't realize, but imaging is relatively new. So if we go back into the 1970s and 1980s, most of these problems, like cysts or fibroids, were detected on pelvic exam. The doctor would feel a mass. Sometimes there was imaging available, sometimes there wasn't. Even for obstetrics, we didn't have really routine imaging available until around the 80s and 90s. Um, so it's the type of thing that we've come a long way in a short period of time to be able to give people more information.
SPEAKER_01:Now, in terms of preparing for ultrasound, do you want to talk about misoprostal or site attack? Because sometimes we do prescribe that. Do you recommend that for most women who are undergoing the saline infusion sonography where the tiny little three-millimeter catheter is inserted in the cervix to put sterile salt water so you get those nice three-dimensional views? Or do you just do it selectively, or any recommendations on that part?
SPEAKER_00:So typically it's only necessary in women who are postmenopausal. For younger women, there is that risk of uh causing a miscarriage. So, in general, I don't use mesoprostol or recommend it for a woman who's of reproductive age unless they've been known to have previous cervical stenosis. For example, they've had surgery on their cervix, they've had other attempts, and they need this medicine to soften the cervix. We give it in menopause women usually two nights before. It may cause some menstrual cramping and some spotting. Some people get a little GI upset with it. The vast majority of people feel fine, but if you've ever taken it and don't feel well, we don't repeat it. You know, in the future we would recommend skipping it. But it's a medicine we use to induce labor, so that will soften the cervix, make it more pliable and easier to dilate to insert the instruments.
SPEAKER_01:And I certainly have a decent number of postmenopausal women who've gone quite a while without estrogen, andor maybe there was some procedure done to their cervix in the past that they really have very tight cervical stenosis that sometimes even the site attack. In those cases, do they have to be relegated to an exam under anesthesia to dilate the cervix, or do you use any other options?
SPEAKER_00:Um well, sometimes we can use tiny dilators almost if you think of it like your tear duct in your eye, how tiny that is. And sometimes we're able to find the path bluntly in the office and then gradually increase the diameter of the of the dilators. But the other thing that is helpful, sometimes we just we're just not able to in the office, and our goal is to do no harm. So we aren't going to be forceful and create a path where there wasn't one. Uh, usually in the operating room under anesthesia, we can insert a scope and then we can actually see if you think of the analogy of an outside door and an inside door. We can see the outside of the cervix, but then all of a sudden you walk in the cave and it's completely black, and you're trying to find that tunnel, right? Um, so if you have a scope and then you can insert it, aha, it's over here. And then sometimes we can pass a tiny dilator under direct visualization to able to open that. It can be a little tedious, but that is a method that we can use that is it is available under anesthesia when it's just not possible in the office.
SPEAKER_01:You have been listening to the Speaking of Women's Health podcast, and we are talking to guest gynecologist and surgeon, Dr. Sharon Sutherland, who directs uh all of our gynecologic uh ultrasound. And when uh women get reports, um sometimes a lot of times there's an anxiety that comes because they don't understand the medical terms, uh, or maybe perhaps an ovarian cyst is is noted. Um, if an ovarian cyst is found, how do you approach that conversation with the uh woman and what do the ultrasound findings mean and um in terms of recommendations for follow-up?
SPEAKER_00:So a lot of it has to do with the patient's reproductive status. Women need to realize that if they're not taking any kind of hormonal suppression, every single month that they're having regular periods, they're typically forming a cyst on the ovary. It's a natural event, and literally the appearance of that cyst will change week by week as their hormonal cycle goes through. So the vast majority of cysts that we find in younger women are those physiologic cysts, and it should say in the report, it might say this is a normal finding. I think the time that we get more concerned is in menopause. We used to think that cysts and menopause were abnormal, but as more and more women are getting imaging, we're finding that many times this is just a normal appearance. They can be followed with follow-up imaging if necessary, or sometimes it has the features that suggest it's benign and they really need no further follow-up.
SPEAKER_01:Well, that's certainly um that's certainly good uh to know. Um do you want to talk about the um uh common misperceptions about ovarian cysts?
SPEAKER_00:Yeah, so I think a lot of people feel like it's a dangerous thing. In other words, it might rupture, it might cause, you know, a problem if it ruptures. Um if the cyst ruptures, typically it's just filled with um a small amount of clear fluid. There might be a tiny bit of bleeding with it, but the majority of this is a normal event if a cyst should rupture. The majority sometimes will just kind of shrink, um, you know, rather than actually rupture if it's if it's something that is not physiologic. We do have a system called um ORAD, which is the ovarian and um radiology and nexal diagnostic system, so data system. So what's happened is through thousands and thousands of images, we've been able to diagnose what are those features that are benign versus those that are malignant. So we use this scoring system, it'll look at the size of the cyst, the echo texture, in other words, is it just fluid-filled like a water balloon, or does it have debris in it? Um, we'll look at the blood flow, we'll look at the borders, and that will give us a score. So if you're getting an ultrasound report, you might see this term called ORADS, and it may have a number. And so if it says ORADS 2, a lot of times, you know, it'll say no follow up imaging needed. The reason it says that is because we see zero, you know, information that would indicate that this is a cancer. So the benefit of ORADs is it prevents women from getting repeated imaging studies that are just uncomfortable and expensive and don't really contribute to improvement. Improvement in health. On the other hand, if it's a higher ORADS score, that might indicate maybe this patient needs blood work to check for ovarian cancer tumor markers, maybe an MRI, potentially either follow-up imaging or even surgery. So it just helps us to sort out those patients who need intervention versus those who don't.
SPEAKER_01:Now I never see a report with an ORADS 1. Is that just a normal ovary?
SPEAKER_00:Yeah, ORADS 1 is normal ovary. So typically most of us just don't. I guess we shouldn't say it, but yeah, we just otherwise it'll say normal in the report.
SPEAKER_01:And I see a lot of ORADs II and a fair number of ORADS 4, but I don't really ever see ORADS III. What's the difference between three and four?
SPEAKER_00:So ORADS III, sometimes it's going to have to do with the size of the cyst, so it might have a benign appearance, um, similar to those in ORADs 2, but ORADS 3, it might be that the size is larger than typical. Um, it may have um uh an irregular border, and a lot of times an ORADS 3 cyst will do a follow-up imaging in in six months. Many times it'll it'll clear because again, our ovaries are active, they're they're constantly changing. Um so it doesn't mean that they need any other testing other than a follow-up ultrasound in six months.
SPEAKER_01:But an ORADS 4 is concerning. It doesn't dis doesn't necessarily mean cancer, but like what percent of the time have they been found to have cancer? 10%, 20%?
SPEAKER_00:So there's a very wide range of variation. It's between five and fifty. So this is what can be very concerning because you may have a 30-year-old patient with an ORADS 4 lesion has certain features that make it look unusual, but in fact, maybe she's just having an ovulation where it caused some clotting within the ovary, and her risk of malignancy is very, very low versus the same appearance on a 70-year-old patient, for example, might predict a higher risk of uh malignancy in that patient. So that's why we need to be careful to not intervene just automatically based on the appearance of the cyst, but take into consideration other factors of the patient, their risk factors of the is this likely to be anything or is it likely to result?
SPEAKER_01:Yeah, I think that's always a good uh piece of advice is take a deep breath. You know, we want to always make sure we're not missing anything serious, uh, but also not over-intervene. Is ORADS V something that's like very likely to be definitively malignant and needs to go straight to a gynecologic oncologist?
SPEAKER_00:Uh typically, yes. Um, sometimes it has to do with the blood flow. Unfortunately, cancers tend to be very highly vascular, um, also depending on the irregularity of the tissue that's within the cyst itself, the size of the cyst, and also ascites, which is where we see free fluid in the belly cavity, that can be a risk factor. Those those together might predict a much higher risk. And sometimes you can imagine this is a little subjective. So when we're reading it, that's where we're sometimes, and we'll get opinions from one another. So sometimes we'll have a colleague look at this and say, I don't know what what do you think? We try to follow these criteria, but um you know, it can the management can change depending on which which class you put patients in.
SPEAKER_01:So I think that imaging has helped so much. I use it quite a bit um in a post-menopausal woman who's having um bleeding because if the endometrium is over, you know, four, certainly five millimeters, then we definitely want to get tissue. Um, and certainly a normal, benign um ultrasound is is is helpful and reassuring. But I think that uh sometimes patients want complete reassurance, and really we need time and lots of other information and follow-up. And it's I think one of the problems of just doing widespread imaging. I've talked about the false positivity of mammograms, you know, which women have had drilled into their head that they need to get. And, you know, I think that some of the better cancer screening tests like cervical cancer screening and PAPS, they're not getting enough of or paying attention to because the interval has been spaced out. Um, so it really does take a lot of clinical judgment. Um, but I tell patients that I can't predict the future and that when we say it's benign, mostly benign, reassuring, I think that's good, but you still need to have follow-up uh with your physician. And I think it's helpful to come to a follow-up visit prepared with these questions, you know, as opposed to just, you know, calling the office, you know, or wanting to have a big discussion about it over the phone when we're really busy seeing seeing patients. I I don't know if you have any comments to make about that in terms of follow-up and um conveying information.
SPEAKER_00:Yeah, sometimes it's very straightforward. So, for example, if it's um an ovarian cyst or something like that that's considered to be a low risk, I would just take verbatim the instructions in the report. Most uh providers are not going to recommend more aggressive follow-up than would be recommended in the report. Same if it says repeat ultrasound in six months. I don't think for many patients they they need an explanation. Obviously, if they do, they're welcome to make a virtual follow-up visit. The ones that are more complicated, like you mentioned, like the OREDS 4, you know, there's something more going on. We could do A, B, or C. Let's talk about what those options are. What do you feel most comfortable with? Same with follow-up of abnormal bleeding. I think the concern that I have is that sometimes we'll order these basic tests, an endometral biopsy, a saline infusion, everything's reassuring. We tell the patient it looks great. However, if you keep bleeding, it's not normal. There's something wrong. And we don't want to keep doing the same tests over and over again. Really, the gold standard is to do a hysteroscopy where we put the camera in the lining of the uterus. We ask we do a global sampling of the whole lining. If we want to rule out cancer, um, that's really the gold standard. So just to let women know, don't settle. We don't want you to keep bleeding. You need to tell us if it's not right.
SPEAKER_01:Yeah, just yesterday um I referred a case to you for office hysteroscopy. She came in with her outside records and pathology uh post-menopausal bleeding less than a year ago, but she's continued to bleed and she's over 70. And I said, well, um, to get a good look at uh where the fallopian tubes open up, which you don't really completely see, right, with uh saline infusion sonography, but you do with global hysteroscopy.
SPEAKER_00:Correct. And that's where sometimes a very small polyp, if you imagine, can be flattened against the wall like a pancake. So with a saline infusion, sometimes it it there could be a small polyp that we don't see on that test, but when we put the scope in and look directly with the video, then we find it indeed there is a polyp.
SPEAKER_01:I had a submucosal fibroid personally that needed to be resected with a hysteroscopic uh DNC, and then there was also a small polyp found that wasn't seen on the ultrasound by the time I came in to have the surgery. So these muscle growths, which are fibroids, these polyps, which are extra tissue growth, are so common. I know that some gynecologists' approach to polyps are different. I personally, because I'm a menopause expert and I know about the benefits of hormone therapy in terms of symptom control, longevity, and reducing disease burden, and there's not really anything else that we offer to midlife women that even approximate those uh types of gains, um, that the uterus is made to bleed. And if you have a structural problem, you're generally going to keep bleeding. And I've seen citations of polyps turning to cancer as maybe low as 1% or as high as 3%. And so I personally don't want to just watch them and repeat and see if they just go away on their own. I don't know what your approach is.
SPEAKER_00:Well, sometimes we'll diagnose these in younger women, maybe in their 20s or 30s. They're asymptomatic, they may just be found in an ultrasound, they're not having any abnormal bleeding, they don't intend to be pregnant anytime soon. And so the advice in those patients is if you don't have symptoms, it's fine to monitor. But I agree once we get to midlife and that polyp is not likely going to regress on its own. Um, some of the studies will show as high as a five to seven percent risk of malignancy, much like colon polyps. Wow. So as we get older, you know, our risk of those polyps um converting is a little higher. And I I I uh do see this. Sometimes even patients have a negative biopsy in the office, but when we go to surgery to take that polyp out, we'll find in fact it was an early cancer that we can uh treat.
SPEAKER_01:I've sometimes seen the reverse where the endometrial biopsy will show like an early cancer, and then they're referred to a gynecologic oncologist for a complete hysterectomy, and the pathology will be negative, and they'll say, I didn't really need that hysterectomy. And I'm like, No, you're really lucky. It was so surface, we actually removed it with a biopsy, but you know, you you needed that treatment. And I've seen the same thing with polyps sometimes, that they definitely have a polyp um and they're set for a DNC to remove it, and then it's not seen because it must just twist and lose its blood supply and just shed on its own.
SPEAKER_00:Or sometimes they're broad-based. So if you think of the classic, it's like the uvula at the back of our throat. If you think of it like a free-hanging growth, but sometimes it's more just a little uh like a pillow that's that's more like uh flat against the surface. And so that's why um sometimes it's important that for even a hysteroscopy, we sample the whole lining because sometimes we might not recognize there's a polyp, but in fact it was there, it was just more broad-based.
SPEAKER_01:And hiding, hmm. Are there any new technologies or advancements in pelvic uh imaging that are exciting and things that we should know about?
SPEAKER_00:Um, one of the ones from infertility is something called hycosy. Classically, women that were undergoing infertility evaluation would have to have a study with X-ray to see if their tubes were open. And this would involve exposure to radiation and it was somewhat painful in radiology. So now we're actually able to use a device that inserts fluid and actually looks under ultrasound guidance to see whether the tubes are open. So I think that's one of the bigger advances. So it doesn't involve radiation and is less uncomfortable for the patient.
SPEAKER_01:Very interesting. So is that used in the field of uh reproductive endocrinology and infertility?
SPEAKER_00:Yes, yeah, it's done with our infertility change.
SPEAKER_01:That's great. So um as we're wrapping up, is there anything else that you want to tell our listeners anything about your practice or any uh tips or pearls that you think our uh listeners should know?
SPEAKER_00:Well, I think that the working with the team in specialized women's health has been a great joy. I think we have a really good team dynamic, and again, that feeling of sharing and conversing and really consulting because none of this is black and white. Um, women don't come with an instruction manual manual, and so that's where when we can work together to help solve these problems or investigate problems, it's been really helpful. I really appreciate working with your team.
SPEAKER_01:Oh, well, likewise. And uh thank you so much uh for joining us, uh Dr. Sutherland, and telling us about your expertise and all this information. I've certainly learned a lot about pelvic ultrasound and and ovarian cyst, which are a very common uh condition. And sometimes we just need follow-up, sometimes we need reassurance, and other times it's more significant. Um so thanks to all of our listeners. Uh be sure to like and share our podcast. And if you don't already subscribe, you can subscribe on Apple Podcasts or Spotify, and we will be back with another episode soon. Remember, be strong, be healthy, and be in charge.
