Diagnosis and management of ovarian endometriomas
- Barbara S Levy, MD, FACOG
Barbara S Levy, MD, FACOG
- Vice President for Health Policy
- American College of Obstetricians & Gynecologists
- Robert L Barbieri, MD
Robert L Barbieri, MD
- Editor-in-Chief — Obstetrics, Gynecology and Women's Health
- Section Editor — General Gynecology and Female Reproductive Endocrinology
- Kate Macy Ladd Professor of Obstetrics, Gynecology and Reproductive Biology
- Harvard Medical School
Endometriomas usually present as a pelvic mass arising from growth of ectopic endometrial tissue within the ovary. They typically contain thick brown tar-like fluid (hence the name "chocolate cyst") and are often densely adherent to surrounding structures, such as the peritoneum, fallopian tubes, and bowel. An endometrioma may be associated with symptoms of endometriosis (eg, pelvic pain, dysmenorrhea, and dyspareunia) or identified at the time of evaluation for a pelvic mass or infertility. A woman with a ruptured endometrioma may initially present with peritoneal signs and symptoms, elevated white blood cell count, and low grade fever, similar to patients with acute pelvic inflammatory disease or appendicitis.
The diagnosis and management of endometriomas will be discussed here. General issues relating to endometriosis are reviewed separately. (See "Endometriosis: Pathogenesis, clinical features, and diagnosis" and "Endometriosis: Treatment of pelvic pain".)
The pathogenesis of endometriomas is not clear. One hypothesis is that retrograde passage of menstrual blood or shedding from endometriosis implants deposit on the ovary. Progressive invagination of the ovarian cortex over these deposits then leads to formation of an endometrioma, which is actually a pseudocyst . The cyst contents of endometriomas contain high concentrations of iron, presumably from chronic bleeding into the cyst, possibly at the time of menses.
Histopathology is required to make a definitive diagnosis of endometrioma. However, a clinical diagnosis can often be made with a high degree of certainty in a woman with histologically confirmed endometriosis and an adnexal mass, since 50 percent of women with endometriosis develop endometriomas, which are often bilateral .
Ultrasound is useful for supporting the clinical diagnosis of endometrioma, but of limited value for diagnosis or determining extent of endometriosis at other sites since it lacks adequate resolution for visualizing adhesions and superficial peritoneal/ovarian implants. However, when there are sonographic signs suggestive of endometriomas, it is likely that moderate to severe endometriosis is present; therefore, if pain is the presenting problem, extensive surgery may be required for relief of pain .
- Brosens IA, Puttemans PJ, Deprest J. The endoscopic localization of endometrial implants in the ovarian chocolate cyst. Fertil Steril 1994; 61:1034.
- Busacca M, Riparini J, Somigliana E, et al. Postsurgical ovarian failure after laparoscopic excision of bilateral endometriomas. Am J Obstet Gynecol 2006; 195:421.
- Ghezzi F, Raio L, Cromi A, et al. "Kissing ovaries": a sonographic sign of moderate to severe endometriosis. Fertil Steril 2005; 83:143.
- Van Holsbeke C, Van Calster B, Guerriero S, et al. Endometriomas: their ultrasound characteristics. Ultrasound Obstet Gynecol 2010; 35:730.
- Cheng YM, Wang ST, Chou CY. Serum CA-125 in preoperative patients at high risk for endometriosis. Obstet Gynecol 2002; 99:375.
- Alborzi S, Zarei A, Alborzi S, Alborzi M. Management of ovarian endometrioma. Clin Obstet Gynecol 2006; 49:480.
- Chapron C, Vercellini P, Barakat H, et al. Management of ovarian endometriomas. Hum Reprod Update 2002; 8:591.
- Bateman BG, Kolp LA, Mills S. Endoscopic versus laparotomy management of endometriomas. Fertil Steril 1994; 62:690.
- Saleh A, Tulandi T. Reoperation after laparoscopic treatment of ovarian endometriomas by excision and by fenestration. Fertil Steril 1999; 72:322.
- Hemmings R, Bissonnette F, Bouzayen R. Results of laparoscopic treatments of ovarian endometriomas: laparoscopic ovarian fenestration and coagulation. Fertil Steril 1998; 70:527.
- Loh FH, Tan AT, Kumar J, Ng SC. Ovarian response after laparoscopic ovarian cystectomy for endometriotic cysts in 132 monitored cycles. Fertil Steril 1999; 72:316.
- Donnez J, Wyns C, Nisolle M. Does ovarian surgery for endometriomas impair the ovarian response to gonadotropin? Fertil Steril 2001; 76:662.
- Beretta P, Franchi M, Ghezzi F, et al. Randomized clinical trial of two laparoscopic treatments of endometriomas: cystectomy versus drainage and coagulation. Fertil Steril 1998; 70:1176.
- Seracchioli R, Mabrouk M, Frascà C, et al. Long-term cyclic and continuous oral contraceptive therapy and endometrioma recurrence: a randomized controlled trial. Fertil Steril 2010; 93:52.
- Abbott JA, Hawe J, Clayton RD, Garry R. The effects and effectiveness of laparoscopic excision of endometriosis: a prospective study with 2-5 year follow-up. Hum Reprod 2003; 18:1922.
- Fedele L, Bianchi S, Zanconato G, et al. Laparoscopic excision of recurrent endometriomas: long-term outcome and comparison with primary surgery. Fertil Steril 2006; 85:694.
- Koga K, Takemura Y, Osuga Y, et al. Recurrence of ovarian endometrioma after laparoscopic excision. Hum Reprod 2006; 21:2171.
- Busacca M, Chiaffarino F, Candiani M, et al. Determinants of long-term clinically detected recurrence rates of deep, ovarian, and pelvic endometriosis. Am J Obstet Gynecol 2006; 195:426.
- Kikuchi I, Takeuchi H, Kitade M, et al. Recurrence rate of endometriomas following a laparoscopic cystectomy. Acta Obstet Gynecol Scand 2006; 85:1120.
- Liu X, Yuan L, Shen F, et al. Patterns of and risk factors for recurrence in women with ovarian endometriomas. Obstet Gynecol 2007; 109:1411.
- Leone Roberti Maggiore U, Scala C, Venturini PL, et al. Endometriotic ovarian cysts do not negatively affect the rate of spontaneous ovulation. Hum Reprod 2015; 30:299.
- Somigliana E, Berlanda N, Benaglia L, et al. Surgical excision of endometriomas and ovarian reserve: a systematic review on serum antimüllerian hormone level modifications. Fertil Steril 2012; 98:1531.
- Raffi F, Metwally M, Amer S. The impact of excision of ovarian endometrioma on ovarian reserve: a systematic review and meta-analysis. J Clin Endocrinol Metab 2012; 97:3146.
- Uncu G, Kasapoglu I, Ozerkan K, et al. Prospective assessment of the impact of endometriomas and their removal on ovarian reserve and determinants of the rate of decline in ovarian reserve. Hum Reprod 2013; 28:2140.
- Benschop L, Farquhar C, van der Poel N, Heineman MJ. Interventions for women with endometrioma prior to assisted reproductive technology. Cochrane Database Syst Rev 2010; :CD008571.
- Flyckt R, Soto E, Falcone T. Endometriomas and assisted reproductive technology. Semin Reprod Med 2013; 31:164.
- Vercellini P, Vendola N, Bocciolone L, et al. Laparoscopic aspiration of ovarian endometriomas. Effect with postoperative gonadotropin releasing hormone agonist treatment. J Reprod Med 1992; 37:577.
- Saleh A, Tulandi T. Surgical management of ovarian endometrioma. Infertil Reprod Med Clin North Am 2000; 11:61.
- Vercellini P, Chapron C, De Giorgi O, et al. Coagulation or excision of ovarian endometriomas? Am J Obstet Gynecol 2003; 188:606.
- Hart RJ, Hickey M, Maouris P, et al. Excisional surgery versus ablative surgery for ovarian endometriomata. Cochrane Database Syst Rev 2005; :CD004992.
- Muzii L, Bellati F, Palaia I, et al. Laparoscopic stripping of endometriomas: a randomized trial on different surgical techniques. Part I: clinical results. Hum Reprod 2005; 20:1981.
- Muzii L, Bianchi A, Bellati F, et al. Histologic analysis of endometriomas: what the surgeon needs to know. Fertil Steril 2007; 87:362.
- Reich H, Abrao MS. Post-surgical ovarian failure after laparoscopic excision of bilateral endometriomas: is this rare problem preventable? Am J Obstet Gynecol 2006; 195:339.
- Vercellini P, DE Matteis S, Somigliana E, et al. Long-term adjuvant therapy for the prevention of postoperative endometrioma recurrence: a systematic review and meta-analysis. Acta Obstet Gynecol Scand 2013; 92:8.
- Muzii L, Marana R, Caruana P, et al. Postoperative administration of monophasic combined oral contraceptives after laparoscopic treatment of ovarian endometriomas: a prospective, randomized trial. Am J Obstet Gynecol 2000; 183:588.
- Differential diagnosis
- Indications for surgery
- - Relief of pain
- - Exclusion of malignancy
- - Fertility potential
- - Management of ovarian endometriosis cysts prior to IVF
- - Conservative surgery (cystectomy)
- - Definitive surgery (oophorectomy)
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS