Endometriosis: 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
An ovarian endometrioma is a cystic mass arising from ectopic endometrial tissue within the ovary. It contains thick, brown, tar-like fluid, which may be referred to as a "chocolate cyst." Endometriomas are often densely adherent to surrounding structures, such as the peritoneum, fallopian tubes, and bowel. This topic will review management of ovarian endometriomas. Information on adnexal masses and the clinical diagnosis and management of endometriosis is discussed separately. (See "Approach to the patient with an adnexal mass" and "Endometriosis: Pathogenesis, clinical features, and diagnosis".)
The goals of endometrioma treatment are to relieve symptoms (eg, pain or mass), prevent complications related to the adnexal mass (eg, rupture or torsion), exclude malignancy, improve subfertility, and preserve ovarian function.
Relief of symptoms — Endometriomas that cause pain or a mass effect are removed to relieve the patient's symptoms [1-4].
Prevention of cyst complications — Enlarging cysts are removed because they increase the risk for ovarian torsion, cyst rupture, and the possibility of malignancy . Ovarian torsion is a surgical emergency. (See "Ovarian and fallopian tube torsion", section on 'Surgical evaluation'.)
Exclusion of malignancy — Endometriosis of the ovary is associated with a small increased risk of development of or transformation to ovarian cancer; the most common histologies are clear cell and endometrioid [6,7]. For this reason, endometriomas are removed if they have an atypical appearance on imaging studies or other concerning features (eg, enlarging size) . (See "Endometriosis: Pathogenesis, clinical features, and diagnosis", section on 'Link to cancer'.)
- Chapron C, Vercellini P, Barakat H, et al. Management of ovarian endometriomas. Hum Reprod Update 2002; 8:591.
- Dunselman GA, Vermeulen N, Becker C, et al. ESHRE guideline: management of women with endometriosis. Hum Reprod 2014; 29:400.
- 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.
- Practice Committee of the American Society for Reproductive Medicine. Treatment of pelvic pain associated with endometriosis: a committee opinion. Fertil Steril 2014; 101:927.
- Practice bulletin no. 114: management of endometriosis. Obstet Gynecol 2010; 116:223.
- Wentzensen N, Poole EM, Trabert B, et al. Ovarian Cancer Risk Factors by Histologic Subtype: An Analysis From the Ovarian Cancer Cohort Consortium. J Clin Oncol 2016; 34:2888.
- Mogensen JB, Kjær SK, Mellemkjær L, Jensen A. Endometriosis and risks for ovarian, endometrial and breast cancers: A nationwide cohort study. Gynecol Oncol 2016; 143:87.
- Hart RJ, Hickey M, Maouris P, Buckett W. Excisional surgery versus ablative surgery for ovarian endometriomata. Cochrane Database Syst Rev 2008; :CD004992.
- Loverro G, Carriero C, Rossi AC, et al. A randomized study comparing triptorelin or expectant management following conservative laparoscopic surgery for symptomatic stage III-IV endometriosis. Eur J Obstet Gynecol Reprod Biol 2008; 136:194.
- Harrison RF, Barry-Kinsella C. Efficacy of medroxyprogesterone treatment in infertile women with endometriosis: a prospective, randomized, placebo-controlled study. Fertil Steril 2000; 74:24.
- 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.
- 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.
- Goodman L, Goldberg JM, Flyckt RL, et al. Effect of surgery on ovarian reserve in women with endometriomas, endometriosis. Am J Obstet Gynecol 2016.
- 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.
- Ozaki R, Kumakiri J, Tinelli A, et al. Evaluation of factors predicting diminished ovarian reserve before and after laparoscopic cystectomy for ovarian endometriomas: a prospective cohort study. J Ovarian Res 2016; 9:37.
- Goodman LR, Goldberg JM, Flyckt RL, et al. Effect of surgery on ovarian reserve in women with endometriomas, endometriosis and controls. Am J Obstet Gynecol 2016; 215:589.e1.
- Muzii L, Achilli C, Lecce F, et al. Second surgery for recurrent endometriomas is more harmful to healthy ovarian tissue and ovarian reserve than first surgery. Fertil Steril 2015; 103:738.
- Alborzi S, Zarei A, Alborzi S, Alborzi M. Management of ovarian endometrioma. Clin Obstet Gynecol 2006; 49:480.
- 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.
- 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.
- Coccia ME, Rizzello F, Mariani G, et al. Ovarian surgery for bilateral endometriomas influences age at menopause. Hum Reprod 2011; 26:3000.
- Tanprasertkul C, Manusook S, Somprasit C, et al. Antimullerian hormone changes after laparoscopic ovarian cystectomy for endometrioma compared with the nonovarian conditions. Minim Invasive Surg 2014; 2014:654856.
- Saleh A, Tulandi T. Surgical management of ovarian endometrioma. Infertil Reprod Med Clin North Am 2000; 11:61.
- 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.
- Donnez J, Nisolle M, Gillerot S, et al. Ovarian endometrial cysts: the role of gonadotropin-releasing hormone agonist and/or drainage. Fertil Steril 1994; 62:63.
- Marana R, Caruana P, Muzii L, et al. Operative laparoscopy for ovarian cysts. Excision vs. aspiration. J Reprod Med 1996; 41:435.
- 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.
- Georgievska J, Sapunov S, Cekovska S, Vasilevska K. Effect of two laparoscopic techniques for treatment of ovarian endometrioma on ovarian reserve. Med Arch 2015; 69:88.
- 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.
- 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.
- Ferrero S, Venturini PL, Gillott DJ, et al. Hemostasis by bipolar coagulation versus suture after surgical stripping of bilateral ovarian endometriomas: a randomized controlled trial. J Minim Invasive Gynecol 2012; 19:722.
- Sönmezer M, Taşkın S, Gemici A, et al. Can ovarian damage be reduced using hemostatic matrix during laparoscopic endometrioma surgery? A prospective, randomized study. Arch Gynecol Obstet 2013; 287:1251.
- Kuroda M, Kuroda K, Arakawa A, et al. Histological assessment of impact of ovarian endometrioma and laparoscopic cystectomy on ovarian reserve. J Obstet Gynaecol Res 2012; 38:1187.
- Song T, Lee SH, Kim WY. Additional benefit of hemostatic sealant in preservation of ovarian reserve during laparoscopic ovarian cystectomy: a multi-center, randomized controlled trial. Hum Reprod 2014; 29:1659.
- Ata B, Turkgeldi E, Seyhan A, Urman B. Effect of hemostatic method on ovarian reserve following laparoscopic endometrioma excision; comparison of suture, hemostatic sealant, and bipolar dessication. A systematic review and meta-analysis. J Minim Invasive Gynecol 2015; 22:363.
- Peters A, Rindos NB, Lee T. Hemostasis During Ovarian Cystectomy: Systematic Review of the Impact of Suturing Versus Surgical Energy on Ovarian Function. J Minim Invasive Gynecol 2017; 24:235.
- Laughlin-Tommaso SK, Stewart EA, Grossardt BR, et al. Incidence, time trends, laterality, indications, and pathological findings of unilateral oophorectomy before menopause. Menopause 2014; 21:442.
- Read MD, Edey KA, Hapeshi J, Foy C. The age of ovarian failure following premenopausal hysterectomy with ovarian conservation. Menopause Int 2010; 16:56.
- Cooper GS, Thorp JM Jr. FSH levels in relation to hysterectomy and to unilateral oophorectomy. Obstet Gynecol 1999; 94:969.
- Rocca WA, Grossardt BR, Maraganore DM. The long-term effects of oophorectomy on cognitive and motor aging are age dependent. Neurodegener Dis 2008; 5:257.
- Zhou G, Liu J, Sun F, et al. Cognitive functioning in elderly women who underwent unilateral oophorectomy before menopause. Int J Neurosci 2011; 121:196.
- Roeters van Lennep JE, Heida KY, Bots ML, et al. Cardiovascular disease risk in women with premature ovarian insufficiency: A systematic review and meta-analysis. Eur J Prev Cardiol 2016; 23:178.
- 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.
- Seracchioli R, Mabrouk M, Manuzzi L, et al. Post-operative use of oral contraceptive pills for prevention of anatomical relapse or symptom-recurrence after conservative surgery for endometriosis. Hum Reprod 2009; 24:2729.
- Seo JW, Lee DY, Yoon BK, Choi D. The Efficacy of Postoperative Cyclic Oral Contraceptives after Gonadotropin-Releasing Hormone Agonist Therapy to Prevent Endometrioma Recurrence in Adolescents. J Pediatr Adolesc Gynecol 2017; 30:223.
- Muzii L, Di Tucci C, Achilli C, et al. Continuous versus cyclic oral contraceptives after laparoscopic excision of ovarian endometriomas: a systematic review and metaanalysis. Am J Obstet Gynecol 2016; 214:203.
- Bono Y, Kyo S, Kiyono T, et al. Concurrent estrogen action was essential for maximal progestin effect in oral contraceptives. Fertil Steril 2014; 101:1337.
- Abou-Setta AM, Al-Inany HG, Farquhar CM. Levonorgestrel-releasing intrauterine device (LNG-IUD) for symptomatic endometriosis following surgery. Cochrane Database Syst Rev 2006; :CD005072.
- Cho S, Jung JA, Lee Y, et al. Postoperative levonorgestrel-releasing intrauterine system versus oral contraceptives after gonadotropin-releasing hormone agonist treatment for preventing endometrioma recurrence. Acta Obstet Gynecol Scand 2014; 93:38.
- Chen YJ, Hsu TF, Huang BS, et al. Postoperative maintenance levonorgestrel-releasing intrauterine system and endometrioma recurrence: a randomized controlled study. Am J Obstet Gynecol 2017.
- Maul LV, Morrision JE, Schollmeyer T, et al. Surgical therapy of ovarian endometrioma: recurrence and pregnancy rates. JSLS 2014; 18.
- Guzel AI, Topcu HO, Ekilinc S, et al. Recurrence factors in women underwent laparoscopic surgery for endometrioma. Minerva Chir 2014; 69:277.
- Haraguchi H, Koga K, Takamura M, et al. Development of ovarian cancer after excision of endometrioma. Fertil Steril 2016; 106:1432.
- Ferrero S, Scala C, Racca A, et al. Second surgery for recurrent unilateral endometriomas and impact on ovarian reserve: a case-control study. Fertil Steril 2015; 103:1236.
- TREATMENT GOALS
- Relief of symptoms
- Prevention of cyst complications
- Exclusion of malignancy
- Treatment of subfertility
- Preservation of ovarian function
- TREATMENT OPTIONS
- OUR APPROACH
- SURGICAL PROCEDURES
- Conservative surgery (cystectomy)
- Definitive surgery (oophorectomy with or without hysterectomy)
- POSTOPERATIVE MANAGEMENT
- SOCIETY GUIDELINE LINKS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS