Ovaries and Endometriomas

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Endometriomas are a type of endometriosis cyst on the ovary. Management of endometriomas can be complex as there are many schools of thought on how they should be handled. Generalists, gynecologists, or fertility experts will often suggest a wait-and-watch approach when faced with a patient who has an endometrioma. Some will suggest that surgery is only warranted for cysts above a certain size. They might even cite potential damage in the context of fertility concerns. A watch-and-wait approach is a reasonable option for many and sometimes even a skilled excision surgeon will recommend the same, depending on your circumstances. The trouble is, unlike many other kinds of cysts (the common kinds that are not related to endometriosis), no amount of waiting will change the fact that endometriomas do not resolve on their own.  There are different techniques used when surgically treating an endometrioma. Some will just drain the cyst, but that doesn’t eliminate what caused the cyst to form in the first place. Even with effective skilled excision, other endometriomas can present later on.  Accessing more advanced surgical care makes sense for two key reasons: (1) removing an endometrioma effectively is a challenging task and (2) endometriomas can be an indicator of more extensive endometriosis elsewhere that will also need to be addressed.

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Studies

“Ovarian endometriomas are indicators for pelvic endometriosis and are rarely isolated. Particularly, left endometriomas were found to be associated with rectal DIE and left uterosacral ligament localization and bilateral endometriomas correlated with adhesions and pouch of Douglas obliteration, whereas no correlation was found between endometrioma size and DIE. Determining appropriate management, whether clinical or surgical, is critical for ovarian endometriomas and concomitant adhesions, endometriosis, and adenomyosis in patients desiring future fertility.”

“Endometriomas (ovarian endometriotic cysts) are a commonly diagnosed form of endometriosis, owing to the relative ease and accuracy of ultrasound diagnosis. They frequently present a clinical dilemma as to whether and how to treat them when found during imaging or incidentally during surgery. Previously published guidelines have provided recommendations based on the best available evidence, but without technical details on the management of endometriosis….Owing to the limited evidence available, recommendations are mostly based on clinical expertise….It is generally accepted that endometriosis presents in three different entities, which are frequently found together: peritoneal lesions, deep endometriosis and ovarian endometriotic cysts (endometriomas) (Nisolle and Donnez, 1997). Endometriomas are probably the most commonly diagnosed form of endometriosis because of the relative ease and accuracy of ultrasound diagnosis. Although their exact prevalence and incidence are not known, they have been reported in 17–44% of women with endometriosis (Busacca and Vignali, 2003). The presence of ovarian endometriomas has been reported as being a marker for deep endometriosis (Redwine, 1999) and multifocal deep vaginal, intestinal and ureteric lesions (Chapron et al., 2009).”

“The objective of this study was to evaluate the significance of severe preoperative pain for patients presenting with ovarian endometrioma (OMA)…. After multiple logistic regression analysis, uterosacral ligaments involvement was related with a high severity of chronic pelvic pain [odds ratios (OR) = 2.1; 95% confidence interval (CI): 1.1–4.3] and deep dyspareunia (OR = 2.0; 95% CI: 1.1–3.5); vaginal involvement was related with a higher intensity of lower urinary symptoms (OR = 13.4; 95% CI: 3.2–55.8); intestinal involvement was related with an increased severity of dysmenorrhoea (OR = 5.2; 95% CI: 2.7–10.3) and gastro-intestinal symptoms (OR = 7.1; 95% CI: 3.3–15.3). CONCLUSIONS: In case of OMA, severe pelvic pain is significantly associated with deeply infiltrating lesions. In this situation, the practitioner should perform an appropriate preoperative imaging work-up in order to evaluate the existence of associated deep nodules and inform the patient in order to plan the surgical intervention strategy.”

OTHER OVARIAN-RELATED ISSUES

  • Nonovarian Cystic Lesions of the Pelvis: 

Moyle, P. L., Kataoka, M. Y., Nakai, A., Takahata, A., Reinhold, C., & Sala, E. (2010). Nonovarian cystic lesions of the pelvis. Radiographics, 30(4), 921-938. Retrieved from https://pubs.rsna.org/doi/full/10.1148/rg.304095706?fbclid=IwAR0O4FKOnDt66Cbar32GNJUIWCnWOJUWgAno9F3tmtCq0Fzp_09PTSC5QQM& 

“”Not all cystic lesions in the female pelvis are ovarian. It is important to consider disease processes that may mimic those of the ovaries because they affect patient management. It also is important to be familiar with the imaging characteristics of the various pelvic cysts, their anatomic locations, and the patient’s clinical history to make an accurate diagnosis……..peritoneal inclusion cyst, paraovarian cyst, mucocele of the appendix, obstructed fallopian tube (eg, hydrosalpinx, pyosalpinx, and hematosalpinx), uterine leiomyoma, adenomyosis, spinal meningeal cyst, unicornuate uterus, lymphocele, cystic degeneration of lymph nodes, lymphangioleiomyomatosis, hematoma, and abscess. A cystic pelvic mass is nonovarian if it is separate from the normal ovaries.”

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