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Endometrioma

Endometrioma of Ovary

Endometriosis is defined as ectopic development and proliferation of endometrial glands and connective tissue, with ovarian endometrioma being the most common type. Main symptoms are dysparenuria, dysmenorrhea and pelvic pain. The diagnosis is made through ultrasonography and MRI, whereas laparoscopy is used in both diagnostic and therapeutic purposes. Because infertility may ensue, various surgical approaches have been recommended, but recurrence rates reach up to 30%.


Presentation

Despite the fact that an asymptomatic course can be observed in many women, the clinical presentation usually involves at least some gynecological symptoms. Most common complaints include chronic pelvic pain, which can be related to menstrual cycles that are often irregular, dysparenuria, fatigue and altered bowel/bladder movements [6]. Constipation, diarrhea or hematochezia are not uncommon, whereas irritable bowel syndrome and migraine headaches have also been reported [8].

Soft Tissue Mass
  • Abstract We present the case of a 39-year-old woman with a 2- to 3-month history of a soft tissue mass involving the abdominal wall and increasing symptoms that fluctuated relative to her menses.[ncbi.nlm.nih.gov]
  • This entity must be kept in mind by plastic surgeons evaluating patients who present with soft-tissue masses of the abdominal wall in the setting of previous combined hysterectomy and abdominoplasty.[ncbi.nlm.nih.gov]
Hypothermia
  • Perioperative nursing care includes patient teaching, taking steps to prevent surgical site infection and inadvertent hypothermia, ensuring availability of supplies (eg, the graft for abdominal wall repair if needed), and postoperative pain management[ncbi.nlm.nih.gov]
Abdominal Pain
  • This allowed for complete excision of the abdominal wall endometrioma and resolution of the cyclic, focal abdominal pain. Copyright 2015 Elsevier Inc. All rights reserved.[ncbi.nlm.nih.gov]
  • Clinical characteristics of the patients (age, history of infertility, previous surgery, and abdominal pain), the cysts (location, diameter, and volume) and the procedure (duration and complications) were recorded.[ncbi.nlm.nih.gov]
  • Abstract A 24-year-old single woman was referred to our department due to intermittent abdominal pain. Because her serum CA 125 concentration was extremely elevated an ovarian malignancy was suspected.[ncbi.nlm.nih.gov]
  • Abstract We present a rare case of an endometrioma present within and firmly adherent to the broad ligament in a patient who experienced an episode of acute abdominal pain.[ncbi.nlm.nih.gov]
  • Plastic surgeons should be aware of the association of endometriosis with chronic pelvic/abdominal pain.[ncbi.nlm.nih.gov]
Pelvic Mass
  • CONCLUSION: Rupture of a large ovarian endometrioma can lead to a high serum concentration of CA 125, a condition which, in addition to the detected pelvic mass, may mimic a malignant process.[ncbi.nlm.nih.gov]
  • It is also identified at the time of evaluation for a pelvic mass or infertility during laparoscopic surgery.[laparoscopyhospital.com]
  • An endometrioma is a benign cyst or pelvic mass made up of localized endometriosis . They are also known as chocolate, endometrioid, endometrial, or endometriotic cysts.[hystersisters.com]
  • In a study by Kupfer et al they found the most common appearance for an endometrioma was that of a cystic pelvic mass which contained homogeneous low-level echoes (found in 82% of their patients).[fetalsono.com]
Pelvic Pain
  • Surgical excision is more effective than fenestration/coagulation of endometrioma for pelvic pain but decreases antimullerian hormone.[ncbi.nlm.nih.gov]
  • Author information 1 Department of Obstetrics and Gynecology, Division of Advanced Laparoscopy and Pelvic Pain, University of North Carolina, Chapel Hill, NC.[ncbi.nlm.nih.gov]
  • The secondary outcomes included dysmenorrhea, CA125 levels, noncyclic pelvic pain, and side effects.[ncbi.nlm.nih.gov]
  • Endometriosis symptoms of dysmenorrhea, dyspareunia, and nonmenstrual pelvic pain also improved with treatment.[ncbi.nlm.nih.gov]
  • Prospective, randomized, double-blind, controlled trial of laser laparoscopy in the treatment of pelvic pain associated with minimal, mild, and moderate endometriosis. ‎ Pagina 249 - Ling FW. for the Pelvic Pain Study Group.[books.google.ro]
Dysmenorrhea
  • The secondary endpoint was the change in dysmenorrhea as evaluated by VAS (visual analog scale) scores before treatment and at 3 and 6 cycles of treatment.[ncbi.nlm.nih.gov]
  • The number-needed-to-treat benefit for dysmenorrhea recurrence at 30 months was 5.[ncbi.nlm.nih.gov]
  • Endometriosis symptoms of dysmenorrhea, dyspareunia, and nonmenstrual pelvic pain also improved with treatment.[ncbi.nlm.nih.gov]
  • KEYWORDS: cyclophilin A; dysmenorrhea; endometrioma recurrence; endometriosis; ımmunohistochemistry [Indexed for MEDLINE] Free full text[ncbi.nlm.nih.gov]
  • Oral contraceptive pills improve dysmenorrhea but not dyspareunia or noncyclic pelvic pain. Management of the patient with endometrioma should be individualized based on each patient's particular symptoms and short-term and long-term fertility goals.[ncbi.nlm.nih.gov]
Dyspareunia
  • Endometriosis symptoms of dysmenorrhea, dyspareunia, and nonmenstrual pelvic pain also improved with treatment.[ncbi.nlm.nih.gov]
  • Oral contraceptive pills improve dysmenorrhea but not dyspareunia or noncyclic pelvic pain. Management of the patient with endometrioma should be individualized based on each patient's particular symptoms and short-term and long-term fertility goals.[ncbi.nlm.nih.gov]
  • […] referred to a tertiary center in Tehran, Iran, between January 1, 2013 and December 31, 2014 to undergo laparoscopic cystectomy for ovarian endometriomas at least 30 mm in diameter, or regardless of size for patients with infertility, dysmenorrhea, dyspareunia[ncbi.nlm.nih.gov]
  • CASE: A 27-year-old, nulliparous woman presented with a painful suburethral mass, dyspareunia and voiding difficulty. Ultrasonographic examination showed an echolucent mass over the suburethral area measuring 3.7 cm in diameter.[ncbi.nlm.nih.gov]
  • Second of 4 parts on cystic adnexal pathology A 25-year-old patient presents with pelvic pain and dyspareunia. A 19-year-old patient with a history of ovarian cystectomy for dermoid cyst reports pelvic pain.[mdedge.com]
Pelvic Pain in Women
  • Petraglia F,Hornung D, Seitz C, Faustmann T, Gerlinger C, et al. (2012) Reduced pelvic pain in women with endometriosis: efficacy of long-term dienogest treatment. Arch GynecolObstet 285: 167-173.[omicsonline.org]
Salpingitis
  • BACKGROUND: Endometriotic lesions affect the fallopian tubes in 6% of patients with endometriosis and adhesions involve the salpinges in 26%.[ncbi.nlm.nih.gov]

Workup

The most important part in the diagnostic workup of women with suspected endometrioma is obtaining a thorough patient history that contains information regarding previous gynecological surgery, as well as the onset and progression of symptoms. A detailed and meticulous physical examination with an emphasis on abdominal palpation and both bimanual and speculum examination is equally important [8]. Ultrasonography, either vaginal or abdominal are good methods for initial assessment, but usually both should be performed in all women with irregular menstrual cycles in order to identify the underlying cause. Cysts that contain tar-like fluid that may be up to several centimeters in diameter in the ovaries (more frequently in the left) are considered as diagnostic hallmarks of endometriosis [2]. To support these findings, an MRI should be performed, but the gold standard of diagnosis is laparoscopy, which often the main form of treatment as well [7]. This method is not only superior because it provides a direct view into the abdomen and allows visualization of endometriotic cysts, but because it also enables exclusion other pathologies based on macroscopic criteria, such as neoplasms and other lesions in the peritoneum [7].

Treatment

Various forms of surgical treatment have been described in literature, including laparoscopic treatment, aspiration cystectomy, use of lasers and complete removal of various parts of the reproductive system through laparotomy [10]. The choice of treatment depends on factors including age, previous surgery and experience of the surgeon. Even though surgery is considered as the optimal therapeutic approach in women suffering from endometriosis, it's efficacy remains controversial, despite the fact that infertility is a significant complication if untreated [8]. The primary reason are recurrence rates have shown to be up to 30% in 5-year follow-ups according to certain reports [5], which questions the actual use of surgery when it comes to endometrioma. Nevertheless, complications such as cyst rupture and further disease progression are considered as sufficient indications for treatment.

Prognosis

Although the diagnosis can be efficiently made through the use of appropriate imaging studies and laparoscopy, recurrence rate after surgery range from 12-30% after 5 years of follow-up [11]. Additionally, endometrioma is found to be a significant risk factor for infertility, as the formation of ovarian cysts substantially impacts the ovarian architecture and diminishes the ovarian reserves [12], which is why an early diagnosis is necessary in reducing the chances for permanent inability to conceive.

Etiology

The etiology seems to be multifactorial, involving genetic, inflammatory and neuroendocrine events [3]. Initial theories have suggested retrograde menstruation as a mode of introduction of uterine tissue into the adjacent female reproductive structures, whereas the proliferation of progenitor cells from the bone marrow into uterine tissue has recently been proposed [3]. The influence of estrogen, evasion of immune defenses, and genetic predisposition have also shown to be important in the etiology of this disorder [3]. The exact cause, however, remains unknown.

Epidemiology

Studies have shown that between 17 and 44% of patients with endometriosis suffer from ovarian endometrioma [10]. In fact, this condition is considered as one of the most common gynecological problems seen in clinical practice [5] [10]. Endometriosis, in general, is most frequently seen in women during childbearing age (between 25 and 35 years of age), mostly due to the influence of ovarian steroid hormones on uterine tissue [4]. Epidemiological reports suggests that the incidence of endometriosis is approximately 4 to 60% in women who to report irregular menstrual cycles, while the cause of infertility was attributed to endometrioma 20 to 30% of cases [5]. Established risk factors include prior gynecological surgery, presence of adhesions and use of ovarian stimulation drugs (OSDs) [6]. Additionally, a seven-fold increased risk is seen in women with first-degree relatives suffering from this condition [4]. On the other hand, pregnancy is the one of the most important protective factors [6].

Sex distribution
Age distribution

Pathophysiology

The initial theories regarding the development of ovarian endometrioma included a phenomenon of retrograde menstruation, the mechanical introduction of uterine tissue into the ovaries [5]. When endometrial cells reach the ovaries, they attach to the mesothelial cells, establish their own vascular supply and produce ectopic endometrial tissue [4]. Another theory includes impaired immune mechanisms that render the immune system unable to recognize uterine tissue outside of its normal location. Consequently, when macrophages and other leukocytic lineages recognize the presence of foreign tissue in the ovaries, a strong proinflammatory reaction occurs involving cytokine and growth factors such as interleukin-1, interleukin-6, interleukin 8 and vascular endothelial growth factor (VEGF) [4]. When VEGF is secreted, the appearance of new blood vessels further nurtures endometrial cells and contributes to further disease progression [4]. Although genetic polymorphism and possibly other mutations have been associated with endometriosis, coupled with the fact that a significantly increased risk has been established in women with a positive family history, the exact pathophysiological mechanism is yet to be confirmed [4].

Prevention

The single most important preventive strategy is an early diagnosis with high clinical suspicion of various gynecological diseases in the setting of irregular menstrual cycles and symptoms that may accompany this condition. The role of pregnancy as a protective factor has been well established, which is why surgery is often performed in order to provide enough time for women of childbearing age to conceive and reduce the chances of recurrence.

Summary

Endometriosis is a chronic inflammatory disorder defined as the presence of uterine glands and stroma outside of the uterine cavity [1]. Endometrioma is considered as the most common subtype and is characterized by the appearance of ovarian endometriotic cysts [2]. The cause of endometriosis in general is incompletely understood, but presumably involves inflammatory, genetic and endocrine factors. The roles of estrogen and progesterone, the two most important female reproductive hormones, have been well established in the pathogenesis of endometriosis, whereas genetic susceptibility and defects in the immune mediated mechanisms have also been described [3]. Endometriosis is most frequently diagnosed in women between 25 and 35 years of age, primarily because of the abundant presence of ovarian steroid hormones for the purposes of reproduction [4]. Irregular menstrual cycle is shown to be the most significant risk factor for endometriosis, showing an incidence rate between 40 - 60% in this patient subgroup [5]. Moreover, between 20 to 30% of women who are having difficulties with conception suffer from endometriosis [1]. Additional risk factors include primary gynecological surgery, presence of adhesions and use of ovulation drugs [6]. The clinical presentation may be asymptomatic in many patients [4], but symptoms such as dysparenuria, dysmenorrhea, chronic pelvic pain and persistent infertility are reported as most common [4]. Menstrual cyclic pain may also be noted [7]. Fatigue, altered bowel movement and urination, as well as migraine headaches are documented [7]. A presumptive diagnosis can be made based on clinical criteria, whereas imaging studies such as pelvic ultrasonography and magnetic resonance imaging (MRI) may be used for confirmation [7]. Laparoscopy, however, is considered as the gold standard when it comes to identification, but also treatment of endometriomas [8]. Although uniform treatment guidelines have not been established [9], surgery has been advocated in many patients in order to prevent complications such as endometrioma rupture, development of a pelvic abscess, infertility and further progression of endometriosis [8]. Unfortunately, a high rate of recurrence (6-67%) was observed across various studies after surgery, with much higher rates in patients receiving preoperative, but not postoperative hormonal therapy [5]. Pregnancy has shown to be a protective factor for recurrence, which is why all attempts to enable conception with surgery should be made [5].

Patient Information

Endometrioma is one of the most common forms of endometriosis, a condition in which uterine tissue is found outside of the uterus, for example in the ovaries, the Fallopian tubes and the surrounding tissues in the abdomen. The cause presumably involves genetic, immune-mediated and hormonal factors, but the exact mechanism of development remains unknown. It is assumed that uterine glands reach the ovaries during retrograde menstruation, when uterine content travels backwards through the fallopian tube and ends in the ovaries. Subsequently, an intense inflammatory reaction occurs as a response to foreign tissue in the ovaries, followed formation of new blood vessels due to stimulation of molecules created by white blood cells. These events paradoxically lead to further growth and proliferation of uterine tissue, with the end-result being formation of endometriotic cysts that can be as large as several centimeters in diameter. This condition is most frequently seen in women between 25-35 years of age and it is established that approximately 60% of women with irregular menstrual cycles develop this condition. Several risk factors has been established, such as prior gynecological surgery, use of ovulation stimulatory drugs (OSDs) and positive family history, since a 7-fold increase risk as seen in women with first-degree relatives who already suffer from endometriosis. Some women may develop no symptoms at all, whereas irregular menstrual cycles that can be extremely painful, altered bowel movements, fatigue and migraine headaches may be reported. To make the diagnosis of endometriosis, it is important to perform a full physical examination that may suggest the origin of the symptoms. Ultrasonography, either abdominal or vaginal, is considered as a good initial diagnostic procedure, while MRI is recommended for confirmation. A procedure called laparoscopy is considered as gold standard, which comprises insertion of small instruments through the abdominal wall and direct visualization of endometrioma. Surgical treatment is aimed to remove endometrioma from the abdomen, but in the case of larger cysts, removal of ovaries or adjacent structures may be necessary. Controversy regarding surgery exists due to the fact that recurrence rate have shown to be as high as 60%, but because infertility is one of the most feared complications of endometrioma, surgery should be performed in order to provide enough time for childbearing women to conceive. In fact, pregnancy has shown to be a protective factor against endometrioma, which is which is why family counseling and pregnancy plans should be considered in the preoperative assessment and follow-up.

References

Article

  1. Porter RS, Kaplan JL. Merck Manual of Diagnosis and Therapy. 19th Edition. Merck Sharp & Dohme Corp. Whitehouse Station, N.J; 2011.
  2. Kennedy S, Bergqvist A, Chapron C, et al. ESHRE Special Interest group for Endometriosis and Endometrium Guideline Development group. ESHRE guideline for the diagnosis and treatment of endometriosis. Hum. Reprod. 2005; 20(10): 2698–2704.
  3. Burney RO, Giudice LC. Pathogenesis and Pathophysiology of Endometriosis. Fertil Steril. 2012;98(3):10.1016/j.fertnstert.2012.06.029.
  4. Macer ML, Taylor HS. Endometriosis and Infertility: A review of the pathogenesis and treatment of endometriosis-associated infertility. Obstet Gynecol Clin North Am. 2012;39(4):535-549.
  5. Selçuk İ, Bozdağ G. Recurrence of endometriosis; risk factors, mechanisms and biomarkers; review of the literature.J Turk Ger Gynecol Assoc.. 2013;14(2):98-103.
  6. Porpora MG, Pallante D, Ferro A, Crisafi B, Bellati F, Benedetti Panici P. Pain and ovarian endometrioma recurrence after laparoscopic treatment of endometriosis: a long-term prospective study. Fertil. Steril. 2010;93(3):716–721.
  7. Hsu AL, Khachikyan I, Stratton P. Invasive and non-invasive methods for the diagnosis of endometriosis. Clin Obstet Gynecol. 2010;53(2):413-419.
  8. Ünlü C, Yıldırım G. Ovarian cystectomy in endometriomas: Combined approach. J Turk Ger Gynecol Assoc. 2014;15(3):177-189.
  9. Kaponis A, Taniguchi F, Azuma Y, Deura I, Vitsas C, Decavalas GO, et al. Current treatment of endometrioma. Obstet Gynecol Surv. 2015;70(3):183-195.
  10. Chapron C, Vercellini P, Barakat H, Vieira M, Dubuisson JB. Management of ovarian endometriomas Hum. Reprod. 2002;8(6):591-597.
  11. Chon SJ, Lee SH, Choi JH, Lee JS. Preoperative risk factors in recurrent endometrioma after primary conservative surgery. Obstet Gynecol Sci. 2016;59(4):286-294.
  12. Kitajima M, Defrère S, Dolmans MM, Colette S, Squifflet J, Van Langendonckt A, et al. Endometriomas as a possible cause of reduced ovarian reserve in women with endometriosis. Fertil Steril. 2011;96(3):685-691.

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Last updated: 2017-08-09 17:34