What is the diagnosis and treatment for Endometrioma (Endometriotic Cyst)?

From the Guidelines

The most effective approach for managing endometrioma involves a combination of hormonal therapy and surgical excision, with the goal of alleviating symptoms, preserving fertility, and improving quality of life. When considering treatment options, it's essential to take into account the patient's symptoms, the size of the endometrioma, and their fertility goals. For symptomatic patients, hormonal therapy is often the first line of treatment, including combined oral contraceptives, progestins, or GnRH agonists, which work by suppressing estrogen and thereby reducing the growth of endometrial tissue 1. Some key points to consider in the management of endometrioma include:

• The use of expanded protocol transvaginal ultrasound (TVUS) for diagnosis, which has been shown to have a higher sensitivity than routine pelvic US in detecting deep endometriosis 1.
• The importance of surgical planning and the role of imaging in informing patient decision-making and reducing the need for repeat surgeries 1.
• The potential benefits of laparoscopic excision over drainage alone in reducing recurrence rates, particularly for larger cysts or those causing severe pain 1.
• The need for regular monitoring with ultrasound for patients undergoing conservative management and the importance of counseling patients about the potential impacts on fertility and the chronic nature of endometriosis 1. In terms of specific treatment recommendations, laparoscopic excision is recommended for symptomatic patients with large endometriomas or those who desire fertility, as it has been shown to reduce recurrence rates and improve outcomes. Additionally, hormonal therapy should be tailored to the individual patient's needs and may involve the use of combined oral contraceptives, progestins, or GnRH agonists. Overall, a comprehensive approach to managing endometrioma should prioritize the patient's symptoms, fertility goals, and quality of life, while also taking into account the latest evidence and guidelines in the field 1.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION Therapy with norethindrone acetate tablets must be adapted to the specific indications and therapeutic response of the individual patient. ... Endometriosis Initial daily dosage of 5 mg norethindrone acetate tablets for two weeks. Dosage should be increased by 2. 5 mg per day every two weeks until 15 mg per day of norethindrone acetate tablets is reached. INDICATIONS AND USAGE Norethindrone Acetate Tablets, USP are indicated for the treatment of secondary amenorrhea, endometriosis, and abnormal uterine bleeding due to hormonal imbalance in the absence of organic pathology, such as submucous fibroids or uterine cancer.

Norethindrone acetate is indicated for the treatment of endometriosis. The initial daily dosage is 5 mg for two weeks, increasing by 2.5 mg every two weeks until 15 mg per day is reached 2. Norethindrone acetate tablets are specifically indicated for the treatment of endometriosis 2.

From the Research

Definition and Forms of Endometrioma

• Endometrioma can take one of three forms: endometriotic ovarian cyst (ovarian endometrioma), superficial or peritoneal endometriosis, and deep infiltrating endometriosis (DIE) 3
• DIE is considered the most aggressive form, and patients are often affected by more than one type together 3

Treatment Options

• Treatment options for endometrioma include expectant management, medical and/or surgical treatment, and in vitro fertilization and embryo transfer (IVF-ET) 4
• The choice of treatment depends mostly on the associated symptoms, with surgery being the preferred choice in most cases 4
• Medical treatment may only treat associated pain, but not the endometrioma itself 4

Surgical Treatment

• Laparoscopic excision of the endometrioma wall is considered the procedure of choice 4
• Surgical excision may damage the ovarian reserve, but recent evidence suggests that part of the damage may be due to the presence of the endometrioma itself 4
• Indication to surgical treatment should balance the possible risks of damaging the ovarian reserve with the advantages of surgery in terms of satisfactory pain relief rates and pregnancy rates 4
• Cystectomy of ovarian endometriomas has been the first-line treatment for management for many years because it provides improved pain relief, reduces recurrence rates, and was thought to be favorable in in vitro fertilization 5

Expectant Management

• Expectant management may be beneficial for asymptomatic patients with small, stable endometriomas 5
• A growing body of evidence is demonstrating benefit, or at least no harm, in expectant management for asymptomatic patients with small, stable endometriomas 5

Medical Management

• Medical management is often very effective and appropriate first line 5
• Medical therapy could improve endometriosis-associated symptoms, but it never offers a definite treatment for symptomatic patients, who often require surgical treatment 3

Modern Approaches to Surgical Management

• Surgery should be performed with microsurgical precision by experienced hands to minimize the risk of further follicular deprivation 6
• Early treatment can possibly prevent further progression of the disease 6
• Adapted surgical approaches like a two-step approach or a combination of excisional and ablative surgery may be considered in case of a large endometrioma 6