What is the treatment for endometrioma?

Treatment of Endometrioma

The primary treatment for endometrioma is surgical excision through laparoscopic cystectomy, as this provides the best outcomes for symptom relief, reduced recurrence rates, and preservation of fertility potential. 1, 2

Diagnosis and Evaluation

• Imaging: Transvaginal ultrasound is the best initial imaging modality with high specificity for diagnosing endometriomas 2
• MRI: Consider when ultrasound findings are inconclusive or to assess extent of deep infiltrating endometriosis 3
• Key diagnostic features: Classic "ground glass" appearance on ultrasound, homogeneous low-level internal echoes, and minimal vascularity on Doppler examination 2

Treatment Algorithm

1. Surgical Management (First-line)

Laparoscopic excision of the endometrioma wall (cystectomy) is the procedure of choice based on the following benefits:

• Superior outcomes: Lower recurrence rates compared to ablation techniques 2
• Better symptom relief: More effective for pain management 2
• Tissue diagnosis: Allows histological examination to rule out malignancy 2
• Improved fertility: Higher spontaneous pregnancy rates in subfertile women compared to ablation 2, 3

Surgical Technique Considerations:

• Avoid bipolar hemostasis as it causes the most damage to ovarian reserve 3
• Use careful stripping technique to minimize removal of healthy ovarian tissue 2
• Consider suturing rather than electrocautery for hemostasis to preserve ovarian function 3

2. Medical Management (Adjunctive therapy)

Medical therapy alone is generally ineffective for treating endometriomas but may be used:

• Post-surgical: To prevent recurrence after surgical excision 4
• For symptom control: When surgery is contraindicated or delayed 4

Medical Options:

• First-line: Combined oral contraceptives (COC) or levonorgestrel-releasing intrauterine system (LNG-IUS) 4
• Second-line: Progestin-only pills, GnRH analogs with add-back therapy, or dienogest 4

3. Special Considerations for Fertility

• For women planning immediate pregnancy: Surgical excision is preferred prior to attempting natural conception 2
• For women undergoing IVF: Current evidence suggests that surgical removal of endometriomas does not improve reproductive outcomes with assisted reproductive technology 3
• For large endometriomas (>4cm): Consider surgical removal before IVF to improve access for oocyte retrieval and reduce risk of infection 2

Important Caveats

• Ovarian reserve: Surgery may reduce markers of ovarian reserve such as anti-Müllerian hormone (AMH) 3
• Recurrence risk: Endometriomas have a high recurrence rate (up to 30% within 5 years) even after surgical excision 5
• Individualized approach: Consider patient's age, symptom severity, ovarian reserve status, and fertility desires when determining management 2
• Bilateral endometriomas: Exercise extreme caution with bilateral surgery due to higher risk of compromising ovarian reserve 3

When to Consider Alternative Approaches

• Asymptomatic small endometriomas (<3cm): May consider expectant management with monitoring 5
• Poor ovarian reserve: Consider more conservative approaches to preserve remaining function 3
• Recurrent endometriomas: Long-term hormonal suppression may be preferred over repeated surgeries 4

Surgical management remains the cornerstone of endometrioma treatment, offering the best outcomes for symptom control and fertility. However, the potential impact on ovarian reserve must be carefully weighed against the benefits, particularly in women with diminished ovarian reserve or those desiring future fertility.