What are the treatment options for endometrioma ovarian cysts?

Treatment Options for Endometrioma Ovarian Cysts

Surgical treatment through laparoscopic cystectomy is the primary therapeutic approach for endometrioma ovarian cysts, especially for symptomatic cysts larger than 4 cm or in cases of infertility that have failed to achieve pregnancy after 1-1.5 years of attempts. 1

Surgical Management

Indications for Surgery

• Symptomatic cysts (pain, pressure)
• Cysts larger than 4 cm (due to risk of rupture or torsion) 1
• Infertility cases after failed conception attempts
• Suspected malignancy

Surgical Techniques

1. Laparoscopic cystectomy with stripping technique:

   • Most effective approach for complete removal
   • Involves adhesiolysis and removal of the cyst along with its capsule
   • Better pain control and lower recurrence rates compared to drainage or ablation 2

2. Alternative techniques (for preserving ovarian reserve):

   • Ablation techniques
   • Combined technique
   • Three-step approach
   • These show less decline in anti-Müllerian hormone postoperatively 3

Considerations for Ovarian Reserve

• Cystectomy can reduce ovarian reserve both short-term and long-term 2
• Higher risk factors for ovarian reserve decline:
  • Endometrioma pathology
  • Large cyst size
  • Bilateral presentation
  • Repeated surgeries

Special Considerations

• Small asymptomatic cysts (<4 cm) should not be treated surgically, especially in women over 35 1
• Unilateral oophorectomy with sparing of the contralateral ovary is the most effective prevention for recurrent ovarian endometriosis in women who have completed childbearing 1

Medical Management

Role of Hormonal Therapy

• Limited role as primary treatment for endometriomas 4
• May be considered in cases where diffuse endometriosis is associated with pain 1

Medical Options

1. Progestin therapy:

   • Norethindrone acetate: 5-15 mg daily (gradually increased by 2.5 mg every two weeks) 5
   • Medroxyprogesterone acetate: 200 mg daily for steroid-receptor positive tumors 6

2. Combined hormonal contraceptives:

   • Continuous low-dose monophasic oral contraceptives

3. GnRH agonists:

   • For short-term pain management
   • Significant side effects limit long-term use

Post-Surgical Medical Therapy

• Post-operative hormonal suppression treatment has not shown significant effect on recurrence rates compared to surgery alone 7
• A 6-month course of hormonal suppression after laparoscopic cystectomy showed no significant difference in recurrence rates compared to placebo 7

Fertility Considerations

For Women Desiring Pregnancy

• Women with infertility should attempt pregnancy as soon as possible after treatment 1
• For patients who fail to conceive naturally and/or are older than 35 years, IVF should be the treatment of choice 1

For Women with Completed Childbearing

• Consider unilateral oophorectomy with sparing of the contralateral ovary if recurrent endometrioma occurs in the same ovary 1

Recurrence Management

• Recurrence rates after laparoscopic cystectomy range from 10-17% at 18 months follow-up 7
• Recurrent ovarian surgery is not recommended due to further damage to ovarian reserve 4

Common Pitfalls and Caveats

• Repeated surgeries significantly diminish ovarian reserve and should be avoided when possible
• Incomplete excision of the cyst wall leads to higher recurrence rates
• Excessive use of electrosurgery during cystectomy can damage healthy ovarian tissue
• Delaying treatment in symptomatic patients can lead to increased pain, adhesions, and fertility issues

Follow-Up Recommendations

• Clinical examination and transvaginal ultrasound at regular intervals (typically every 6 months) to monitor for recurrence
• Earlier follow-up for patients with severe symptoms or high risk of recurrence