What are the recommended treatment options for managing an endometrioma?

Management of Endometriomas

The preferred treatment for endometriomas is laparoscopic excision of the endometrioma wall (cystectomy), as it provides the best outcomes for pain relief, recurrence prevention, and fertility. 1

Diagnosis and Evaluation

• Transvaginal ultrasound (TVUS) is the initial imaging modality of choice for diagnosing endometriomas 2
• MRI may be used when ultrasound findings are inconclusive or to assess the extent of deep infiltrating endometriosis 2
• Key diagnostic features of endometriomas on ultrasound:
  • Unilocular or multilocular cysts with homogeneous low-level internal echoes
  • No internal blood flow on color Doppler
  • Ground glass appearance

Treatment Options

1. Surgical Management

Laparoscopic cystectomy (excision) is superior to ablation for:

• Lower recurrence rates
• Better pain relief
• Improved spontaneous pregnancy rates in subfertile women 3

Surgical technique considerations:

• Avoid bipolar hemostasis as it causes the most damage to ovarian reserve 3
• Use careful stripping technique to minimize damage to healthy ovarian tissue
• Consider preoperative assessment of ovarian reserve (AMH levels) 4

2. Medical Management

Medical therapy alone is generally ineffective for endometriomas but may help with associated pain symptoms 5:

• Combined hormonal contraceptives (various routes of administration)
• Progestins, particularly levonorgestrel-releasing IUS
• GnRH analogs (with add-back therapy) as a last option

Medical therapy can be used:

• Before surgery to reduce inflammation
• After surgery to prevent recurrence 5, 4

3. Expectant Management

May be appropriate for:

• Asymptomatic small endometriomas
• Women not seeking immediate fertility
• Women with diminished ovarian reserve where surgery may further compromise fertility 6

Special Considerations for Fertility

For women planning natural conception:

• Surgical excision improves spontaneous pregnancy rates in subfertile women 3

For women planning ART/IVF:

• Current evidence suggests that ovarian cystectomy does not improve reproductive outcomes for women undergoing assisted reproductive technology 3, 6
• Consider these factors before surgery:
  1. Size of endometrioma (>4cm may interfere with oocyte retrieval)
  2. Pain symptoms
  3. Baseline ovarian reserve
  4. Risk of malignancy

Treatment Algorithm

1. Symptomatic endometriomas with pain:

   • First-line: Laparoscopic cystectomy
   • Post-operative hormonal suppression to prevent recurrence

2. Asymptomatic endometriomas in women seeking fertility:

   • For natural conception: Laparoscopic cystectomy
   • For IVF: Consider expectant management if endometrioma <4cm and not interfering with oocyte retrieval

3. Recurrent endometriomas:

   • Long-term hormonal suppression
   • Repeat surgery only if symptomatic or suspicious for malignancy

Pitfalls to Avoid

• Surgical damage to ovarian reserve: Bipolar coagulation should be minimized; use suturing or hemostatic agents instead 3
• Incomplete excision: Can lead to higher recurrence rates
• Delayed diagnosis: Endometriomas are associated with deep infiltrating endometriosis; early diagnosis allows for comprehensive treatment planning 4
• Ignoring malignancy risk: Although rare, endometriomas have a small risk of malignant transformation; surgical specimens should always be sent for pathological examination 1

Monitoring and Follow-up

• Regular ultrasound monitoring for recurrence
• Assessment of pain symptoms
• Evaluation of ovarian reserve if fertility is desired
• Long-term hormonal suppression may be needed to prevent recurrence in high-risk cases 4