What is the management approach for endometrioma?

Management of Endometriomas

The management of endometriomas should prioritize laparoscopic cystectomy (excision of the endometrioma wall) as the procedure of choice, as it provides the best balance of low recurrence rates, pain relief, and improved spontaneous pregnancy rates, despite concerns about ovarian reserve. 1, 2

Initial Assessment and Decision Framework

When evaluating an endometrioma, the primary drivers of management are:

• Size of the endometrioma: Lesions >4 cm should be removed to reduce pain and improve spontaneous conception rates 3
• Presenting symptoms: Pain versus infertility versus asymptomatic incidental finding 4, 2
• Patient's fertility goals: Immediate conception desired versus future fertility preservation 5
• Ovarian reserve status: Anti-Müllerian hormone (AMH) and antral follicle count should be assessed before any intervention 1

Treatment Algorithm by Clinical Scenario

For Symptomatic Patients with Pain

Surgical excision is the preferred first-line treatment, as medical therapy is inefficient and cannot be recommended for ovarian endometriomas 3, 2. The surgical approach should be:

• Laparoscopic cystectomy (stripping technique) as the gold standard 2
• Modified combined cystectomy may be more efficient when the capsule is densely adherent to avoid incomplete removal 3
• Ablation techniques (laser or plasma energy) appear to have minimal effect on ovarian reserve while maintaining low recurrence rates, making them a reasonable alternative 1

For Patients with Infertility

The decision pathway depends on additional factors:

• If no significant pain: Consider proceeding directly to IVF-ET as a suitable alternative to surgery, particularly when ovarian reserve is already compromised 2
• If concurrent pain or endometrioma >4 cm: Surgery is preferred, as excision improves spontaneous pregnancy rates and provides pain relief 3, 2
• Fertility preservation counseling is mandatory before any surgical intervention, given the risk of further diminishing ovarian reserve 1

For Asymptomatic Incidental Findings

• Endometriomas <4 cm: Expectant management with surveillance is reasonable 3
• Endometriomas ≥4 cm: Consider surgical removal to obtain tissue for histopathology (to rule out rare ovarian malignancy) and prevent future complications 2

Surgical Technique Selection

The choice among surgical approaches has distinct trade-offs:

• Cystectomy (excision): Low recurrence rate (best long-term outcome) but higher risk of diminished ovarian reserve 1, 2
• Ablation (laser/plasma): Minimal effect on ovarian reserve with low recurrence rates, making it attractive for patients with borderline ovarian reserve 1
• Sclerotherapy: Mixed results for both ovarian reserve preservation and recurrence rates; generally not preferred 1
• Oophorectomy: Reserved only for cases where ovarian preservation is not feasible 1

Critical Pitfalls to Avoid

Do not use medical therapy as primary treatment for endometriomas, as it is inefficient for cyst resolution and only addresses associated pain symptoms 3, 2. Medical therapy may be used post-operatively to prevent recurrence, but not as standalone treatment.

Do not delay fertility preservation counseling until after surgery has already damaged ovarian reserve 1. This discussion must occur before any surgical intervention, particularly in patients with:

• Bilateral endometriomas
• Already diminished ovarian reserve (low AMH)
• Age >35 years
• Previous ovarian surgery

Do not assume all endometriomas require immediate surgery. The decision must weigh the endometrioma-mediated damage to the ovary (which occurs even without surgery) against the surgical damage to ovarian reserve 5, 2. In some cases, particularly with small asymptomatic cysts in patients pursuing IVF, expectant management or proceeding directly to IVF may be superior.

Shared Decision-Making Considerations

The management of endometrioma-related subfertility remains controversial and depends heavily on patient intentions and priorities 5. Patients should be counseled on:

• Recurrence rates: Cystectomy has the lowest recurrence but highest ovarian damage 1
• Spontaneous pregnancy potential: Surgery improves natural conception rates if ovarian reserve is preserved 2
• IVF success rates: May be comparable with or without prior surgery, depending on individual factors 2
• Risk of malignancy: Rare but present, making tissue diagnosis valuable in some cases 2