What is the recommended management for a 37-year-old multiparous female with bilateral complex cysts, likely endometriomas?

Management of Bilateral Endometriomas in a 37-Year-Old Multiparous Woman

For a 37-year-old multiparous woman with bilateral complex cysts likely representing endometriomas, laparoscopic cystectomy is the preferred first-line treatment, as it provides definitive diagnosis, optimal symptom relief, lowest recurrence rates, and preserves fertility options. 1

Initial Diagnostic Confirmation

• Ultrasound characteristics to confirm endometriomas include: homogeneous low-level echoes (ground glass appearance) with size <10 cm, which are classified as O-RADS 2 (classic benign lesions). 2

• If imaging is not definitive or lesions show atypical features (irregular walls, solid components, high vascularity with color score ≥4, or size ≥10 cm), refer to ultrasound specialist or obtain MRI for better characterization before proceeding. 2

• MRI pelvis is recommended preoperatively to map disease extent, identify deep infiltrating lesions, and plan the surgical approach, which reduces morbidity by decreasing incomplete surgeries and need for repeat procedures. 3

Surgical Management Algorithm

When Surgery is Indicated:

• Symptomatic endometriomas causing pain warrant surgical intervention as the definitive treatment. 3, 1

• Endometriomas >4 cm in diameter should be treated surgically due to risk of rupture or torsion. 4

• Bilateral endometriomas in a 37-year-old represent a scenario where surgical excision is preferred over observation, given her age and the bilateral nature of disease. 1, 4

Surgical Technique:

• Laparoscopic ovarian cystectomy (stripping technique) is superior to ablation or sclerotherapy because it enables pathologic diagnosis, provides better symptom relief, has lower recurrence rates, and optimizes fertility outcomes. 5, 1

• Complete cyst capsule removal with preservation of normal ovarian tissue is the goal, though this can be challenging with densely fibrotic endometriomas. 1

• Systematic exploration of the entire abdomen and pelvis should be performed to identify and treat all endometriotic foci, not just the ovarian cysts. 3

Critical Surgical Pitfall:

• Cystectomy carries risk of diminished ovarian reserve by damaging ovarian cortex, particularly concerning with bilateral disease. 5, 1 Fertility preservation counseling is mandatory preoperatively for this 37-year-old patient, even if she has completed childbearing, as she may experience premature ovarian insufficiency. 5

Medical Management Considerations

Preoperative Hormonal Suppression:

• Preoperative medical treatment before cystectomy has no demonstrated benefit and should not delay surgery. 6, 1

Postoperative Hormonal Suppression:

• Postoperative hormonal suppression can decrease risk of endometrioma recurrence. 1 Options include:

  • Continuous oral contraceptives are first-line, providing equivalent pain relief to more costly regimens with superior safety profiles. 3, 7
  • Progestins demonstrate similar efficacy to oral contraceptives in reducing pain. 3
  • GnRH agonists for at least 3 months provide significant pain relief for refractory cases, but mandatory add-back therapy is required to prevent bone mineral loss. 3, 7

• However, low-dose cyclic oral contraceptives do not significantly affect long-term recurrence rates after surgical treatment. 6

Medical Treatment Alone is Inadequate:

• The efficacy of medical treatment as sole therapy for endometriomas is not demonstrated. 6 Aspiration and washing of endometriotic cysts, even combined with postoperative GnRH agonists, is ineffective. 8

Management Based on Fertility Goals

If Fertility is Desired:

• Surgery should be performed promptly if the patient desires future pregnancy, as medical treatment does not improve fertility outcomes. 3

• If pregnancy is not achieved within 1-1.5 years post-surgery, in vitro fertilization should be considered, especially given her age of 37 years. 4

If Childbearing is Complete:

• For recurrent endometriomas in the same ovary after initial surgery, unilateral oophorectomy with sparing the contralateral ovary is the most efficient preventive measure. 4

• Hysterectomy with bilateral salpingo-oophorectomy remains the definitive approach for completed childbearing with severe symptoms. 3

Recurrence Risk and Long-Term Monitoring

• Up to 44% of women experience symptom recurrence within one year after surgery, highlighting the need for ongoing management. 3, 7

• If not surgically removed, annual ultrasound surveillance should be considered for endometriomas <10 cm. 2

• In postmenopausal patients, risk of malignant transformation (clear cell and endometrioid carcinomas) is higher in endometriomas, requiring closer monitoring. 2

Key Clinical Pitfalls to Avoid

• Small asymptomatic cysts should not be treated surgically, especially in patients older than 35 years, as surgery may unnecessarily compromise ovarian reserve. 4

• Recurrent ovarian surgery is not recommended due to cumulative damage to ovarian reserve; consider unilateral oophorectomy instead. 6, 4

• Simple aspiration without cystectomy is ineffective and should not be performed. 8