What is the treatment plan for endometrioma?

Treatment Plan for Endometrioma

Surgical Management is First-Line for Symptomatic Endometriomas

Laparoscopic cystectomy (complete excision of the endometrioma wall) is the preferred surgical approach for endometriomas, as it provides superior outcomes for symptom relief, recurrence prevention, and fertility compared to ablative techniques or sclerotherapy. 1, 2

When to Operate

• Symptomatic endometriomas causing pelvic pain, dysmenorrhea, or dyspareunia should undergo laparoscopic excision 2, 3
• Asymptomatic women over age 40 should be offered surgery due to malignancy risk 4
• Large endometriomas (>4 cm) warrant surgical removal to rule out malignancy and prevent complications 1, 4
• Small, densely fibrotic endometriomas (1-3 cm) present technical challenges due to obliteration of the plane between cyst capsule and normal ovarian cortex, but cystectomy remains preferred when symptomatic 1

Surgical Technique Considerations

• Complete excision (cystectomy) over ablation or sclerotherapy enables pathologic diagnosis, improves symptom control (>90% pain relief at one year), reduces recurrence rates, and optimizes fertility outcomes 1, 2
• Expect postoperative reduction in AMH levels, though AFC may remain stable or improve, and some AMH recovery occurs during follow-up 5
• The ovarian reserve damage is multifactorial—partly from the endometrioma itself and partly from surgical excision 2, 5

Medical Management: Hormonal Suppression

Primary Medical Therapy Indications

• Women not seeking immediate conception with pain symptoms should receive first-line hormonal therapy with progestins (norethindrone acetate or dienogest) or combined oral contraceptives, which achieve >90% pain relief at one year 3
• Endometriomas do not shrink with medical therapy alone—hormones only treat associated pain, not the cyst itself 4, 2

Perioperative Hormonal Use

• Preoperative hormonal suppression improves operative outcomes and should be considered before surgery 1
• Postoperative hormonal suppression decreases endometrioma recurrence risk (which otherwise approaches 30-40% after surgery alone) and should be routinely prescribed 1, 2

Fertility-Specific Management Algorithm

For Women Seeking Pregnancy

• If no significant pain and endometrioma <4 cm: Proceed directly to IVF without surgery, as laparoscopic excision prior to IVF offers no additional benefit over expectant management 4
• If significant pain present: Perform cystectomy first, as surgery may increase spontaneous conception rates and provides pain relief 2, 5
• Combination approach (surgery followed by IVF) may achieve optimal fertility outcomes when both pain and infertility coexist 5

Critical Fertility Caveat

Do not operate on asymptomatic endometriomas in women planning IVF—the ovarian reserve damage from surgery may outweigh any theoretical benefit, and IVF success rates are similar with or without prior endometrioma surgery 4, 5

When Medical Therapy Fails

Surgical excision becomes mandatory when:

• Hormonal treatment is ineffective or not tolerated (occurs in ~30% of women, with side effects including erratic bleeding, weight gain, decreased libido, headache) 3
• Symptomatic bowel stenosis develops 3
• Ureteral stenosis with hydronephrosis occurs 3
• Suspicion of malignancy (particularly in women >40 years) 4

Common Pitfalls to Avoid

• Performing surgery on asymptomatic small endometriomas in young women seeking fertility—this unnecessarily damages ovarian reserve 4, 5
• Using ablative techniques instead of cystectomy—while ablation may preserve more ovarian tissue, it increases recurrence rates and prevents pathologic diagnosis 1, 2
• Failing to prescribe postoperative hormonal suppression—this leads to high recurrence rates (30-40%) 1, 2
• Operating on endometriomas before IVF in asymptomatic women—this provides no fertility benefit and may harm ovarian reserve 4