What to do if an endometriosis cyst bursts?

Management of Ruptured Endometrioma

Most ruptured endometriomas can be managed conservatively with supportive care including pain control with NSAIDs, observation for hemodynamic stability, and close monitoring for signs of peritonitis or acute abdomen that would necessitate surgical intervention. 1

Immediate Assessment and Acute Management

When an endometrioma ruptures, the priority is determining whether conservative or surgical management is appropriate:

Clinical Evaluation

• Assess hemodynamic stability - Check vital signs, orthostatic changes, and signs of significant intraperitoneal bleeding 1
• Evaluate for acute abdomen - Peritoneal signs, rebound tenderness, and guarding suggest need for urgent surgical consultation 1
• Pain severity assessment - Most ruptures cause acute pelvic pain that can be managed medically 2, 1

Conservative Management (First-Line for Stable Patients)

• NSAIDs for pain control - These are first-line therapy for endometriosis-related pain and should be initiated immediately 3, 2, 1
• Observation period - Monitor for 24-48 hours to ensure clinical stability 1
• Avoid immediate surgery unless indicated - Most ruptures resolve without surgical intervention 1, 4

Indications for Urgent Surgical Intervention

• Hemodynamic instability despite resuscitation 1
• Signs of acute peritonitis or severe acute abdomen 1
• Suspected ovarian torsion (though less common with rupture) 4
• Failure of conservative management with worsening clinical status 1

Post-Acute Management and Follow-Up

Imaging After Acute Phase

• Transvaginal ultrasound in 8-12 weeks to assess for residual cyst, reformation, or other pathology 3, 5, 6
• MRI if ultrasound findings are unclear or show concerning features 3
• Do not perform fine-needle aspiration - This is contraindicated for ovarian masses 7, 5

Hormonal Suppression Therapy (Critical for Prevention)

Initiate hormonal therapy promptly after the acute event to prevent recurrence, as 25-34% of patients experience recurrent pain within 12 months without treatment 2:

• Combined oral contraceptives - Equally effective as other options with mean pain reduction of 13-17 points on 100-point scale 3, 2
• Progestin-only options (oral or depot medroxyprogesterone) - Equivalent efficacy to more costly regimens 3, 2
• GnRH agonists for 3+ months if first-line options fail, with add-back therapy to prevent bone loss 3, 2

Surveillance Requirements

• Annual ultrasound follow-up is mandatory for endometriomas due to small (<1%) but real risk of malignant transformation 3, 5
• Watch for changing morphology - Development of solid components or vascularity requires MRI evaluation 7, 5
• Higher vigilance in postmenopausal women - Risk of malignant transformation increases significantly 7

Surgical Considerations for Recurrent or Large Cysts

When to Consider Surgery After Rupture

• Cysts >4 cm that reform after rupture have increased risk of re-rupture or torsion 4
• Recurrent symptomatic cysts despite hormonal therapy 4
• Infertility patients who failed to conceive after 1-1.5 years, especially if >35 years old 4
• Severe pain unresponsive to medical management - 11-19% have no pain reduction with hormones 2

Surgical Approach

• Laparoscopic cystectomy with capsule removal is most efficient, including adhesiolysis and removal of remaining endometriotic foci 4
• Avoid surgery for small asymptomatic cysts, particularly in women >35 years 4
• Consider unilateral oophorectomy for recurrent cysts in same ovary if childbearing complete 4

Critical Pitfalls to Avoid

• Do not rush to surgery - Small asymptomatic endometriomas should not be treated surgically, especially in older reproductive-age women 4
• Do not delay hormonal therapy - 25-34% recurrence rate within 12 months without treatment makes early initiation essential 2
• Do not apply simple cyst algorithms - Endometriomas require different management than simple ovarian cysts 7, 5
• Do not forget annual surveillance - Even after rupture and resolution, yearly follow-up is required due to malignancy risk 3, 5
• Do not perform transvaginal aspiration for cysts >5 cm, particularly in postmenopausal women 5