From the Guidelines
Surgical removal of an endometrioma is recommended for a 23-year-old patient experiencing significant pain, as it provides better pain relief and lower recurrence rates compared to medical management alone. The primary approach would typically involve laparoscopic excision (removal) of the endometrioma cyst wall. Before surgery, medical management may be attempted with hormonal therapies such as combined oral contraceptives, progestins, or GnRH agonists with add-back therapy, as suggested by the ACOG committee 1. However, these medications typically suppress symptoms temporarily rather than treating the underlying endometrioma.
For a young patient, fertility preservation is an important consideration, so surgeons should use careful techniques to minimize damage to healthy ovarian tissue. The patient should be counseled about the risk of endometrioma recurrence after surgery and the potential need for repeat procedures. Surgery is particularly indicated when the endometrioma is larger, causes persistent pain despite medical therapy, or if there is concern about malignancy. The decision should ultimately be individualized based on the severity of symptoms, the patient's fertility desires, and the characteristics of the endometrioma.
Some key points to consider include:
- The depth of endometriosis lesions correlates with the severity of pain, and painful lesions are those that involve peritoneal surfaces innervated by peripheral spinal nerves 1.
- Medical therapy, such as progestins, danazol, oral contraceptives, nonsteroidal anti-inflammatory drugs, and GnRH agonists, can reduce the size of lesions but has not been proven to eradicate them 1.
- There is no evidence that medical therapy affects the future fertility of women with endometriosis, and studies are lacking that suggest the absence of treatment is associated with a decline in fertility 1.
From the Research
Treatment Options for Endometrioma
- Medical treatment options for endometrioma include progestin, especially dienogest, and oral contraceptive (OC) use after conservative surgery, which have been reported to reduce the risk of endometrioma recurrence 2.
- The use of gonadotropin-releasing hormone (GnRH) agonist followed by OC or dienogest alone has been shown to be effective in preventing recurrence of endometrioma after laparoscopic surgery 2.
- Postoperative levonorgestrel-releasing intrauterine system (LNG-IUS) use has been found to be comparable to the use of cyclic OC in preventing endometrioma recurrence 3.
Surgical Intervention
- Drainage of the cyst (surgical therapy) combined with postoperative GnRH-a suppression has been found to be a better treatment modality than the use of GnRH-a (medical therapy) alone for endometriomas 4.
- Surgical intervention may be necessary for endometriomas that are causing pain, especially if medical treatment options are not effective.
Considerations for a 23-Year-Old Patient
- For a 23-year-old patient with an endometrioma causing pain, surgical intervention may be considered, especially if medical treatment options are not effective 4.
- The decision to remove an endometrioma should be individualized and based on the patient's symptoms, medical history, and treatment goals.
- It is essential to discuss the potential benefits and risks of surgical intervention with a healthcare provider to determine the best course of treatment 2, 3, 4.