Endometriosis can present in three anatomical forms, called phenotypes, which can be isolated or associated: superficial endometriosis, ovarian endometriosis (ovarian endometrioma or endometriotic ovarian cyst), and deep endometriosis (involvement of different organs: vagina, intestines, bladder, ureter, etc.).

Ovarian endometrioma, a frequent endometriotic lesion (15 to 40% of women with endometriosis), is a cyst with a thick wall and a hematic content (chocolate liquid). They may be unilateral or bilateral, and are more frequently seen on the left side. Their size is highly variable. They can be large (8–10 cm).

They are benign ovarian cysts, the risk of developing ovarian cancer is very low (less than 1%). The mechanisms of occurrence are poorly understood and controversial.

Read also : What Is The Endometriosis

What are the symptoms of ovarian endometriosis?

The ovarian location of endometriosis is not responsible for any specific symptomatology.

These are mainly:

These are the two signs most frequently observed in cases of endometriosis.

Nevertheless, the discovery of ovarian endometriomas is not synonymous with pelvic pain or infertility. In other words, just because you have an endometriotic ovarian cyst does not necessarily mean that you will have significant pain and/or difficulties in conceiving a child.

How do you get a diagnosis?

The existence of severe pain if you have an endometriotic ovarian cyst should encourage your specialist to look for associated deep endometriosis lesions. This is essential for the therapeutic strategy and to define the modalities of an intervention if surgery is indicated.

The clinical examination (vaginal touch) may be normal. It is necessary to look for an impaction or a latero-uterine mass, unilateral or bilateral, more or less sensitive.

LUNA helps you:

LUNA offers you the LunaEndoScore® test, the CE-certified medical device for the diagnosis of endometriosis, which will allow you to know your own risk of endometriosis by answering a questionnaire based on medical expertise.

Intended use

LunaEndoScore® is intended to assist in the screening of endometriosis by calculating a risk score that determines the probability of being affected by endometriosis based on the user’s answers to a questionnaire.

What are the complementary examinations?

The first-line and reference examination for the diagnosis of endometriotic ovarian cysts is pelvic ultrasound, carried out vaginally by a practitioner with expertise in endometriosis imaging.

Nuclear magnetic resonance imaging (NMR) should not (except in the case of virgin patients) be carried out as a first-line procedure. It will be indicated in the most complex cases, particularly when the endometrioma is associated with deep endometriosis and/or to quantify the extent of adenomyosis.

Surgery has no place in the diagnosis of endometriotic ovarian cysts. Advances in recent years have made it possible for an experienced sonographer or radiologist to make the diagnosis. Histological evidence (study of biological tissue following sampling), which would require surgical intervention, is not necessary. There is now no indication for surgery in the diagnosis of endometriosis.

What are the treatments for ovarian endometriosis?

The main treatment options are as follows

  • Analgesic treatments to relieve pain
  • Hormonal treatments to block menstruation. There are different types of hormonal treatment: oestrogen-progestin pills, progestins, Dienogest, hormonal IUD, LH-RH analogue, etc.
  • Surgery must be carried out by laparoscopy (whenever possible, which is the case in the vast majority of cases) and by an endoscopic surgeon who is not only experienced but also familiar with the disease. Treatment can be conservative (removal of the cyst = cystectomy or plasma jet vaporization) or radical (removal of the ovary = adnexectomy).
  • Medically assisted reproduction (MAP) using different techniques, in vitro fertilization (IVF) with or without intracytoplasmic sperm injection (ICSI), giving priority in this context of endometriosis to delayed transfers, i.e., at a distance from the MAP after vitrification (freezing of the embryos) and hormonal treatment to prepare the endometrium and increase the chances of implantation
  • Puncture under ultrasound control with alcoholisation of the cyst, which is rarely used in practice because of the very high risk of recurrence.

 

The rules to be respected by health professionals for the implementation of a treatment

  • Your wishes and priorities must be respected (preferences regarding the various possible treatments, life plans, desire for pregnancy, etc.)
  • Comprehensive management of endometriosis must be put in place, i.e., not focusing on the cyst alone, but also taking into account the possibility of deep lesions and/or associated adenomyosis.

The discovery of an endometriotic ovarian cyst requires :

  • to question the existence of a desire for pregnancy either immediate or longer term;
  • to consider the indication for an evaluation of the ovarian reserve (hormone measurements and follicle count) and to address the problem of possible fertility preservation (oocyte vitrification).
  • Surgery should no longer be performed systematically from the outset.
  • Surgical removal of ovarian endometriomas does not increase the chances of pregnancy before MAP. In other words, if a MAP is decided, there is no need to surgically remove the cysts beforehand.

Conclusion

Endometrioma is a very common endometriotic lesion. Its diagnosis is based on vaginal ultrasound performed by a referent practitioner. Therapeutic management is exceptionally an emergency (very rare cases of rupture or infection) and must instead be carried out in consultation with the patient as part of a global management of the disease, taking into account the patient’s wishes and priorities.

Written and scientifically validated by Pr Charles Chapron

Head of the Gynecology and Obstetrics II and Reproductive Medicine Department at the Cochin Hospital in Paris.

Read also : What Are The Symptoms Of Endometriosis ?