Evidence-based management of endometrioma

Endometriosis and Adenomyosis: Modern Concepts of Their Clinical Outcomes, Treatment, and Management

Endometriosis and adenomyosis are complex gynecological conditions characterized by diverse clinical presentations, including superficial peritoneal endometriosis (SPE), ovarian endometrioma (OMA), and deep infiltrating endometriosis (DIE). The hallmark features of these pathologies involve the manifestation of pain symptoms and infertility, and approximately 30% of patients are asymptomatic. Despite ongoing research, definitive treatments for these conditions remain elusive, and clinical management primarily revolves around medical or surgical interventions. Recent advancements in our understanding of the efficacy of various treatment modalities, including medical therapy and surgical interventions, have provided clinicians with valuable insights into pain relief and fertility preservation. This review aims to provide an updated overview of the latest literature on clinical outcomes, treatment options, and management strategies for different types of endometriosis. By synthesizing the newest available data, this review seeks to inform clinicians and guide decision making based on factors such as patients' symptom severity, childbearing desire, and overall health.

The effect of surgery or medication on pain and quality of life in women with endometrioma. A systematic review and meta-analysis

For patients with endometrioma it is unclear what treatment: surgery and/or medication, is more effective in reducing pain and improving quality of life (QoL). This systematic review and meta- analysis aimed to provide an overview of the existing evidence on the effects of surgery and/or medication (i.e. analgesics and/or hormonal medication) on pain and QoL. A search through CENTRAL, MEDLINE and Embase was conducted. The study population had to be women treated for endometrioma. Retrospective or prospective studies reporting about QoL and/or the following types of pain were reviewed: dysmenorrhea, dyspareunia, chronic pelvic pain, and pain that was not well defined in the included article (referred to as pain). We performed a meta-analysis on mean visual analogue scale (VAS) scores and proportions of patients experiencing different types of pain over time. QoL was described narratively. Out of 11.515 articles, 76 studies including 7148 patients were included for the systematic review. The meta-analysis consisted of 52 studies including 4556 patients. No studies compared medication with surgery. And there were no studies on analgesics. Meta-analysis showed that surgery and/or medication often reduced VAS scores and proportions of all types of pain over time. Surgery and medication combined seems more effective in reducing VAS scores of pain compared to surgery alone, but not to medication alone (estimated mean difference = 0.17, p < 0.0001 and -0.98, p = 0.0339). QoL improved after medication (follow up ≤ 12 months) and QoL was unchanged or worsened after surgery and medication combined (follow up ≤ 24 months). However, these were results from a total of 5 studies. Both surgery and medication reduce endometriosis-related pain in patients with endometrioma. However, there is lack of uniform, good quality data comparing surgery with medication to draw firm conclusions. For better-informed treatment decisions, further studies including a standardized core-outcome set at fixed follow-up times, are necessary.

Acute Presentation of Asymptomatic Giant Endometrioma in Pregnancy: A Case Report

Endometriomas are associated with severe endometriosis and are uncommon in asymptomatic women. Reported cases of giant endometriomas are few especially in pregnancy. Decidualization of endometriomas can mimic malignancies in pregnancy. Fetal outcomes can be good after excision of large endometriomas in the 2nd trimester. We present a case of giant endometrioma diagnosed in an asymptomatic woman who developed symptoms after becoming pregnant. Clinical findings, investigations, and histopathology were consistent with ovarian endometrioma. Maternal and fetal outcomes were good after the excision of the mass.

Impact of cystectomy versus ablation for endometrioma on ovarian reserve: a systematic review and meta-analysis

OBJECTIVE

To investigate whether cystectomy or ablation for endometrioma has less impact on ovarian reserve as evaluated by antral follicle count (AFC) and antimüllerian hormone (AMH) levels.

DESIGN

Systematic review and meta-analysis.

SETTING

Not applicable.

PATIENT(S)

Patients with endometriomas undergoing cystectomy or ablation.

INTERVENTION(S)

All prospective studies comparing cystectomy with ablation for endometrioma in the PubMed, EMBASE, MEDLINE and Web of Science until April 3, 2022 were retrieved and reviewed. Medical treatment used as adjuvant therapy for the surgery was excluded. Two authors assessed eligibility and risk of bias independently. The statistical data were pooled using the Review Manager software.

MAIN OUTCOME MEASURE(S)

The changes of AMH levels and AFC values in cystectomy group and ablation group, including intergroup comparisons and intragroup comparisons.

RESULT(S)

Four randomized clinical trials and 2 prospective cohort studies were eligible for the meta-analysis, with a total of 294 patients. In the intergroup comparisons, preoperative AFC values were similar with low heterogeneity, but postoperative AFC values were significantly lower in cystectomy than ablation (mean differences [MD], -1.33; 95% credible interval, -2.15 to -0.51; I² = 57%). In the intragroup comparisons of AFC values, sensitivity analyses showed a significant decrease in cystectomy (MD, -1.93; 95% credible interval, -2.40 to -1.45; I² = 0%) at 6-month follow-up, compared with no reduction in ablation. The intragroup comparisons of AMH levels supported negative effects on ovarian reserve of both cystectomy (MD, -1.26; 95% credible interval, -1.64 to -0.88; I² = 45%) and ablation (MD, -0.70; 95% credible interval, -1.07 to -0.32; I² = 0%).

CONCLUSION(S)

Both ablation and cystectomy have significantly detrimental effects on ovarian reserve as evaluated by AMH, but the ablation causes relatively less damage to ovarian reserve as appraised by AFC.

CLINICAL TRIAL REGISTRATION NUMBER

CRD42020152823;PROSPERO (york.ac.uk).

Antral follicle count is reduced in the presence of endometriosis: a systematic review and meta-analysis

Studies suggest that the presence of endometriosis may lead to impaired ovarian reserve, while results evaluating the changes in antral follicle count (AFC) in endometriosis remain controversial. A systematic search returned 15 studies, of which nine compared AFC between patients with and without endometriosis, five articles reported differences in AFC between affected and unaffected ovaries in patients with unilateral ovarian endometriosis and one reported both of the above two situations. Overall results showed a significant decrease in AFC and anti-Müllerian hormone (AMH) and increase in serum FSH concentrations in patients with endometriosis when compared with controls. Additionally, the AFC for the ovary with the endometrioma was also significantly lower than that of the contralateral ovary in patients with unilateral ovarian endometriosis. Moreover, it appears that the AFC in patients with endometriosis where the ovaries are not affected or in early stage were not significantly different in the control group. These findings demonstrate that endometriosis is associated with reduced AFC and AMH and elevated serum concentrations of FSH, suggesting a reduction in ovarian reserve in patients with endometriosis, especially in those with ovarian endometrioma and advanced stage.

Effects of laparoscopic cystectomy on ovarian reserve in patients with endometrioma and dermoid cyst

Objective:

To compare the effects of laparoscopic cystectomy on ovarian reserve between women with endometrioma and dermoid cyst.

Materials and Methods:

Thirty-six patients were diagnosed as having endometrioma (group A) and 32 patients with dermoid cyst (group B) using ultrasonography. Preoperative anti-mullerian hormone (AMH) levels were measured and unilateral antral follicle counts (AFC) were calculated for the ovary side containing the cyst. Laparoscopic cystectomy was performed using the stripping technique for all participants. After 3 months, all participants were re-evaluated between the third and sixth day of their menstrual cycle to determine AFC and AMH levels.

Results:

The mean serum preoperative AMH level and AFC level were significantly lower in group A than in group B (p=0.001, p=0.002), respectively. At 3 months after the surgery, serum AMH levels decreased significantly in group A from 2.04±0.68 to 1.47±0.55 (p=0.001), and from 2.60±0.57 to 2.17±0.56 in group B (p=0.001). In group A, unilateral (operated side) AFC levels decreased significantly from 4.05±1.24 to 2.16±0.94 (p=0.001), and in group B, it decreased significantly from 4.93±0.94 to 3.40±0.87 (p=0.001). The decrease in AMH levels was significantly higher in group A than in group B (p=0.033). The decrease in AFC levels was also significantly higher in group A than in group B (p=0.044).

Conclusion:

Laparoscopic stripping has destructive effects on serum AMH levels and the operated side AFC levels after surgery for patients with endometrioma and dermoid cysts, and laparoscopic excision of endometrioma has more destructive effects on ovarian reserve than dermoid cysts.

Novel diagnosis of mesenteric endometrioma: Case report

RATIONALE

Mesenteric cysts are benign gastrointestinal cystic lesions, with an incidence of <1/100 000. They usually develop in the small bowel mesentery, mesocolon (24%), retroperitoneum (14.5%), and very rarely originate from the sigmoid mesentery. Endometriomas represent a localized type of endometriosis and are usually within the ovary. Our case is unique because there are no reports in the literature of endometrial mesenteric cysts.

PATIENT CONCERNS

We present a case of a 29-year-old woman who underwent a routine gynecologic control.

DIAGNOSIS

Clinical examination and imaging identified 2 endometriomas on the left and posterior to the uterus.

INTERVENTIONS

The patient underwent exploratory laparoscopy. Unexpectedly, a 10 cm mesenteric cyst was identified; this was associated with adhesions in the left adnexal area and a left ovarian endometrioma. The classic surgical approach which was necessary identified the mesenteric cyst with cranial mesosigmoid and ileal adhesions, as well as distal adhesions which included the uterus, ileum, left ovarian endometrioma, left hydrosalpinx, left ureter, and rectum. The cyst was removed completely and a left adnexectomy was performed because of the presence of the endometrioma and adhesions.

OUTCOMES

The patient's outcome was favorable, with discharge at 72 hours after surgery. The histopathological report revealed that both the mesenteric and ovarian cysts were endometriomas.

LESSONS

Our case is unusual in that a mesenteric cyst was identified in a patient with no clinical symptoms. Furthermore, the histopathological examination revealed the endometriotic origin of the mesenteric cyst which has not previously been reported in the literature.

When more is not better: 10 'don'ts' in endometriosis management. An ETIC * position statement

A network of endometriosis experts from 16 Italian academic departments and teaching hospitals distributed all over the country made a critical appraisal of the available evidence and definition of 10 suggestions regarding measures to be de-implemented. Strong suggestions were made only when high-quality evidence was available. The aim was to select 10 low-value medical interventions, characterized by an unfavorable balance between potential benefits, potential harms, and costs, which should be discouraged in women with endometriosis. The following suggestions were agreed by all experts: do not suggest laparoscopy to detect and treat superficial peritoneal endometriosis in infertile women without pelvic pain symptoms; do not recommend controlled ovarian stimulation and IUI in infertile women with endometriosis at any stage; do not remove small ovarian endometriomas (diameter <4 cm) with the sole objective of improving the likelihood of conception in infertile patients scheduled for IVF; do not remove uncomplicated deep endometriotic lesions in asymptomatic women, and also in symptomatic women not seeking conception when medical treatment is effective and well tolerated; do not systematically request second-level diagnostic investigations in women with known or suspected non-subocclusive colorectal endometriosis or with symptoms responding to medical treatment; do not recommend repeated follow-up serum CA-125 (or other currently available biomarkers) measurements in women successfully using medical treatments for uncomplicated endometriosis in the absence of suspicious ovarian cysts; do not leave women undergoing surgery for ovarian endometriomas and not seeking immediate conception without post-operative long-term treatment with estrogen-progestins or progestins; do not perform laparoscopy in adolescent women (<20 years) with moderate-severe dysmenorrhea and clinically suspected early endometriosis without prior attempting to relieve symptoms with estrogen-progestins or progestins; do not prescribe drugs that cannot be used for prolonged periods of time because of safety or cost issues as first-line medical treatment, unless estrogen-progestins or progestins have been proven ineffective, not tolerated, or contraindicated; do not use robotic-assisted laparoscopic surgery for endometriosis outside research settings. Our proposal is to better address medical and surgical approaches to endometriosis de-implementing low-value interventions, with the aim to prevent unnecessary morbidity, limit psychological distress, and reduce the burden of treatment avoiding medical overuse and allowing a more equitable distribution of healthcare resources.

Clinical Characteristics and Outcomes of Laparoscopic Surgery in Ovarian Endometrioma Cases Treated at a Gynecology Clinic

Objectives:

The aim of this study was to retrospectively investigate the clinical and surgical outcomes of patients diagnosed with ovarian endometrioma in a hospital gynecology clinic and to investigate the safety and efficacy of treatment with laparoscopic surgery.

Methods:

The data of 44 patients who were operated on for ovarian endometrioma were analyzed retrospectively.

Results:

The mean age of the patients was 30.1±5.3 years. The mean cyst size was 7.0±5.3 cm. In all, 54% of the patients had dysmenorrhea, and 29.5% of the patients were infertile. Laparoscopy was successfully performed in all of the patients, and no complications were observed in any patient. Furthermore, it was found that ovarian reserve tests in the infertile patients were not negatively affected.

Conclusion:

With sufficient experience, laparoscopy is a very safe and effective method of surgery in ovarian endometrioma. If a laparoscopic cystectomy is performed with the proper technique, it does not adversely affect ovarian reserve.

[Surgical management of endometrioma: Different alternatives in term of pain, fertility and recurrence. CNGOF-HAS Endometriosis Guidelines]

Surgical management of ovarian endometrioma is most often part of a global approach of endometriosis pathology. Isolated endometrioma are rare. Laparoscopic cystectomy is the gold standard for surgical management of endometrioma. Nevertheless, this technique impacts the ovarian function. The hemostasis of the ovarian cyst bed should be performed to conserve the ovarian stroma. Ultrasonography-guided cyst aspiration, laparoscopic drainage and simple bipolar coagulation are not recommended as first line of treatment. Based on the actual literature, we cannot state the place of laser-vaporization and plasma-energy ablation in surgical management. Ethanol sclerotherapy could be an alternative to treat recurrent endometrioma. Uncompleted surgical removal of endometriosis lesions increases the recurrence rate. Endometriosis management should take into account the research and treatment of all the pelvic lesion, especially before surgical management of endometrioma. In this context, the evaluation of ovarian reserve could be useful before surgery.

Ovarian reserve evaluation after laparoscopic cyst enucleation, depending on applied haemostasis technique and with particular consideration of endometrial cysts

AIM OF THE STUDY

was an evaluation of the effects, exerted by obtained haemostasis on ovarian reserve, depending on haemostasis technique, applied after laparoscopic enucleation of endometrial cysts.

MATERIAL AND METHODS

Sixty-six female patients, at the age of 20-35 years, were included into the study. The diameters of the cystic lesions were within 40-70 mm. The patients were randomly assigned to two study groups. Group 1 involved patients after laparoscopic enucleation of ovarian cysts, in whom haemostasis was achieved by ovary suturing, while Group 2 included patients with haemostasis achieved by bipolar coagulation technique. Cyst enucleation was performed in all the patients by the stripping method. Ovarian reserve markers: AFC (antral follicle count), AMH (anti-Müllerian hormone), and inhibin B were assayed before and three months after the surgery.

RESULTS

The preoperative values of AMH, AFC, and inhibin B were similar in both studied groups. After a three-month follow up, the post-operative levels of AMH and inhibin B were significantly lower (p < 0.05), while the numbers of antral follicles did not reveal any statistical differences (p > 0.05). While comparing endometrial and dermoid cysts in the sutured group of patients, the difference, regarding AMH, was statistically significant (2.13 vs. 4.69, p = 0.03). In the group of patients after bipolar coagulation, the corresponding differences did not attain statistical significance (2.21 vs. 6.51, p = 0.86).

CONCLUSIONS

Comparing pre- and post-operative levels of AMH and inhibin B, regardless of the applied haemostasis technique, a statistically significant reduction of the ovarian reserve was observed in either group. Comparing both haemostasis techniques, no method was demonstrated that would have decreased less the levels of AMH, AFC, or inhibin B.

Continuous versus cyclic oral contraceptives after laparoscopic excision of ovarian endometriomas: a systematic review and metaanalysis

In the lack of evidence consistently supporting the use of continuous vs cyclic oral contraceptives after surgery for endometriosis, we conducted a systematic review and metaanalysis with the objective of comparing a continuous vs a cyclic oral contraceptive schedule administered after surgical excision of ovarian endometriomas. A PubMed, MedLine, and Embase search through December 2014 was conducted, with the use of a combination of key words and text words related to endometrioma, endometriosis, oral contraceptives, oral estroprogestins, laparoscopy, and surgery. Studies directly comparing a continuous vs a cyclic schedule administered after surgical treatment of endometriomas were included, with pain and endometrioma recurrence rates as the primary outcomes. Three reviewers independently assessed methodology and extracted data from selected studies. The primary outcomes were considered pain recurrence (evaluated separately for dysmenorrhea, noncyclic chronic pelvic pain, and dyspareunia) and endometrioma recurrence evaluated at ultrasonography. Dichotomous outcomes from each study were expressed as risk ratio (RR) with a 95% confidence interval (CI). Three randomized clinical trials and 1 prospective controlled cohort study were included, for a total of 557 patients with endometriosis, 343 patients of whom had ovarian endometriomas completing the assigned treatment and follow-up. Lower recurrence rates for dysmenorrhea were obtained with a continuous schedule (RR, 0.24; 95% CI, 0.06-0.91; P = .04). Nonsignificant differences were present for chronic pelvic pain and dyspareunia. A continuous oral contraceptive schedule was associated with a nonsignificant reduction of cyst recurrence rates compared with a cyclic schedule (RR, 0.54; 95% CI, 0.28-1.05; P = .07). A continuous oral contraceptive regimen, as opposed to a cyclic regimen, may be suggested after surgery for endometriomas because of lower dysmenorrhea recurrence rates. Due to the small number and small sample sizes of the included studies, further randomized clinical trials are needed to confirm the findings of the present systematic review. Also, outcomes related to patient satisfaction and quality of life should be addressed.

How Predictable Is the Operative Time of Laparoscopic Surgery for Ovarian Endometrioma?

Endometriosis is a tricky albeit common disease whose management largely relies on laparoscopy. We have studied the operative times of laparoscopic endometrioma surgery in order to assess their predictability and possible predictors. One hundred forty-eight laparoscopies were included, with a median operative time of 70 minutes (mean 75.14; 95% CI: 70.03–80.24). Half of the cases had a duration within 15–20 minutes above or below the median (IQR: 55–93.75), but the whole dataset ranged from 20 to 180 minutes, and the standard deviation was relatively large (31.4). Surgical times were significantly related to technical (number and size of the cysts) and nontechnical factors (age, parity, dysmenorrhea, and family history). At multiple logistic regression, after adjusting for number and size of the cysts, surgical times below the first quartile were associated with older age (>30 years old: aOR: 3.590; 95% CI: 1.417–9.091) and parity (≥1 delivery: aOR: 3.409; 95% CI: 1.343–8.651). Longer times, above the third quartile, were instead predicted by a familial anamnesis of endometriosis (aOR: 3.639; 95% CI: 1.246–10.627). Our findings indicate highly variable surgical times, which are predicted by unexpected nontechnical factors. This is consistent with the complexity of endometriosis and its treatment. Productivity and efficiency in endometriosis surgery should focus on the quality of healthcare outcomes rather than on the time spent in the operating theatres.

The impact on ovarian reserve of haemostasis by bipolar coagulation versus suture following surgical stripping of ovarian endometrioma: a meta-analysis

Concern is increasing that the use of bipolar coagulation or suturing to obtain haemostasis after surgical stripping of ovarian endometrioma could affect ovarian reserve. To compare the ovarian damage associated with the use of bipolar coagulation with ovarian suture as determined by anti-Müllerian hormone (AMH), FSH and antral follicle count, 21 studies were identified. Pooled analysis of 312 patients showed the average serum level of AMH was lower in the coagulation group than in the suture group (3-month follow-up: weighted mean difference (WMD) -0.75 ng/ml, 95% confidence interval (CI) -1.82 to 0.31; 6 months: WMD -1.45 ng/ml, 95% CI -2.43 to -0.47; 12 months: WMD -1.01 ng/ml; 95% CI -1.85 to -0.17), although heterogeneity was high. The weighted overall average levels of FSH between the two groups were not statistically significantly different 3 months after surgery (WMD 0.37 mIU/ml; 95% CI -1.56 to 1.30). The mean antral follicle count in the coagulation group was significantly less than in the suture group at 3 months' follow-up (WMD -2.53, with 95% CI -4.94 to -0.12). This study showed bipolar coagulation did more harm to the ovarian reserve than the suture haemostasis during excision of ovarian cyst as shown by a significant postoperative reduction in AMH.

Medical management of recurrent endometrioma with long-term norethindrone acetate

PURPOSE

Evaluate the efficacy of norethindrone acetate in the resolution of symptoms and regression of recurrent endometrioma.

PATIENTS AND METHODS

Retrospective chart review at SUNY Downstate Medical Center of patients with a history of surgical excision of endometrioma (with histological confirmation) and recurrent endometrioma (demonstrated by strict sonographic criterion of endometrioma) who were willing to undergo follow-up. Patients were prescribed norethindrone acetate to be taken daily with follow-up sonograms until cysts regressed. Statistical analysis included Student's t-test and a simple linear regression model to assess cyst regression over time during treatment.

RESULTS

Degree of pain was significantly lower on treatment when compared to baseline (P < 0.00001). Cyst size was significantly smaller in as little as 3 months (P < 0.0001). Average rate of regression with continuous treatment was 0.025 ± 0.015 cm/day. Total mean ± standard deviation regression time is 10.28 ± 8.25 months.

CONCLUSION

Norethindrone acetate was effective in eradicating symptoms and producing complete regression of recurrent endometriomas. It should be considered for patients who are likely to adhere to a prolonged treatment regimen and comply with recommendations for surveillance with serial sonograms.