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Semin Reprod Med 2017; 35(01): 025-030
DOI: 10.1055/s-0036-1597126
Review Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Management of Endometriomas

Ludovico Muzii
1   Department of Obstetrics and Gynecology, “Sapienza” University of Rome, Rome, Italy
,
Chiara Di Tucci
1   Department of Obstetrics and Gynecology, “Sapienza” University of Rome, Rome, Italy
,
Mara Di Feliciantonio
1   Department of Obstetrics and Gynecology, “Sapienza” University of Rome, Rome, Italy
,
Giulia Galati
1   Department of Obstetrics and Gynecology, “Sapienza” University of Rome, Rome, Italy
,
Ludovica Verrelli
1   Department of Obstetrics and Gynecology, “Sapienza” University of Rome, Rome, Italy
,
Violante Di Donato
1   Department of Obstetrics and Gynecology, “Sapienza” University of Rome, Rome, Italy
,
Claudia Marchetti
1   Department of Obstetrics and Gynecology, “Sapienza” University of Rome, Rome, Italy
,
Pierluigi Benedetti Panici
1   Department of Obstetrics and Gynecology, “Sapienza” University of Rome, Rome, Italy
› Author Affiliations
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Publication History

Publication Date:
07 December 2016 (online)

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Erratum: Management of EndometriomasSemin Reprod Med 2017; 35(04): 390-392
DOI: 10.1055/s-0037-1606279

Abstract

Ovarian endometriomas affect 17 to 44% of women with endometriosis, and are often associated with pelvic pain and infertility. Treatment options include expectant management, medical and/or surgical treatment, and in vitro fertilization and embryo transfer (IVF-ET). The choice of treatment depends mostly on the associated symptoms. In most cases, surgery is the preferred choice, since endometriomas do not respond to medical treatment, which may only treat associated pain. In case of infertility, IVF-ET may be a suitable alternative to surgery, particularly when there is no associated pain. According to the best available scientific evidence, laparoscopic excision of the endometrioma wall should be considered the procedure of choice. Concerns have been raised as to the possibility that surgical excision may damage the ovarian reserve, but recent evidences demonstrate that part of the damage may be due to the presence of the endometrioma itself. Indication to surgical treatment should balance the possible risks of damaging the ovarian reserve with the advantages of surgery in terms of satisfactory pain relief rates and pregnancy rates, and of obtaining tissue specimen for ruling out the rare cases of unexpected ovarian malignancy. A score system to guide the clinician in the decision to perform or withhold surgery is presented.

Keywords

endometrioma - laparoscopy - medical treatment - ovarian reserve - surgical treatment
 

  • References

  • 1 Chapron C, Vercellini P, Barakat H, Vieira M, Dubuisson JB. Management of ovarian endometriomas. Hum Reprod Update 2002; 8 (6) 591-597
    CrossrefPubMedGoogle Scholar
  • 2 Practice Committee of the American Society for Reproductive Medicine. Endometriosis and infertility: a committee opinion. Fertil Steril 2012; 98 (3) 591-598
    CrossrefPubMedGoogle Scholar
  • 3 Practice Committee of the American Society for Reproductive Medicine. Treatment of pelvic pain associated with endometriosis: a committee opinion. Fertil Steril 2014; 101 (4) 927-935
    CrossrefPubMedGoogle Scholar
  • 4 Olive DL, Stohs GF, Metzger DA, Franklin RR. Expectant management and hydrotubations in the treatment of endometriosis-associated infertility. Fertil Steril 1985; 44 (1) 35-41
    CrossrefPubMedGoogle Scholar
  • 5 Guerriero S, Ajossa S, Mais V, Risalvato A, Lai MP, Melis GB. The diagnosis of endometriomas using colour Doppler energy imaging. Hum Reprod 1998; 13 (6) 1691-1695
    CrossrefPubMedGoogle Scholar
  • 6 Muzii L, Angioli R, Zullo M, Panici PB. The unexpected ovarian malignancy found during operative laparoscopy: incidence, management, and implications for prognosis. J Minim Invasive Gynecol 2005; 12 (1) 81-89 , quiz 90–91
    PubMedGoogle Scholar
  • 7 Kennedy S, Bergqvist A, Chapron C , et al; ESHRE Special Interest Group for Endometriosis and Endometrium Guideline Development Group. ESHRE guideline for the diagnosis and treatment of endometriosis. Hum Reprod 2005; 20 (10) 2698-2704
    CrossrefPubMedGoogle Scholar
  • 8 Dunselman GA, Vermeulen N, Becker C , et al; European Society of Human Reproduction and Embryology. ESHRE guideline: management of women with endometriosis. Hum Reprod 2014; 29 (3) 400-412
    CrossrefPubMedGoogle Scholar
  • 9 Alcázar JL, Castillo G, Jurado M, García GL. Is expectant management of sonographically benign adnexal cysts an option in selected asymptomatic premenopausal women?. Hum Reprod 2005; 20 (11) 3231-3234
    CrossrefPubMedGoogle Scholar
  • 10 Alcázar JL, Olartecoechea B, Guerriero S, Jurado M. Expectant management of adnexal masses in selected premenopausal women: a prospective observational study. Ultrasound Obstet Gynecol 2013; 41 (5) 582-588
    CrossrefPubMedGoogle Scholar
  • 11 Alcázar JL, Royo P, Jurado M , et al. Triage for surgical management of ovarian tumors in asymptomatic women: assessment of an ultrasound-based scoring system. Ultrasound Obstet Gynecol 2008; 32 (2) 220-225
    CrossrefPubMedGoogle Scholar
  • 12 Adamson GD, Pasta DJ. Surgical treatment of endometriosis-associated infertility: meta-analysis compared with survival analysis. Am J Obstet Gynecol 1994; 171 (6) 1488-1504 , discussion 1504–1505
    CrossrefPubMedGoogle Scholar
  • 13 Guzick DS, Silliman NP, Adamson GD , et al. Prediction of pregnancy in infertile women based on the American Society for Reproductive Medicine's revised classification of endometriosis. Fertil Steril 1997; 67 (5) 822-829
    CrossrefPubMedGoogle Scholar
  • 14 Vercellini P, Somigliana E, Viganò P, Abbiati A, Barbara G, Crosignani PG. Surgery for endometriosis-associated infertility: a pragmatic approach. Hum Reprod 2009; 24 (2) 254-269
    CrossrefPubMedGoogle Scholar
  • 15 Leyland N, Casper R, Laberge P, Singh SS ; SOGC. Endometriosis: diagnosis and management. J Obstet Gynaecol Can 2010; 32 (7) (Suppl. 02) S1-S32
    PubMedGoogle Scholar
  • 16 Valentin L, Ameye L, Franchi D , et al. Risk of malignancy in unilocular cysts: a study of 1148 adnexal masses classified as unilocular cysts at transvaginal ultrasound and review of the literature. Ultrasound Obstet Gynecol 2013; 41 (1) 80-89
    CrossrefPubMedGoogle Scholar
  • 17 Zanetta G, Trio D, Lissoni A , et al. Early and short-term complications after US-guided puncture of gynecologic lesions: evaluation after 1,000 consecutive cases. Radiology 1993; 189 (1) 161-164
    CrossrefPubMedGoogle Scholar
  • 18 Giorlandino C, Taramanni C, Muzii L, Santillo E, Nanni C, Vizzone A. Ultrasound-guided aspiration of ovarian endometriotic cysts. Int J Gynaecol Obstet 1993; 43 (1) 41-44
    CrossrefPubMedGoogle Scholar
  • 19 Zanetta G, Lissoni A, Dalla Valle C, Trio D, Pittelli M, Rangoni G. Ultrasound-guided aspiration of endometriomas: possible applications and limitations. Fertil Steril 1995; 64 (4) 709-713
    CrossrefPubMedGoogle Scholar
  • 20 Gonçalves FC, Andres MP, Passman LJ, Gonçalves MO, Podgaec S. A systematic review of ultrasonography-guided transvaginal aspiration of recurrent ovarian endometrioma. Int J Gynaecol Obstet 2016; 134 (1) 3-7
    CrossrefPubMedGoogle Scholar
  • 21 Padilla SL. Ovarian abscess following puncture of an endometrioma during ultrasound-guided oocyte retrieval. Hum Reprod 1993; 8 (8) 1282-1283
    CrossrefPubMedGoogle Scholar
  • 22 Muzii L, Marana R, Caruana P, Catalano GF, Mancuso S. Laparoscopic findings after transvaginal ultrasound-guided aspiration of ovarian endometriomas. Hum Reprod 1995; 10 (11) 2902-2903
    CrossrefPubMedGoogle Scholar
  • 23 Diernaes E, Rasmussen J, Soerensen T, Hasch E. Ovarian cysts: management by puncture?. Lancet 1987; 1 (8541) 1084
    PubMedGoogle Scholar
  • 24 Yap C, Furness S, Farquhar C. Pre and post operative medical therapy for endometriosis surgery. Cochrane Database Syst Rev 2004; (3) CD003678
    PubMedGoogle Scholar
  • 25 Beretta P, Franchi M, Ghezzi F, Busacca M, Zupi E, Bolis P. Randomized clinical trial of two laparoscopic treatments of endometriomas: cystectomy versus drainage and coagulation. Fertil Steril 1998; 70 (6) 1176-1180
    CrossrefPubMedGoogle Scholar
  • 26 Alborzi S, Momtahan M, Parsanezhad ME, Dehbashi S, Zolghadri J, Alborzi S. A prospective, randomized study comparing laparoscopic ovarian cystectomy versus fenestration and coagulation in patients with endometriomas. Fertil Steril 2004; 82 (6) 1633-1637
    CrossrefPubMedGoogle Scholar
  • 27 Carmona F, Martínez-Zamora MA, Rabanal A, Martínez-Román S, Balasch J. Ovarian cystectomy versus laser vaporization in the treatment of ovarian endometriomas: a randomized clinical trial with a five-year follow-up. Fertil Steril 2011; 96 (1) 251-254
    CrossrefPubMedGoogle Scholar
  • 28 Hart RJ, Hickey M, Maouris P, Buckett W. Excisional surgery versus ablative surgery for ovarian endometriomata. Cochrane Database Syst Rev 2008; 16 (2) CD004992
    PubMedGoogle Scholar
  • 29 Raffi F, Metwally M, Amer S. The impact of excision of ovarian endometrioma on ovarian reserve: a systematic review and meta-analysis. J Clin Endocrinol Metab 2012; 97 (9) 3146-3154
    CrossrefPubMedGoogle Scholar
  • 30 Pados G, Tsolakidis D, Assimakopoulos E, Athanatos D, Tarlatzis B. Sonographic changes after laparoscopic cystectomy compared with three-stage management in patients with ovarian endometriomas: a prospective randomized study. Hum Reprod 2010; 25 (3) 672-677
    CrossrefPubMedGoogle Scholar
  • 31 Tsolakidis D, Pados G, Vavilis D , et al. The impact on ovarian reserve after laparoscopic ovarian cystectomy versus three-stage management in patients with endometriomas: a prospective randomized study. Fertil Steril 2010; 94 (1) 71-77
    CrossrefPubMedGoogle Scholar
  • 32 Muzii L, Panici PB. Combined technique of excision and ablation for the surgical treatment of ovarian endometriomas: the way forward?. Reprod Biomed Online 2010; 20 (2) 300-302
    CrossrefPubMedGoogle Scholar
  • 33 Donnez J, Lousse JC, Jadoul P, Donnez O, Squifflet J. Laparoscopic management of endometriomas using a combined technique of excisional (cystectomy) and ablative surgery. Fertil Steril 2010; 94 (1) 28-32
    CrossrefPubMedGoogle Scholar
  • 34 Muzii L, Achilli C, Bergamini V , et al. Comparison between the stripping technique and the combined excisional/ablative technique for the treatment of bilateral ovarian endometriomas: a multicentre RCT. Hum Reprod 2016; 31 (2) 339-344
    PubMedGoogle Scholar
  • 35 Roman H, Auber M, Mokdad C , et al. Ovarian endometrioma ablation using plasma energy versus cystectomy: a step toward better preservation of the ovarian parenchyma in women wishing to conceive. Fertil Steril 2011; 96 (6) 1396-1400
    CrossrefPubMedGoogle Scholar
  • 36 Angioli R, Muzii L, Montera R , et al. Feasibility of the use of novel matrix hemostatic sealant (FloSeal) to achieve hemostasis during laparoscopic excision of endometrioma. J Minim Invasive Gynecol 2009; 16 (2) 153-156
    CrossrefPubMedGoogle Scholar
  • 37 Ghafarnejad M, Akrami M, Davari-Tanha F, Adabi K, Nekuie S. Vasopressin effect on operation time and frequency of electrocauterization during laparoscopic stripping of ovarian endometriomas: a randomized controlled clinical trial. J Reprod Infertil 2014; 15 (4) 199-204
    PubMedGoogle Scholar
  • 38 Muzii L, Marana R, Angioli R , et al. Histologic analysis of specimens from laparoscopic endometrioma excision performed by different surgeons: does the surgeon matter?. Fertil Steril 2011; 95 (6) 2116-2119
    CrossrefPubMedGoogle Scholar
  • 39 Muzii L, Bellati F, Palaia I , et al. Laparoscopic stripping of endometriomas: a randomized trial on different surgical techniques. Part I: clinical results. Hum Reprod 2005; 20 (7) 1981-1986
    CrossrefPubMedGoogle Scholar
  • 40 Muzii L, Bellati F, Bianchi A , et al. Laparoscopic stripping of endometriomas: a randomized trial on different surgical techniques. Part II: pathological results. Hum Reprod 2005; 20 (7) 1987-1992
    CrossrefPubMedGoogle Scholar
  • 41 Guo SW. Recurrence of endometriosis and its control. Hum Reprod Update 2009; 15 (4) 441-461
    CrossrefPubMedGoogle Scholar
  • 42 Busacca M, Marana R, Caruana P , et al. Recurrence of ovarian endometrioma after laparoscopic excision. Am J Obstet Gynecol 1999; 180 (3, Pt 1) 519-523
    CrossrefPubMedGoogle Scholar
  • 43 Morgante G, Ditto A, La Marca A, De Leo V. Low-dose danazol after combined surgical and medical therapy reduces the incidence of pelvic pain in women with moderate and severe endometriosis. Hum Reprod 1999; 14 (9) 2371-2374
    CrossrefPubMedGoogle Scholar
  • 44 Seracchioli R, Mabrouk M, Manuzzi L , et al. Post-operative use of oral contraceptive pills for prevention of anatomical relapse or symptom-recurrence after conservative surgery for endometriosis. Hum Reprod 2009; 24 (11) 2729-2735
    CrossrefPubMedGoogle Scholar
  • 45 Vercellini P, DE Matteis S, Somigliana E, Buggio L, Frattaruolo MP, Fedele L. Long-term adjuvant therapy for the prevention of postoperative endometrioma recurrence: a systematic review and meta-analysis. Acta Obstet Gynecol Scand 2013; 92 (1) 8-16
    CrossrefPubMedGoogle Scholar
  • 46 Seracchioli R, Mabrouk M, Frascà C , et al. Long-term cyclic and continuous oral contraceptive therapy and endometrioma recurrence: a randomized controlled trial. Fertil Steril 2010; 93 (1) 52-56
    CrossrefPubMedGoogle Scholar
  • 47 Seracchioli R, Mabrouk M, Frascà C, Manuzzi L, Savelli L, Venturoli S. Long-term oral contraceptive pills and postoperative pain management after laparoscopic excision of ovarian endometrioma: a randomized controlled trial. Fertil Steril 2010; 94 (2) 464-471
    CrossrefPubMedGoogle Scholar
  • 48 Muzii L, Maneschi F, Marana R , et al. Oral estroprogestins after laparoscopic surgery to excise endometriomas: continuous or cyclic administration? Results of a multicenter randomized study. J Minim Invasive Gynecol 2011; 18 (2) 173-178
    CrossrefPubMedGoogle Scholar
  • 49 Muzii L, Di Tucci C, Achilli C , et al. Continuous versus cyclic oral contraceptives after laparoscopic excision of ovarian endometriomas: a systematic review and metaanalysis. Am J Obstet Gynecol 2016; 214 (2) 203-211
    CrossrefPubMedGoogle Scholar
  • 50 Muzii L, Achilli C, Lecce F , et al. Second surgery for recurrent endometriomas is more harmful to healthy ovarian tissue and ovarian reserve than first surgery. Fertil Steril 2015; 103 (3) 738-743
    CrossrefPubMedGoogle Scholar
  • 51 Haraguchi H, Koga K, Takamura M , et al. Development of ovarian cancer after excision of endometrioma. Fertil Steril 2016; S0015-0282(16)62507-4
    PubMedGoogle Scholar
  • 52 Kitajima M, Defrère S, Dolmans MM , et al. Endometriomas as a possible cause of reduced ovarian reserve in women with endometriosis. Fertil Steril 2011; 96 (3) 685-691
    CrossrefPubMedGoogle Scholar