{"paper_id":"98fb2fc9-b118-47cf-b86b-38413a267210","body_text":"Copyright@ Tahira Shahzadi | Biomed J Sci & Tech Res | BJSTR. MS.ID.007125.\n36002\nMini Review\nISSN: 2574 -1241       DOI: 10.26717/BJSTR.2022.44.007125\nDilemma in Management of Endometriotic  \nOvarian Cyst\nTahira Shahzadi* and Shazia Maqsood\nDepartment of Obstetrics and Gynaecology, Dr. Sulaiman Al Habib Hospital, Saudi Arabia \n*Corresponding author: Tahira Shahzadi, Department of Obstetrics and Gynaecology, Dr. Sulaiman Al Habib Hospital, \nKhurais Road, Ar Rayan, Riyadh, Saudi Arabia\nARTICLE INFO ABSTRACT\nReceived: \n  June 22, 2022\nPublished: \n  July 01, 2022\nCitation: Tahira Shahzadi, Shazia \nMaqsood. Dilemma in Management of \nEndometriotic Ovarian Cyst. Biomed \nJ Sci & Tech Res 44(5)-2022. BJSTR. \nMS.ID.007125\nA commonly diagnosed form of endometriosis is Endometriotic ovarian cyst \nor Endometriomas, once diagnosed incidentally may cause anxiety. Treatment of \nendometrioma can be conservative, medical, or surgical and Sclerotherapy. Aim \nof treatment is to control symptoms and recurrence. Surgical treatment is done if \nsymptoms are severe to minimize damage to ovaries, recurrence, and formation \nof adhesions. Older age, pseudo capsule stripping and large cyst size may result in \nreduced ovarian reserve. If Endometrioma is found incidentally then clinical dilemma \nis when and how to treat. Recommendations based on previously published guidelines \nare available for treatment of endometriosis but without recommendations on the \npractical aspects of endometrioma surgery. Mostly these recommendations are based \non clinical expertise. Clinical dilemma is debate between planning early treatment and \nsurgery should not be planned if size is less than 3 cm.\nIntroduction  \nOvarian endometrioma or chocolate cyst is ectopic endometrial \ntissue lining ovarian cyst [1]. Presence of endometrial glands \nand stroma outside the uterine cavity is known as endometriosis \n[2]. Endometriosis may present as peritoneal lesions, deep \nendometriosis and ovarian endometriomas. Due to relative ease \nof diagnosis endometriomas are the most diagnosed form of \nendometriosis. Endometriosis have been reported in 17-44% \n[3]. With 10-20% in women in reproductive age most commonly \nbetween 40 and 44 years and approximately 17% of women \nsuffering from infertility [4]. This condition is prevalent among \nthe East Asian race [5]. Endometriosis and endometriomas \nhave the multifactorial ethology [6]. Endometriomas are mostly \nunilateral, commonly left-sided, they are either asymptomatic or \nmay present with symptoms. It is not infrequent to have under \ndiagnosis or misdiagnosis and this is quite common in adolescent \nwomen [7]. Treatment of endometrioma is a clinical dilemma that  \n \nif found in imaging then whether to treat or not and if yes then \nhow to treat. Symptoms of a patient will guide for available options \neither conservative, medical, surgical or combination of both or \nsclerotherapy [8].\nDiscussion \nThe presence of ovarian endometrioses has been found to be \nassociated with deep endometriosis and multifocal deep lesions \n[9]. Endometriomas are mostly unilateral, commonly left-sided \n[10]. Left sided predisposition is explained by anatomic barriers \nlike sigmoid colon that may delay in eliminations of endometriotic \ntissue from left side of pelvis and promotes left sided cysts, in \nsupport this is explained by theory of retrograde menstruation [11]. \nThe pathogenesis of endometrioma is explained as implantation of \nendometrial cells on ovarian surface via tubular lumen that causes \npersistent inflammation, bleeding, cyst formation at implantation \nsite resulting invagination of ovarian cortex, adhesions secondary \n\nCopyright@ Tahira Shahzadi | Biomed J Sci & Tech Res | BJSTR. MS.ID.007125.\nVolume 44- Issue 5\nDOI: 10.26717/BJSTR.2022.44.007125\n36003\nto metaplasia which may result in progressive damage of healthy \novarian tissue [12]. Endometrioma pseudo capsule is ovarian \nepithelium containing oocytes and follicular structures. The \nreason of endometrioma-related infertility remains unclear. \nPossible theories may be damage to affected ovary or tubo-ovarian \ndistortion anatomy and cellular damage resulting in follicular loss \n[13]. Other factors may be involved including immune factors, \ninflammatory factors, environmental toxins, and genetic factors \n[14]. Endometrioma may present with dyspareunia, dysmenorrhea, \npelvic pain, bleeding, infertility, and dysuria. It is not infrequent to \nhave under diagnosis or misdiagnosis and this is quite common \nin adolescent women. Ovarian endometriomas may predispose \nto ovarian malignancies, especially clear cell carcinoma and \nendometrioid adenocarcinoma. \nFor Endometrioma diagnosis, transvaginal ultrasonography is \na very sensitive and specific. Unilocular cyst with a “ground glass” \nhomogeneity, low levels of echogenicity, and poor vascularization, \none  to  four  compartments  and  no  papillary  structures  with  \ndetectable blood flow [15], which had been adopted in the \nESHRE guidelines [16] are typical ultrasound characteristics of \nendometriomas [17]. One useful diagnostic indicator is immobility \nas adherent to pelvic side wall. Diagnosis and treatment of \nendometrioma another useful tool is laparoscopy. A new promising \nbiomarker is Human epidydimal secretory protein E4 used in the \ndifferential diagnosis of endometriosis cyst. The combination of HE4 \nand CA 125 assay could discriminate ovarian endometriosis cysts \nfrom malignant ovarian tumours effectively [18]. The advantage of \nHE4 over CA125 is mainly in the detection of borderline ovarian \ntumours and early-stage epithelial ovarian and tubal cancers. After \ndiagnosis, possible options are either expectant management or \ntreatment depending on symptoms, age, fertility concerns, ovarian \nreserve and previous history of treatment with specific reference \nto past surgical interventions; nature of the cyst; and the fertility \nwishes of the woman [19]. Treatment of incidental disease in \notherwise asymptomatic women is currently not recommended, \nas still the natural progression and development history of \nendometriomas is not well understood.\nTreatment of endometrioma is a clinical dilemma that if \nfound in imaging then whether to treat or not and if yes then how \nto treat. Symptoms of a patient will guide for available options \neither medical treatment progestins , oestrogen suppression or \nsurgical or combination of both. An incidental finding of an ovarian \nendometrioma in young women with regular menstrual cycles \nand without suspicion of malignancy who wish to conceive should \nbe encouraged for natural conception before seeking fertility \ntreatment. While the evidence of the impact of an endometrioma \non spontaneous conception is limited. Aim of surgical treatment \nis removal of endometriotic tissue, to have sufficient sample for \nhistopathology and to preserve maximum ovarian tissue in cases \nwhere fertility is desired and to avoid risk of menopause. With \nsurgical treatment risk is unintentional removal of ovarian follicles \nwhich is later shown by reduced levels or antral follicle count on \nultrasound or reduction in serum anti- Müllerian hormone (AMH) \n[20]. To reduce recurrence after surgery medical therapy may be \nused. Recurrence rate of endometriomas after surgical treatment \nare 30-40 % [21]. So to delay recurrence of ovarian endometrioma \nin 2014, European Society of Human Reproduction and Embryology \n(ESHRE) recommended for ovarian cystectomy instead of drainage \nand coagulation of endometriosis in cases of surgical treatment, \nsince ovarian cystectomy can reduce endometriosis-associated \npain and recurrence rate effectively [22]. Fertility is affected by \npresence of endometrioma [23], while after IVF overall pregnancy \nrates are unaffected [24]. Any surgical intervention to remove \nendometrioma may be associated with decrease ovarian reserve \nand possible recurrence [25]. At present, no consensus has been \nreached on the timing of surgery in young women; whether surgery \nshould be delayed in infertile women planning IVF is still debated \n[26]. \nPossible complications with non-surgical approach are:\n1) Difficulties during oocyte retrieval \n2) Progression of endometriosis\n3) Missing an occult early-stage malignancy \n4) Risk of development of a pelvic abscess or rupture of the \nendometrioma\n5) Follicular fluid contamination with endometrioma content \nMost common mode of treatment is surgical which is \nlaparoscopic cystectomy, benefit is reduced pain symptoms and \nrecurrence. Excision of endometrioma in comparison with drainage \nof endometrioma with or without ablation of pseudo capsule is \nassociated with better outcome and higher pregnancy rates [27]. \nHowever, ovarian cystectomy can lead to decreased ovarian reserve \nor due to excessive coagulation can be reason [28]. So to attain \nfollicular development, increased amounts of gonadotropins are \nneeded [29]. Laparoscopic cyst fenestration and ablation of the cyst \ncapsule is another alternative method which improve pelvic pain \nand result in high patient satisfaction but high recurrence. That’s \nwhy opinion shifted towards more conservative approach. In 2013, \nThe European Society of Human Reproduction and Embryology \nguideline suggested that surgery should be considered only if size \nof endometrioma is >3 cm, to improve access to follicles or pain \n[30]. Size play an important role in decrease ovarian reserve before \n\nCopyright@ Tahira Shahzadi | Biomed J Sci & Tech Res | BJSTR. MS.ID.007125.\nVolume 44- Issue 5\nDOI: 10.26717/BJSTR.2022.44.007125\n36004\nsurgery and difficulty for complete removal in case of superficial \ndestruction as well as damage to ovary in case of surgical excision. \nPost-operative medical treatment markedly reduces the recurrence \nrate of endometrioma [31]. Therefore, long-term medical \ntreatment to prevent recurrence is routinely recommended [32]. \nPost-operative medical treatments including oral contraceptives \nGnRH agonists, and progesterone commonly used to suppress \npossible residual lesions due to the oestrogen-reducing effects [33]. \nHowever, each of these treatments has reported adverse effects. \nPost operative medication needs, or efficacy was not studied in \nwomen aged 40 year or more.\nMedical treatment used for treatment of endometrioma \ninclude Oral contraceptive pills, progestins, gonadotropin-releasing \nhormone agonists [34] as well as aromatase inhibitors are helpful \nto reduce size, symptoms, and post-surgery recurrence [35]. \nHowever, problem is reappearance of symptoms after stopping \nmedical treatment [36]. To reduce recurrence after aspiration \nanother promising method is sclerotherapy [37]. It involves \ninjecting into cyst cavity a sclerosing agent which can be either \nremoved by washing or left within cyst. It is thought that it will \nwork by causing inflammation and fibrosis causing destruction of \nepithelial lining of cyst and at the end will cause obliteration of cyst \n[38]. It has been shown that sclerotherapy is cost effective method \nfor endometrioma but not widely used [39]. Pain improved in 68-\n96% independent from duration of ethanol inside endometriotic \ncyst. Compared to laparoscopic cystectomy, with sclerotherapy \nnumber of oocytes retrieved during IVF treatments was higher \nbut no difference in pregnancy rates after sclerotherapy and \nuntreated cases. Sclerotherapy was found to be safe with possible \ncomplication of transient abdominal pain. After sclerotherapy \ndifference in the recurrence rate in studies can be due to variation \nin selection criteria (cyst size and number of cysts), technique used \n(sclerosing agent, concentration, installed volume, and retention \ntime), duration of ethanol inside the endometrioma and the follow-\nup time. Risk of unexpected malignancy with typical features of \nendometrioma has been found in 1% in patients [40]. Other factors \nwill influence the decision in an asymptomatic patient like the rate \nof growth, the age of patients, personal and family history of breast \nand ovarian malignancies [41].\nOther alternative is phytotherapeutic options obtained from \nplants or herbal preparations some of them work by influencing \napoptosis, epigenetic factors, angiogenetic processes, cell survival, \noxidative stress and oestrogen modulation [42]. During course of \nfertility treatment, endometrioma often present a clinical dilemma \ndue to uncertainty regarding decision of either to operate or \nmanage conservatively while balancing possible risk of surgery on \novarian reserve. So far guidance available from either small and/\nor retrospective controlled studies. Surgery does not improve the \nresults of IVF treatment [43], but a sequential use of surgery and \nIVF in those that do not conceive spontaneously probably results \nin slightly higher cumulative pregnancy rates [44]. There may be \nspilling of chocolate fluid of endometrioma in peritoneal cavity in \nwomen undergoing IVF. This fluid may not induce endometriosis \nbut is adhesiogenic [45]. Considering the risk of ovarian damage \nduring surgery and the excellent results of IVF, actual guidelines \n[46] therefore have concluded that if IVF indicated then should not \nundergo surgery if size of endometrioma is ˂ than 3-4cm. Surgical \ntreatment of endometriomas prior to IVF is widely practiced, [47] \nalthough debatable on its effect and need. To date, there has been no \nevidence that surgical treatment improves reproductive outcome \nof women treated with the use of ART , no difference in the clinical \npregnancy rate and the number of oocytes retrieved from women \nwho had surgical treatment compared with those with intact \nendometrioma. Cancellation rate and number of retrieved oocytes \nwere comparable. After surgical treatment of endometrioma there \nis lower antral follicle count and higher doses of gonadotrophins \nrequired for ovarian stimulation. \nWomen of advanced reproductive age, asymptomatic, those \nwith reduced ovarian reserve, bilateral endometriomas or a history \nof prior ovarian surgery may benefit from proceeding directly with \nIVF, as Ovarian reserve may be compromised further after surgery. \nIn case of symptomatic women, large endometrioma, intact ovarian \nreserve, suspicious features of cyst on radiological investigations \nor with clinical features surgery may be considered. There is \nrisk of Infertility and Premature Ovarian failure after treatment \nof endometrioma in very young women. Pathophysiology and \nmanifestation of endometriomas in adolescents may be different \nthan adult women [48]. The diagnosis of endometriosis in \nadolescents is often delayed due to several factors. Regarding \nearly diagnosis followed by surgical removal of endometriomas \nin the adolescent population, currently no original studies are \npresent as fertility is a major concern as well as future recurrence. \nNew concept is early treatment instead of postponing surgery to \nprevent adhesions, ovarian damage and recurrence. Considering \nthat the endometriosis in cystic ovarian endometriosis is only \nsuperficial, a superficial destruction by electro surgery, CO 2 laser \nor alcohol should be sufficient before the development of more \nlesions and size of endometrioma is getting more or symptoms \nbecoming more severe or concern of fertility arises. With these \nconcepts, the use of THL in women with infertility should be \nreconsidered. Transvaginal hydro-laparoscopy (THL) [49,50] offers \na minimal invasive procedure for early diagnosis and treatment of \nsmall endometrioma up to a diameter of 20 mm not seldom these \nsmall endometriotic cyst are missed at routine vaginal ultrasound \nexamination in approximately 50% of the cases. \n\nCopyright@ Tahira Shahzadi | Biomed J Sci & Tech Res | BJSTR. MS.ID.007125.\nVolume 44- Issue 5\nDOI: 10.26717/BJSTR.2022.44.007125\n36005\nIt is always surprising after opening of such small cysts to see \nthe pronounced presence of inflammation and neo-angiogenesis, \na signature for the aggressiveness of the disease in these early \nstages. Due to concern of ovarian reserve early stages treatment \nusing ablative technique with a bipolar 5Fr probe causes a \nminimal trauma and a lower risk for recurrences [51]. In absence \nof suspicious radiological, clinical features chances of missing \nan occult malignancy in an endometrioma is extremely low and \nsurgery is not advised. But in later life risk of developing ovarian \ncancer can be a concern with the lifetime probability increasing \nfrom 1% to 2% in the presence of an endometrioma [52].\nConclusion \nNeed clear guidelines for when to treat, when to stay \nconservative and if need treatment then what mode of treatment \nout of available options should be used keeping in view risk of \nrecurrence, reduced ovarian reserve and fertility concerns. All \navailable options have their own benefits and risks. So in current \ncircumstances we need to decide either to stay conservative or \ntreatment depending on symptoms or need for intervention.\nReferences\n1. (2014) Practice Committee of the American Society for Reproductive \nMedicine. Treatment of pelvic pain associated with endometriosis: a \ncommittee opinion. Fertility and Sterility 101: 927-935.\n2. Burney RO, Giudice LC (2012) Pathogenesis and pathophysiology of \nendometriosis. Fertility and Sterility 98: 511-519.\n3. 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Current Opinion in Obstetrics and \nGynecology 24: 136-140.\n\nCopyright@ Tahira Shahzadi | Biomed J Sci & Tech Res | BJSTR. MS.ID.007125.\nVolume 44- Issue 5\nDOI: 10.26717/BJSTR.2022.44.007125\n36006\nSubmission Link: https://biomedres.us/submit-manuscript.php\nAssets of Publishing with us\n• Global archiving of articles\n• Immediate, unrestricted online access\n• Rigorous Peer Review Process\n• Authors Retain Copyrights\n• Unique DOI for all articles\nhttps://biomedres.us/\nThis work is licensed under Creative\nCommons Attribution 4.0 License\nISSN: 2574-1241\nDOI: 10.26717/BJSTR.2022.44.007125\nTahira Shahzadi. Biomed J Sci & Tech Res\n30. Dunselman GA, Vermeulen N, Becker C, Calhaz-Jorge C, D’Hooghe T , et al. \n(2014) ESHRE guideline: management of women with endometriosis. \nHuman Reprodtion 29: 400-412.\n31. Renato Seracchioli, Mohamed Mabrouk, Clarissa Frascà, Linda Manuzzi, \nLuca Savelli, et al. 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Stephan Gordts, Patrick Puttemans, Sylvie Gordts, Ivo Brosens (2015) \nOvarian endometrioma in the adolescent: a plea for early-stage diagnosis \nand full surgical treatment. Gynecological Surgery 12(1): 21-30. \n52. Koch J, Rowan K, Rombauts L, Yazdani A, Chapman M, et al. (2012) \nEndometriosis and infertility-a consensus statement from ACCEPT \n(Australasian CREI Consensus Expert Panel on Trial evidence). \nAustralian and New Zealand Journal of Obstetrics and Gynaecology 52: \n513-22.","source_license":"CC0","license_restricted":false}