Untreated ovarian endometrioma: not just a matter of dimensional change over time

Untreated ovarian endometrioma: not just a matter of dimensional change over time Abstract Linked article: This Correspondence comments on Knez et al. Click here to view the article. When small ovarian endometriomas are detected in asymptomatic young women, there may be doubt as to whether medical intervention or expectant management is in the best interest of the patient. Knez et al. reported that, after a median follow-up of approximately 21 months after initial detection, the diameter of untreated ovarian endometriomas increased in less than one-quarter of the 83 patients included in the study1. The authors concluded that in most women diagnosed with ovarian endometrioma on ultrasound, the cysts showed minimal or no significant growth over time, suggesting that many cases could be managed expectantly1. However, we wonder whether this applies in routine clinical practice beyond such a highly selected population. The vast majority of those considered initially were excluded because surgical or medical treatment was indicated. The remaining patients included had a median age of 39 years, a median gravidity of one conception, a median cyst diameter of only 22.3 mm, and were asymptomatic or had mild pain symptoms that did not require active management despite coexisting deep endometriotic lesions in 70% of cases. Given these atypical characteristics, it cannot be excluded that these participants had a particularly favorable prognosis because their endometriosis was not aggressive. In addition, more than one-third of the 25 individuals with an isolated endometrioma at baseline had evidence of de novo deep endometriotic nodules on follow-up ultrasound. Chaggar et al. have shown recently that intraperitoneal bleeding, usually associated with hemorrhagic ovulation, is often followed by the development of deep endometriosis2. Thus, when assessing disease progression in patients with untreated endometriosis, not only endometriomas should be considered, but also deep endometriotic lesions. In the 58 participants with infiltrating lesions at baseline, were variations detected in the number and/or size of nodules on follow-up ultrasound? Notably, in a recent large population-based cohort study, women with ovarian and/or deep endometriotic lesions had an almost ten-fold increased risk of ovarian cancer compared to women without endometriosis3. In this high-risk subgroup of patients, Knez et al. suggested expectant management1, while others have contemplated risk-reducing salpingo-oophorectomy4. However, in addition to these two opposing options, prolonged medical suppression of ovulatory menses could be recommended as an alternative primary oncological preventive measure when ovarian endometriomas are detected5. Before opting for expectant management, asymptomatic women with small ovarian endometriomas who do not wish to conceive should be informed that endometriosis is a chronic inflammatory disease with systemic implications. Furthermore, treatment with very-low-dose estrogen–progestogen combinations or progestogen monotherapy prevents bleeding from hemorrhagic corpora lutea, potentially limiting the risk of deep endometriotic lesion formation; reduces the diameter and prevents recurrence of endometriotic cysts; reduces dramatically the risk of ovarian cancer5, which is particularly high in women with endometriomas and deep lesions3, 4, and the risk of endometrial cancer, which seems to be also increased in patients with endometriosis; may limit the risk of future surgical procedures; is reasonably safe in the absence of major contraindications; and is generally well-tolerated. We agree that therapeutic abstention is a reasonable option, but only after complete and detailed information beyond prospective cyst diameter variation is provided. Disclosure P.Ve., P.Vi. and E.S. have received funding from the Italian Ministry of Health-Current Research IRCCS. DATA AVAILABILITY STATEMENT Data sharing not applicable - no new data generated.