The management of ovarian endometrial cysts

The management of endometrioma differs depending on the life stage of the patient, such as the patients'' age, the presence or absence of the desire for conception. In this lecture, I will divide the patient''s life stage into three stages: 1) from menarche to childbearing, 2) while childbearing, 3) after finishing childbearing (or deciding not to do) and will organize matters to prioritize by these stages. 1) Form menarche to childbearing Give priority to minimizing the decline of future fertility caused by endometrioma. According to the basic research and observational studies, it is suggested that the presence of endometrioma may cause a decrease of ovarian function. When adhesions or deep lesions develop, the subsequent fertility is further deteriorated. Therefore, rather than leaving endometriosis, it is desirable to control or remove the lesion by medication or surgical therapy. However, surgery itself also has the aspect of lowering ovarian function. Also, if postoperative recurrence occurs, the ovarian function further decreases. Therefore, when surgery is planned, pay attention not to harm the ovary during the surgery, and it is necessary to prevent recurrence by medication therapy after surgery and avoid poly-surgery. 2) While childbearing Give priority to improving fertility at that time. If natural timed intercourse does not lead to pregnancy immediately, we will conduct a fertility screening, and begin treatment for male factors, ovulation factors etc if any. Long term ovulation induction is not recommended because that may exacerbate endometriosis. Laparoscopy is recommended for cases where we can expect pregnancy by correcting tubal factor or removal of peritoneal lesions. However, cases that do achieve pregnancy even after laparoscopy, cases with older age or in which ovarian function has already declined, and cases with c tubal adhesion, an early step up to assisted reproductive technology (ART) is desired. Cystectomy prior to ART is not recommended; however, one should be aware that endometrioma may cause infections at oocyte pickup and embryo transfer. 3) After childbearing (or deciding not to do) Prioritize comprehensive health care including prevention of malignancy. Since the malignant transformation of endometrioma mainly occurs after the age of 40, and many cases have finished childbearing at the middle of the 40s, priority is given to the prevention of malignancy, rather than the protection of ovary function / fertility in this stage. Continuous health care support is also necessary even after menopause since women who had previously experienced endometriosis have a higher incidence of cardiovascular disease and osteoporosis etc.