Pathophysiology proposed as the basis for modern management of the ovarian endometrioma

Ivo Brosens, Brosens I, Stephan Gordts, Gordts S, Patrick Puttemans, Puttemans P, Giuseppe Benagiano, Benagiano G
Reproductive biomedicine online · 2013 · vol. 28(2) , pp. 232–238 · doi:10.1016/j.rbmo.2013.09.024 · PMID:24365030 · W2030673451
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Ovarian endometriomas detrimentally impact follicle reserve regardless of size, necessitating early diagnosis via minimally invasive techniques and prompt ablative surgery to preserve ovarian function.

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Abstract

Present management of the ovarian endometrioma focuses on the size of the cyst and dictates that surgery should not be performed unless this exceeds 3 cm, which neglects the complex pathology of this condition. Studies of ovaries with the endometrioma in situ show progressive smooth muscle cell metaplasia and fibrosis of the cortical layer as the main ovarian lesion. There is no correlation between the size of the endometrial cyst and the degree of ovarian pathology: it is the mere presence of an ovarian endometrioma that has a detrimental impact on the cortical layer's follicle reserve. Cystectomy in young patients with an endometrioma may be particularly detrimental to follicle reserve, with the ovarian parenchyma loss at the time of surgery being related to the cyst's diameter. An underutilized diagnostic procedure, transvaginal hydrolaparoscopy with in-situ inspection of the cyst wall by ovarioscopy, allows careful diagnosis of ovarian pathology and selection of appropriate surgery with minimal invasiveness. Thus, available evidence shows that expectant management may not be the best choice when an endometrioma is suspected. On the contrary, early diagnosis through a minimally invasive technique, followed by early ablative surgery whenever indicated, represents the management of choice to preserve normal ovarian function. Present management of ovarian endometriomata is based on the size of the cyst and dictates that surgery should not be performed unless this exceeds 3cm. We argue that this approach neglects the true pathology of the ovary, since pioneers have studied ovaries with the endometrioma in situ and demonstrated that progressive smooth muscle cell metaplasia and fibrosis in the cortical layer constitute the main features of an endometrioma. There is no correlation between the size of the endometrial cyst and the degree of ovarian pathology: it is in the first place the mere presence of an ovarian endometrioma that has a detrimental impact on follicle reserve. It has been shown that cyst ablation in young patients with an endometrioma may be particularly detrimental to follicle reserve. An underutilized diagnostic procedure, transvaginal needle endoscopy with in-situ inspection after injection of saline suspension into the peritoneal cavity (hydrolaparoscopy) allows careful diagnosis of ovarian cortical pathology by colour changes from pearl-white to dark fibrotic. Thus, available evidence shows that expectant management may not be the best choice when an endometrioma is suspected: the delay in diagnosis causes delay in treatment and progression of the process leading to loss of follicles. On the contrary, early diagnosis through a minimally invasive technique, followed by early ablative surgery whenever indicated, represents the management of choice to preserve normal ovarian function.

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Condition tags

endometriosisendometrioma

MeSH descriptors

Disease Management Endometrial Ablation Techniques Endometriosis Endometriosis Ovarian Diseases Ovarian Diseases Endometrial Ablation Techniques Endometrial Ablation Techniques Endometriosis Endometriosis Female Humans Laparoscopy Laparoscopy Ovarian Diseases Ovarian Diseases

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Cited by (31)

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