Endometrioma

What is Endometrioma?

Endometriosis, a common disease that often affects women of childbearing age, involves inflammation and abnormal growth of tissue similar to the inner lining of the uterus, known as the endometrium, outside the uterus. This usually occurs within the pelvic region, particularly on the ovaries.

Endometriomas, also known as ‘chocolate cysts’ due to the dark fluid inside them, are a type of cyst that forms from endometriosis, primarily on the ovaries. However, endometriosis can also occur in other parts of the abdomen, such as the bowel, within prior surgical scars, and even in rare cases, distant parts of the body like the brain’s cerebellum.

About one in ten women of reproductive age is affected by endometriosis, which is a common cause of chronic pain, painful sexual intercourse (dyspareunia), painful periods (dysmenorrhea), and troubles with fertility. Approximately 17 to 44% of women diagnosed with endometriosis will develop an endometrioma. Presence of endometriomas indicates a more serious stage of endometriosis, which may result in specific issues, such as a reduced amount of eggs in the ovaries, a situation referred to as decreased ovarian reserve.

What Causes Endometrioma?

Endometriomas are generally believed to develop when fragments of the endometrium – the tissue that lines the inside of a woman’s uterus – become displaced and attach themselves elsewhere, often on the ovary. This tissue can bleed, similarly to how the endometrium sheds blood during a woman’s menstrual cycle, leading to the formation of a pool of blood or ‘hematoma’. This happens because this displaced tissue, even though it’s in a different location, still responds to hormonal changes in the body.

But unlike normal hematomas, which can also form in the ovary during ovulation, these hematomas are lined with a sticky type of endometrial tissue and have a higher amount of fibrous tissue. Because of this, these hematomas or endometriomas often lead to adhesions or sticky tissues that can bind organs together. This can cause severe pain and make it challenging for surgeons to remove the endometrioma.

When we talk about the cause of endometriomas, it’s also important to talk about the cause of endometriosis, as this is the condition which often leads to an endometrioma. However, the cause of endometriosis is complex and debated amongst medical professionals. The most accepted theory is known as retrograde menstruation. This theory suggests that during a woman’s menstrual cycle, some of the endometrial tissue flows backward through the fallopian tubes into the pelvis, rather than leaving the body as a period. This tissue can then implant itself in various areas, causing endometriosis. Some of this tissue may attach to an ovary and develop into an endometrioma.

However, most medical experts think that endometriosis probably develops due to a combination of factors, and not just retrograde menstruation. This is because the theory doesn’t explain why endometriosis can occur in women who haven’t started their periods or have lesions far from the uterus. Other theories include metaplasia – where cells outside of the uterus change into endometrial cells – or the spread of endometrial cells through blood or lymphatic vessels. It’s likely that all these theories combined help explain how endometriosis develops.

Risk Factors and Frequency for Endometrioma

Endometriosis is a condition that affects about 10% of women of childbearing age. However, only around 3% of these women experience significant symptoms. It’s especially common among certain groups, with nearly half of women struggling with infertility and about 70% of women with pelvic pain having the disease.

The prevalence of endometriomas, which are a form of endometriosis, isn’t as well-studied. However, estimates suggest that 17-44% of women with endometriosis will develop an endometrioma. Of these women, 28% will have endometriomas on both ovaries. Within women struggling with fertility, about 17% will have endometriomas.

There’s limited data about what specifically increases the risk of developing endometriomas. However, there are known general risk factors associated with developing endometriosis.

• Never having given birth
• Having your first period at a young age (typically before 11-13 years old)
• Reaching menopause late, having short menstrual cycles (less than 27 days)
• Experiencing heavy periods
• Having abnormalities in the reproductive tract
• Being taller than 68 inches
• Having a low body mass index (BMI)
• Eating a lot of trans fats
• Being exposed to a drug called diethylstilbestrol while in the womb

Besides these risk factors, endometriosis can also increase the risk of other health issues. Some of these, like infertility, chronic pelvic pain, and painful bowel movements and intercourse, are well-known. Endometriosis also increases the risk for certain types of ovarian cancer. However, the overall risk remains low. Multiple studies have found that women with endometriosis are more likely to develop clear cell and endometrioid ovarian cancer. One study from Finland found this increased risk specifically in women who had endometriomas.

Signs and Symptoms of Endometrioma

Endometriosis is a condition often experienced by females of reproductive age who haven’t had children. Its symptoms can include prolonged and painful periods, chronic pelvic pain, pain during sexual activities or defecation, among others. Though menstrual cycles are usually regular, they can sometimes be shorter than usual (less than 27 days). The pain often begins 2 to 3 days before the onset of periods and usually starts easing a few days after the periods have begun.

Endometriomas, which are commonly found on the ovaries, can cause extreme pain. The pain is often located on the side of the lesion, but if the condition is severe and lesions are on both sides, patients might experience pain throughout the pelvic area. If an ovarian endometrioma bursts, the leaking fluid can cause widespread pain and inflammation, presenting a serious medical condition.

Endometriomas are usually found on the ovaries, but they can also appear elsewhere. For example, there have been documented cases of endometriomas inside abdominal surgical scars, lungs, and brain. So, even if pain occurs in unexpected places, endometriosis should not be ruled out, particularly if the pain occurs in sync with menstrual cycles.

• Pelvic pain
• Heavy periods
• Painful periods
• Back pain
• Pain during sexual intercourse
• Painful defecation
• Painful urination
• Frequent urination
• Nausea/vomiting
• Bloating

Endometriosis, including those who have endometriomas, usually don’t show much on physical exams. If endometriomas are large enough, they might be felt during a bimanual exam, but other than that, these patients often don’t present abnormal findings. There could be tenderness in the pelvic area or the area affected, which can vary depending on the timing of the menstrual cycle; pain is typically more intense just before the onset of periods. Also, there might be a fixed or backward-tilting uterus indicating scarring from endometriosis, and at times, the uterosacral ligaments, which connect the uterus to the sacrum, can feel nodular.

Patient presenting after the rupture of an endometrioma may exhibit symptoms of an abdominal emergency. These can include signs like a rigid abdomen, rebound pain, and involuntary tensing of the abdominal muscles.

Testing for Endometrioma

Endometriomas, a type of cyst linked to endometriosis, can often be seen through imaging, such as an ultrasound or an MRI scan. However, these cysts might look similar to other types of cysts, and the only way to be sure of what they are is through surgery. If no signs of endometriomas are seen in scans or other tests, diagnosing endometriosis can be difficult. The best way to confirm endometriosis is by directly looking at the lesions during surgery.

Though there’s no specific test that can definitely diagnose endometriosis, certain lab tests can help guide your doctor. These might include a complete blood count (CBC), which can check for signs of infection or anemia (a common condition in those with heavy periods), or tests for markers like cancer antigen-125 (CA-125), which can sometimes be higher in women with endometriosis. Urine tests can rule out a urinary tract infection as the cause of the symptoms, and testing for sexually transmitted infections can rule out STIs as the cause as well.

A transvaginal ultrasound is often employed to find a possible cause of pelvic pain. It’s important to know that early or small endometriosis growths can’t be seen on ultrasound or any other scans. But endometriomas, a type of cyst that forms in people with endometriosis, can often be found on ultrasound. These cysts typically look like simple, low echo, or ground-glass cysts.

Other imaging types include MRI and CT scans. MRI scans are better able to detect certain types of masses in the pelvic area than an ultrasound. CT scans can also identify some types of pelvic masses, but doesn’t provide a detailed image of the mass. Because of these limitations, and the higher cost of MRI and potential radiation exposure from CT scans, ultrasound is the method most commonly used.

The most accurate way to diagnose endometriosis is via laparoscopy, a type of minimally invasive surgery. During this surgery, a tiny camera is inserted into the body, allowing the surgeon to view the reproductive organs and potentially see signs of endometriosis. Lesions – areas of endometriosis growth – are often blue or black, but can also be red, white, or colorless. If there’s severe disease presence, there might be significant adhesions (scar tissue), peritoneal defects (damage to the lining of the abdominal wall), or endometriomas. Biopsies can be taken during surgery for further examination. If infertility is also an issue, a procedure to check the fallopian tubes can be performed.

Laparoscopy is crucial in diagnosing endometriosis because it’s the most reliable way to confirm this illness, particularly in cases where endometriomas are present. It’s a key part of treatment for patients suffering from stubborn endometriosis or problematic endometriomas.

Treatment Options for Endometrioma

Endometriosis, a condition where tissue similar to the lining of the womb starts to grow in other places, can generally be treated with medication or surgery. Simpler cases of endometriosis might be taken care of with hormonal birth control pills, certain versions of progesterone (a hormone, which can come in pill form or be inserted directly into the uterus), drugs that affect other hormones, such as GnRH agonists (for example, leuprolide), or medicines that affect male hormones, like androgens (one example being danazol).

However, if a patient’s endometriosis gets so advanced that they develop endometriomas (a type of cyst caused by endometriosis), then the treatment usually leans towards surgery. While the GnRH agonists mentioned earlier can help with shrinking endometriomas, patients usually report no change in their pain levels. So, these kinds of drugs are not typically used for those with endometriomas.

The surgical approach to treating endometriosis can range from less extensive to more extensive options, depending on the individual’s symptoms and whether or not they want to have children in the future. Less extensive surgery might involve getting rid of the endometrial growths (usually with a laser or a tool that uses heat), draining the endometrioma, and taking out the lining of the cyst. For those dealing with severe pain and not interested in having children later, some might consider hysterectomy (removal of the uterus) and bilateral salpingo-oophorectomy (removal of both fallopian tubes and ovaries) as a more thorough solution.

Most of the time, surgeries are done laparoscopically, which involves using a long, thin tool with a camera on the end, inserted through a small incision in the abdomen. Specifically for endometrioma removal, it’s crucial to remove the entire cyst wall during the procedure rather than just draining the cyst. Doing so has been shown to prevent the endometriomas from coming back. And for those having trouble with getting pregnant naturally, this procedure can actually increase the chances of a successful pregnancy.

However, one concern with surgically removing endometriomas, especially for women who are dealing with infertility and thinking about in-vitro fertilization (IVF which is a procedure helping with fertilization, embryo development, and implantation), is whether it could reduce the amount of ovarian reserve (number of eggs remaining in a woman’s ovaries). Studies have shown a decrease in the level of AMH (anti-mullerian hormone, a hormone that fertility specialists use to estimate the number of remaining eggs) following surgery to remove an endometrioma. Additionally, 2 to 3% of patients experienced ovarian failure (loss of normal ovarian function before age 40) after having surgery to remove endometriomas from both ovaries. These risks are important to consider when deciding whether surgery is the right choice for the patient, given their plans for having children. For patients being seen by a fertility specialist and considering IVF, endometriomas are often managed with watchful waiting, unless severe symptoms or issues with egg retrieval occur.

After surgery, some doctors recommend medication to help prevent the endometriosis from coming back. There are studies that show a 6-month treatment plan with birth control pills can help prevent return of the condition. But, this treatment choice would also depend on whether or not the patient is trying to get pregnant.

What else can Endometrioma be?

If you suspect a patient has endometriomas, it’s important to consider all other possibilities since they can often resemble other conditions or diseases.

Often, patients have an unclear kind of pelvic pain so it’s necessary to consider other potential causes of this pain. These include:

• Ectopic pregnancy
• Appendicitis
• Pelvic inflammatory disease
• Ovarian torsion
• Diverticulitis
• Urinary tract infection
• An ovarian cyst (not endometrioma)
• Sexually transmitted diseases (like gonorrhea, chlamydia)

If an imaging scan shows a mass in the adnexal area, certain characteristics can help determine what type of mass it is. For example, endometriomas typically show as a ground glass appearance on ultrasound. This can be similar to hemorrhagic cysts, and often the correct diagnosis isn’t made until surgery.

Also, if a patient comes in with sudden or severe abdominal pain and there’s a worry that an endometrioma may have ruptured, it’s crucial to keep other possibilities in mind such as a ruptured ectopic pregnancy or ovarian torsion. These are all urgent situations that require immediate surgical intervention.

Surgical Treatment of Endometrioma

Endometriomas, which are cysts that form on the ovaries, can sometimes develop into a specific type of ovarian cancer known as epithelial ovarian cancer. However, this risk is quite small. A review of 13 studies involving around 9000 women showed that the risk of this type of cancer in women with a history of endometriosis was three times higher.

There’s some evidence to suggest that the activation of certain genes – KRAS and PI3K – might be linked to ovarian cancer in people who’ve had endometriomas. Other genes, like PTEN and ARID1A, might play a role in how such cancers develop. However, it’s important to remember that endometriomas on their own are not labelled as pre-cancerous, and there is typically no need for cancer screening or staging tests because of them.

What to expect with Endometrioma

In general, patients with endometriosis tend to have a positive outlook. This condition is not dangerous or life-threatening. However, it’s important to know that endometriosis is a long-term, often progressive disease. Having endometriomas, which are cysts caused by endometriosis, can mean that the disease is more severe and might lead to more long-term complications.

While treatments can be effective for some time, endometriosis is known to often come back. This means the real challenge of this condition is that there is no absolute cure. This can create long-term problems like pain and difficulty becoming pregnant. On a bright note, most women find that their symptoms get better once they reach menopause, due to the changes in their hormone levels.

Possible Complications When Diagnosed with Endometrioma

The main complications of endometriomas are similar to those associated with general endometriosis. These usually include persistent pain in the pelvic area and issues with fertility. Furthermore, if the endometrioma grows over 6 cm, it creates a higher risk for a condition called ovarian torsion. This is a situation that requires immediate surgery because it could result in the loss of the ovary. It’s also worth noting that women with endometriosis have a slightly increased chance of getting certain types of ovarian cancer. Endometriomas carry a small chance of developing into a malignancy or cancer, albeit this risk is extremely small.

Common Complications:

• The persistent pain in the pelvic area
• Issues with fertility
• Ovarian torsion (especially in endometriomas over 6 cm)
• Possibility of certain types of ovarian cancer
• Small risk of endometriomas turning malignant, although this risk is very low

Preventing Endometrioma

If you have endometriomas, which are cysts that occur with endometriosis, it’s important to understand what you can expect from treatment and what complications might arise due to endometriosis. The standard way to treat endometriomas is by laparoscopic surgery, a procedure that uses small incisions and special instruments to remove the cysts. Before this surgery, it’s crucial that you’re aware of the potential risks and benefits.

Endometriosis, which is a long-lasting condition where tissue similar to your uterine lining grows outside your uterus, is what causes endometriomas to develop. Be aware that about 25% of women experience a recurrence of an endometrioma. In addition to possible recurrence, you may also face challenges with fertility and chronic pelvic pain due to your endometriosis, which might need more treatment.