EndometrIoma Treatment
Endometrioma Treatment: A Personalized Approach for Chocolate Cysts
Endometrioma treatment refers to the medical approach planned for cystic structures that develop in the ovaries due to endometriosis lesions and are commonly known as “chocolate cysts.” Endometrioma does not progress in the same way in every patient; while it may be monitored for a long time without symptoms in some women, in others it may present with severe menstrual pain, chronic pelvic pain, pain during intercourse, bloating, and reproductive problems. Therefore, endometrioma treatment should be planned individually, not only according to the size of the cyst, but also according to pain level, age, desire for pregnancy, ovarian reserve, and accompanying findings (1).
The goal of endometrioma treatment is not only to eliminate the cyst. Reducing pain, improving quality of life, preserving ovarian tissue, and considering fertility are just as important as the cyst itself.
What Is an Endometrioma?
An endometrioma is a cystic structure that develops inside the ovary, contains endometriosis tissue in its wall, and often includes accumulated old blood. For this reason, it is commonly called a “chocolate cyst.” Endometrioma, one of the subtypes of endometriosis, may occur alone or together with intra-abdominal adhesions, deep infiltrating endometriosis, or superficial lesions (1).
The ESHRE patient guide states that endometriomas and moderate-to-severe adhesions may generally be associated with more advanced-stage endometriosis. However, the important point is this: the extent of endometriosis and the severity of symptoms do not always match exactly. A small lesion may be very painful, while a larger endometrioma may sometimes cause fewer symptoms (2).
What Causes Endometrioma?
The exact cause of endometrioma has still not been fully explained. One of the most widely accepted theories is retrograde menstruation; according to this theory, endometrium-like cells in menstrual blood may pass backward through the tubes and settle in the pelvis. Cleveland Clinic states that this backward-flow theory may contribute to cyst development through tissue accumulation in the ovary, repeated bleeding, and inflammation (1). However, the immune system, genetic predisposition, and hormonal environment may also play a role in the process.
A family history, early onset of menstruation, short cycle intervals, prolonged menstrual bleeding, and certain anatomical or hormonal characteristics may increase the risk. However, endometrioma does not necessarily develop in every person with risk factors; similarly, endometrioma may also be detected in patients without clear risk factors.
What Are the Symptoms of Endometrioma?
One of the most common complaints of endometrioma is pain in the groin and pelvic area. This pain may be felt not only during menstrual days but also at different times of the cycle. Cleveland Clinic states that, in addition to pelvic pain, very painful periods, pain during sexual intercourse, pain while urinating or having a bowel movement, frequent urination, back pain, nausea, vomiting, and bloating may also occur (1).
In terms of reproductive health, endometriosis and endometrioma may make it more difficult for some women to conceive due to adhesions and inflammation around the ovaries and tubes. However, according to the ESHRE patient guide, a significant proportion of women diagnosed with endometriosis can achieve spontaneous pregnancy. Therefore, in every patient diagnosed with endometrioma, a planned evaluation approach should be adopted instead of panic (2).
How Is Endometrioma Diagnosed?
The first step in diagnosis is a detailed patient history and gynecological examination. Transvaginal ultrasound is the most commonly used method for evaluating endometrioma; when necessary, a more detailed examination can be performed with MRI. The ESHRE patient guide particularly emphasizes that even if imaging is negative, endometriosis cannot be completely ruled out (2). In other words, symptoms should not be ignored when ultrasound results are normal.
In some cases, the definitive diagnosis is clarified by pathological examination of tissue removed during surgery. Cleveland Clinic also states that the official diagnosis is often confirmed by removing or sampling the cyst during laparoscopy and examining it in the laboratory (1). However, in practice, surgery is not required first in every suspected endometrioma case; clinical and radiological evaluation may be sufficient for treatment planning in many patients.
When Is Endometrioma Treatment Necessary?
Not every endometrioma requires immediate treatment. Cleveland Clinic states that small and painless endometriomas do not always need to be removed, and monitoring may be appropriate in some cases (1). On the other hand, an active treatment plan is more often considered for cysts that cause pain, grow, affect fertility, carry a risk of rupture, or require differential diagnosis in terms of malignancy.
When making a treatment decision, the question is not only “Is there a cyst or not?” The patient’s age, ovarian reserve, pregnancy plan, pain level, previous surgeries, whether the cyst is unilateral or bilateral, and the possibility of accompanying deep endometriosis are also taken into account. Therefore, endometrioma treatment should be considered not as a standard prescription, but as an individualized strategy.
Medication-Based Approach in Endometrioma Treatment
Medications have an important place in endometrioma treatment, especially for pain control and symptom management. The ESHRE patient guide states that NSAIDs or other analgesics may be used alone or together with other treatments to reduce endometriosis-related pain (2). Mayo Clinic also states that over-the-counter NSAIDs such as ibuprofen and naproxen may be used to relieve painful menstrual cramps (3). However, these medications do not eliminate the disease itself.
Hormonal treatment aims for more comprehensive symptom control. Combined hormonal contraceptives, progestin-containing treatments, GnRH agonists, GnRH antagonists, and in some cases aromatase inhibitors are among the treatment options. ESHRE and Mayo Clinic emphasize that these medications can reduce endometriosis-related pain; however, symptoms may return when the medication is stopped (2)(3). Therefore, hormonal treatment is usually considered not as a tool that “eliminates the disease completely,” but as a way to control symptoms and manage the process.
Endometrioma Treatment in Patients Planning Pregnancy
Endometrioma management in patients who wish to become pregnant should be planned more carefully. This is because endometriosis may affect fertility on one hand, while surgical intervention may reduce ovarian reserve on the other. The ESHRE patient guide states that there is no evidence that hormonal treatment increases the chance of spontaneous pregnancy (2). NICE also clearly states that hormonal treatment should not be recommended to increase spontaneous pregnancy rates in women trying to conceive (4).
In cases where pregnancy is planned, laparoscopic surgery may be one of the options that can increase the chance of spontaneous pregnancy in suitable patients. However, ovarian reserve must be taken into account when deciding on surgery. NICE states that laparoscopic ovarian cystectomy or laparoscopic drainage and ablation options may be considered in patients with endometrioma, and that fertility expectations and ovarian reserve should be considered when making the decision (4).
When Is Endometrioma Surgery Considered?
Endometrioma surgery is especially considered in cases that cause significant pain, show a tendency to grow, create suspicion in differential diagnosis, carry a risk of rupture, or are considered clinically significant in infertility evaluation. Cleveland Clinic states that laparoscopy is more often recommended for painful, growing, or larger than 4-centimeter endometriomas (1).
The laparoscopic approach is one of the most commonly preferred surgical methods today. Mayo Clinic states that conservative surgery is often performed laparoscopically and planned according to pain and fertility goals (3). The ESHRE guideline emphasizes that cystectomy in ovarian endometrioma surgery may reduce pain recurrence and endometrioma recurrence compared with drainage and coagulation (2).
However, it should be remembered that surgery is not always risk-free. ESHRE clearly states that special care should be taken to minimize ovarian damage during ovarian endometrioma surgery (2). Especially in patients with bilateral endometrioma, repeated surgeries, or already limited ovarian reserve, the decision for surgery should be made much more carefully.
The surgical decision should not be based only on removing the cyst, but on achieving the best possible result with the least possible ovarian loss.
Comparison Table of Endometrioma Treatment Options
| Treatment Option | Who Is It More Suitable For? | Advantages | Things to Consider |
|---|---|---|---|
| Regular follow-up | Small, asymptomatic, stable cysts | May prevent unnecessary surgery | Growth, increased pain, or imaging changes should be monitored |
| Painkiller treatment | Patients whose main complaint is pain | Provides symptom control | Does not eliminate the disease; long-term use requires medical follow-up |
| Hormonal treatment | Patients who are not planning pregnancy and have pain | May reduce pain and menstruation-related complaints | Symptoms may return when medication is stopped; side effects vary by person |
| Laparoscopic surgery | Selected cases with painful, large, growing cysts or pregnancy plans | May reduce symptoms and increase spontaneous pregnancy chances in some patients | The risk of damage to ovarian reserve and the possibility of recurrence should be evaluated |
| Postoperative hormone treatment | Patients who are not considering pregnancy immediately | May help reduce recurrence risk | Should be re-evaluated according to goals in patients planning pregnancy |
Postoperative Process and Risk of Recurrence
One of the most important issues after endometrioma treatment is the risk of recurrence. Cleveland Clinic states that endometrioma may reappear after treatment and that recurrence may be seen in about one in four people (1). The ESHRE guideline also states that long-term management is important, especially after surgery, and that long-term hormonal treatment may be considered in patients who do not wish to become pregnant in order to reduce endometrioma and symptom recurrence (2). Therefore, treatment is not a process that ends with surgery; it is a long-term management plan that requires follow-up.
The Relationship Between Endometrioma and Pregnancy
The presence of endometriosis may affect pregnancy; however, this does not mean that every patient will be unable to have children. According to the ESHRE patient guide, a significant proportion of women with endometriosis can conceive spontaneously. The same guide emphasizes that trying to become pregnant “so that pregnancy treats endometriosis” is not the right approach (2). In other words, pregnancy is not a substitute for medical treatment.
During pregnancy, existing endometriomas may sometimes change in appearance. ESHRE recommends referral to a center with appropriate expertise if an endometrioma with an atypical appearance is detected on ultrasound during pregnancy (2). Therefore, patients considering pregnancy need conscious follow-up, not panic.
When Is Urgent Evaluation Necessary?
Endometrioma is usually managed in a planned manner; however, urgent evaluation is required in some situations. Cleveland Clinic states that in the case of cyst rupture, fever, sudden and severe abdominal pain, vomiting, marked weakness, or feeling faint are reasons for emergency admission (1). In addition:
- Suspicion of rapid growth or unusual appearance on imaging,
- Increasing pain despite treatment,
- Symptoms of pressure on the bowel or urinary system,
- Newly developing pelvic pain during pregnancy.
In these situations, reassessment should be performed without delay.
Frequently Asked Questions
Endometrioma is generally not a structure that completely disappears on its own. In small and asymptomatic cases, it may remain stable for a while; therefore, regular follow-up may be sufficient in some patients. However, if there is pain, growth, or other risks, active treatment is evaluated.
No. Small, asymptomatic, and clinically low-risk endometriomas may only be monitored in some patients. Surgery is mostly considered in cases such as pain, growth, infertility planning, or risk of complications.
Medication treatment mostly helps with pain and symptom control. Hormonal treatment may suppress disease activity, but it may not mean a permanent and definitive solution. Complaints may return when the medication is stopped.
Especially in surgeries where the cyst wall is removed, the risk of damage to ovarian tissue is taken into account. Therefore, ovarian reserve and future pregnancy plans must be evaluated when deciding on surgery.
This is rare. Cleveland Clinic states that endometriomas can become cancerous, but this is uncommon (1). Still, if imaging findings are unusual or there is clinical suspicion, detailed evaluation is required.
In case of rupture, sudden and severe abdominal pain, fever, vomiting, weakness, and a feeling of fainting may develop. In such a situation, urgent evaluation is required without delay.
References
- Cleveland Clinic. Endometrioma (Chocolate Cyst): Symptoms & Treatment. (https://my.clevelandclinic.org/health/diseases/23409-endometrioma)
- ESHRE (European Society of Human Reproduction and Embryology). Endometriosis — Patient Guide. (https://www.eshre.eu/Guidelines-and-Legal/Guidelines/Endometriosis-guideline/Patient-guide)
- Mayo Clinic. Endometriosis — Diagnosis and treatment. (https://www.mayoclinic.org/diseases-conditions/endometriosis/diagnosis-treatment/drc-20354661)
- NICE (National Institute for Health and Care Excellence). Endometriosis: diagnosis and management. (https://www.nice.org.uk/guidance/ng73)