Surgical Techniques

Endometriomas: Classification and surgical management

Understanding the etiology of endometriomas and implementing a more nuanced classification system can aid in the successful management of this common condition

OBG Manag. 2017 July;29(7):38-43

Rebecca C. Falik, MD, MST

Anjie Li, MD

Frances Farrimond, MD

Gity Meshkat Razavi, MD

Ceana Nezhat, MD

Farr Nezhat, MD

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IN THIS ARTICLE

Disease classification
Surgical management

References

Nezhat C, Buescher E, Paka C, et al. Video-assisted laparoscopic treatment of endometriosis. In: Nezhat C, Nezhat F, Nezhat C, eds. Nezhat’s Video-Assisted and Robotic-Assisted Laparoscopy and Hysteroscopy. 4th ed. New York, NY: Cambridge University Press; 2013:265–302.
Burney RO, Giudice LC. Pathogenesis and pathophysiology of endometriosis. Fertil Steril. 2012;98(3):511–519.
Keyhan S, Hughes C, Price T, Muasher S. An update on surgical versus expectant management of ovarian endometriomas in infertile women. Biomed Res Int. 2015;2015:204792.
Nezhat F, Nezhat C, Allan CJ, Metzger DA, Sears DL. Clinical and histologic classification of endometriomas. Implications for a mechanism of pathogenesis. J Reprod Med. 1992;37(9):771–776.
Burney RO, Giudice LC. The pathogenesis of endometriosis. In: Nezhat C, Nezhat F, Nezhat C, eds. Nezhat’s Video-Assisted and Robotic-Assisted Laparoscopy and Hysteroscopy. 4th ed. New York, NY: Cambridge University Press; 2013:252–258.
Czernobilsky B, Morris WJ. A histologic study of ovarian endometriosis with emphasis on hyperplastic and atypical changes. Obstet Gynecol. 1979;53(3):318–323.
Nezhat F, Nezhat C, Nezhat C, Admon D. A fresh look at ovarian endometriomas. Contemp Ob Gyn. 1994;39(11):81–94.
Donnez J, Lousse JC, Jadoul P, Donnez O, Squifflet J. Laparoscopic management of endometriomas using a combined technique of excisional (cystectomy) and ablative surgery. Fertil Steril. 2010;94(1):28–32.
Nezhat C, Nezhat F, Nezhat C, Seidman DS. Classification of endometriosis. Improving the classification of endometriotic ovarian cysts. Hum Reprod. 1994;9(12):2212–2213.
Nezhat FR, Pejovic T, Reis FM, Guo SW. The link between endometriosis and ovarian cancer: clinical implications. Int J Gynecol Cancer. 2014;24(4):623–628.
Nezhat F, Apostol R, Mahmoud M, el Daouk M. Malignant transformation of endometriosis and its clinical significance. Fertil Steril. 2014;102(2):342–344.
Nezhat FR, Apostal R, Nezhat C, Pejovic T. New insights in the pathophysiology of ovarian cancer and implications for screening and prevention. Am J Obstet Gynecol. 2015;213(3):262–267.
Hart RJ, Hickey M, Maouris P, Buckett W. Excisional surgery versus ablative surgery for ovarian endometriomata. Cochrane Database Syst Rev. 2008;(2):CD004992.
Yates J. Endometriosis and infertility: expert answers to 6 questions to help pinpoint the best route to pregnancy. OBG Manag. 2015;27(6):30–35.
Littman E, Giudice L, Lathi R, Berker B, Milki A, Nezhat C. Role of laparoscopic treatment of endometriosis in patients with failed in vitro fertilization cycles. Fertil Steril. 2005;84(6):1574–1578.
Exacoustos C, Zupi E, Amadio A, et al. Laparoscopic removal of endometriomas: sonographic evaluation of residual functioning ovarian tissue. Am J Obstet Gynecol. 2004;191(1):68–72.
Gonçalves FC, Andres MP, Passman LJ, Gonçalves MO, Podgaec S. A systematic review of ultrasonography-guided transvaginal aspiration of recurrent ovarian endometrioma. Int J Gynaecol Obstet. 2016;134(1):3–7.
Alborzi S, Momtahan M, Parsanezhad ME, Dehbashi S, Zolghadri J, Alborzi S. A prospective, randomized study comparing laparoscopic ovarian cystectomy versus fenestration and coagulation in patients with endometriomas. Fertil Steril. 2004;82(6):1633–1637.
Nezhat C, Crowgey SR, Garrison CP. Surgical treatment of endometriosis via laser laparoscopy. Fertil Steril. 1986;45(6):778–783.

^{Illustration: Kimberly Martens for OBG Management}

Endometriomas are called chocolate cysts due to the dark brown color of the fluid they contain. When possible, endometriomas should be aspirated and irrigated prior to cystectomy to avoid seeding the pelvis with spilled endometriotic contents.

Endometriosis, a disorder in which tissue resembling endometrium develops outside the uterine cavity, is a common cause of pelvic pain and infertility, affecting 6% to 10% of women.¹ Although endometriosis occurs in almost all organs and anatomic locations, it most often affects the pelvic organs.² An ovarian endometrioma, an ovarian cystic mass generally consisting of endometrial glands and stroma, is seen in 17% to 44% of women with endometriosis.³ Endometriomas are sometimes called chocolate cysts for the dark brown, thick, and tarry concentrated hemosiderin-laden fluid they contain, but histology shows that not all chocolate cysts have endometriosis within their walls.⁴ Understanding the etiology of endometriomas and implementing a more nuanced classification system can aid in the successful management of this common condition.

Etiology

Endometriomas are extensively described in the literature, and their origin is the subject of several theories. In 1921, Sampson noted luteal membrane and ovarian epithelial tissues within endometriomas and was the first to indicate that endometriomas may result from the invasion of functional cysts by endometrial tissue.^2,4,5 In 1979, Czernobilsky and Morris⁶ found endometrial and oviduct-like epithelium in ovarian endometriosis and concluded that ovarian tissue may be a common histologic precursor. Several other authors subsequently have reported finding different types of tissue within ovarian endometriomas, and not all of these chocolate cysts showed histologic evidence of endometriosis.^4,7,8

Read about the classification of endometriomas

References

Nezhat C, Buescher E, Paka C, et al. Video-assisted laparoscopic treatment of endometriosis. In: Nezhat C, Nezhat F, Nezhat C, eds. Nezhat’s Video-Assisted and Robotic-Assisted Laparoscopy and Hysteroscopy. 4th ed. New York, NY: Cambridge University Press; 2013:265–302.
Burney RO, Giudice LC. Pathogenesis and pathophysiology of endometriosis. Fertil Steril. 2012;98(3):511–519.
Keyhan S, Hughes C, Price T, Muasher S. An update on surgical versus expectant management of ovarian endometriomas in infertile women. Biomed Res Int. 2015;2015:204792.
Nezhat F, Nezhat C, Allan CJ, Metzger DA, Sears DL. Clinical and histologic classification of endometriomas. Implications for a mechanism of pathogenesis. J Reprod Med. 1992;37(9):771–776.
Burney RO, Giudice LC. The pathogenesis of endometriosis. In: Nezhat C, Nezhat F, Nezhat C, eds. Nezhat’s Video-Assisted and Robotic-Assisted Laparoscopy and Hysteroscopy. 4th ed. New York, NY: Cambridge University Press; 2013:252–258.
Czernobilsky B, Morris WJ. A histologic study of ovarian endometriosis with emphasis on hyperplastic and atypical changes. Obstet Gynecol. 1979;53(3):318–323.
Nezhat F, Nezhat C, Nezhat C, Admon D. A fresh look at ovarian endometriomas. Contemp Ob Gyn. 1994;39(11):81–94.
Donnez J, Lousse JC, Jadoul P, Donnez O, Squifflet J. Laparoscopic management of endometriomas using a combined technique of excisional (cystectomy) and ablative surgery. Fertil Steril. 2010;94(1):28–32.
Nezhat C, Nezhat F, Nezhat C, Seidman DS. Classification of endometriosis. Improving the classification of endometriotic ovarian cysts. Hum Reprod. 1994;9(12):2212–2213.
Nezhat FR, Pejovic T, Reis FM, Guo SW. The link between endometriosis and ovarian cancer: clinical implications. Int J Gynecol Cancer. 2014;24(4):623–628.
Nezhat F, Apostol R, Mahmoud M, el Daouk M. Malignant transformation of endometriosis and its clinical significance. Fertil Steril. 2014;102(2):342–344.
Nezhat FR, Apostal R, Nezhat C, Pejovic T. New insights in the pathophysiology of ovarian cancer and implications for screening and prevention. Am J Obstet Gynecol. 2015;213(3):262–267.
Hart RJ, Hickey M, Maouris P, Buckett W. Excisional surgery versus ablative surgery for ovarian endometriomata. Cochrane Database Syst Rev. 2008;(2):CD004992.
Yates J. Endometriosis and infertility: expert answers to 6 questions to help pinpoint the best route to pregnancy. OBG Manag. 2015;27(6):30–35.
Littman E, Giudice L, Lathi R, Berker B, Milki A, Nezhat C. Role of laparoscopic treatment of endometriosis in patients with failed in vitro fertilization cycles. Fertil Steril. 2005;84(6):1574–1578.
Exacoustos C, Zupi E, Amadio A, et al. Laparoscopic removal of endometriomas: sonographic evaluation of residual functioning ovarian tissue. Am J Obstet Gynecol. 2004;191(1):68–72.
Gonçalves FC, Andres MP, Passman LJ, Gonçalves MO, Podgaec S. A systematic review of ultrasonography-guided transvaginal aspiration of recurrent ovarian endometrioma. Int J Gynaecol Obstet. 2016;134(1):3–7.
Alborzi S, Momtahan M, Parsanezhad ME, Dehbashi S, Zolghadri J, Alborzi S. A prospective, randomized study comparing laparoscopic ovarian cystectomy versus fenestration and coagulation in patients with endometriomas. Fertil Steril. 2004;82(6):1633–1637.
Nezhat C, Crowgey SR, Garrison CP. Surgical treatment of endometriosis via laser laparoscopy. Fertil Steril. 1986;45(6):778–783.

Endometriomas: Classification and surgical management

Understanding the etiology of endometriomas and implementing a more nuanced classification system can aid in the successful management of this common condition

References

Related article:Endometriosis: Expert answers to 7 crucial questions on diagnosis

Etiology

Pages

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Endometriosis: Expert answers to 7 crucial questions on diagnosis