Symptomatic ovarian endometrioma

Specialty: Gynecology and breast.

• Chocolate cyst
• endometriotic ovarian cyst
• painful ovarian mass due to endometriosis

Why it occurs

• Presence of ectopic endometrial tissue within the ovary that suffers repeated cyclical hemorrhages during each menstruation, accumulating old degraded blood with a thick and chocolatey appearance, surrounded by a reactive fibrotic capsule

Initial workup

Transvaginal gynecological ultrasound (shows an adnexal cystic image with a typical pattern of low-level homogeneous internal echogenicity, "ground glass", unilateral or bilateral, without papillary projections or internal Doppler flow). Determination of tumor markers Ca-125 (frequently moderately elevated <100-150 IU/mL, which does not necessarily indicate malignancy). Magnetic resonance imaging of the pelvis to assess associated foci of deep endometriosis.

Standard management

• Dienogest 2 mg orally daily uninterrupted — gestin of choice that reduces the size of the endometrioma and controls pelvic pain
• Combined oral contraceptives in a continuous regimen
• GnRH analogues (Triptorelin 3.75 mg IM monthly) associated with add-back therapy in cases of refractory pain. Surgical treatment (laparoscopic ovarian cystectomy by peeling the endometrioma capsule) is reserved for endometriomas larger than 4-5 cm, pain refractory to medical treatment, suspicion of malignancy or in the context of an active infertility study (note: systematic and unnecessary surgical removal of small endometriomas can severely compromise the patient's ovarian reserve).