17yr old girl present with us which shows a 3cm left side endometrioma. She is symptomatic
since 12yrs but reassured repeatedly that all normal.
Discuss factors influencing the management and treatment options of this patient giving
reasons
Symptomatic endometriosis can be treated both medically and surgically and following will
influence her management
- Patients age and reproductive wishes – this patient is young and in early reproductive age
and probably she has no fertility wishes in the next few years, it is better to delay first
surgery unless it is really necessary coz endometriosis recur at a minimum of 6- 12 months
following surgery , thus she will require multiple surgeries in future with its negative
consequences on future reproduction and with added surgical morbidity - Symptomatology – type of pain syndrome, whether she has dysmenorrhea, premenstrual
pain, postmenstrual pain , chronic pelvic pain, dyschezia, bladder pain, dyspareunia if
sexually active, her QOL. Although symptoms may not be correlated with endometriosis
severity, symptoms like dyschezia will indicate whether bowel walls are involved - Whether she has any complications due to deep endometriosis – eg: hydroureter or
hydronephrosis, which will necessitate intervention to relieve distal ureteric obstruction. - Features of ovarian cyst– if any atypical features present, papillary projection will make
surgery, the first option to histologically confirm endometrioma and exclude rare
occurrence of malignancy -clear cell or endometriod cancer - Size of endometrioma and rate of progression of it– if it becoming rapidly enlarging may
need early surgical intervention. Although torsion is less likely, bleeding into cyst and cyst
rupture can occur causing acute abdominal pain , which can be managed conservatively
and failing that will require surgery - Medical management by hormonal treatment – as one type of drug is not more effective
over the other, choice mainly depend on the side effect profile, contraindication for
hormonal treatment, availability and cost - if surgery required , need to consider the availability of laparoscopic surgeon, skills,
availability of laparoscopic equipment, risk of complication due to previous surgery or
nature of lesions, risk is more if the surgery become complex due to severe endometriosis. - during surgery , to treat endometrioma she will require cystectomy as it reduce recurrence
compared to drainage and ablation of cyst wall. But during cystectomy, adjacent normal
ovarian tissues may also be removed and it may affect her ovarian reserve, further if
bleeding cannot be controlled by other conservative measures, she will ultimately require
oophorectomy. - Patient wishes preference also should be considered
treatment start with counseling of patient, explanation of the disease, its prognosis (on fertility) and
options available for her to relive her symptoms and their limitations
as she is young and have small endometrioma which causing pain symptoms, she will be benefited
by treating medically initially, as it avoids surgical complications and its future implications .
endometriosis is estrogen dependent, by giving following drugs to suppress menstruation, it induce
atrophy and decidualization of endometriotic tissue and thus reduce inflammation and its
consequences in the surrounding tissue (adhesions). But it does not reduce the size of
endometrioma or reverse adhesions . medical treatment is effective for the duration of its use. And
symptoms recure once they are discontinued
The first line drugs available are COCP (continuous preferred over cyclical), oral MPA,
norethisterone. These are widely available and choice will be depend on the side effect profile.
2 nd line drugs are GnRH analogues / LNG ius/GnRH antagonist- due to the cost and side effect profile it will be considered, if first line drug fails
If the patient doesn’t respond to above medical treatment , or size of the endometrioma increase gradually or any concerning features appear in the follow up scan , then she will need surgery
Laparoscopic surgery is preferred over open surgery due to its inherent advantages: less pain, fast recovery and cosmetically acceptable and due to enhanced visualization
During surgery, we should try to excise all the possible endometriotic lesions, superficial vesicle, deep nodules and ovarian cyst. adhesions should be released and ovaries and tubes should be mobilize , there by restoring normal anatomy as much as possible. But radicality of surgery increase the complication, thus surgery should be done by a laparoscopic expert with informed consent from patient. - Excision is preferred over ablation as it reduce the recurrence of symptoms and cyst
Following surgery she will be restarted on hormonal suppression to delay the recurrence of lesions
and symptoms. This should be continued as long as she wishes to delay the pregnancy
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