THE CASE:

A 28-year old, newly-married, nulligravid, consulted for a history of severe dysmenorrhea and
dyspareunia. She does not have any medical problems. Her mother previously underwent a THBSO at her
perimenopausal age for a benign disease allegedly for the same symptoms. Internal examination showed
normal external genitalia, smooth vagina, cervix is firm and smooth but deviated anteriorly, uterus is small
and retroverted, there is a tensely cystic 8x6 cm slightly tender left adnexal mass adherent to the posterior
aspect of the uterus, there are tender nodulations at the cul-de-sac.

1. WHAT IS YOUR MOST PROBABLE DIAGNOSIS?

Endometriosis of the ovary, a.k.a endometrioma, is usually associated with endometriosis in
other areas of the pelvic cavity. It usually affects 17-44% of women with endometriosis. Five percent of
this women have enlargement of the ovaries that is detectable by pelvic examination. Several studies
have documented a familial predisposition to endometriosis with grouping of cases of endometriosis in
mothers and their daughters. Women who have a family history of endometriosis are likely to develop
the disease earlier in life and to have more advanced disease than women whose first-degree relatives
are free of the disease. Ovarian endometriosis is similar to endometriosis elsewhere.
The condition is also known as chocolate cyst because it contains thick, old blood that appear
as brown fluid. In relation to the case, according to Katz, the size of endometriomas can reach up to 5-10
centimeters and can be characterized as large, multiloculated, hemorrhagic cysts and can be unilateral or
bilateral in location, though approximately 28% of endometrioma patients have bilateral endometriomas.
The common symptoms of endometriomas are pelvic pain and dyspareunia. In a study by Fauconnier et
al., they found that ovarian endometriomas did not contribute to chronic pelvic pain, but were highly
associated with deep infiltrating endometriosis, presented in our case by the tender nodulation at the culde-sac, which is known to cause chronic pelvic pain. Ovarian endometriomas can be further complicated
by the formation of adhesions that can fixate the pelvic organs. Fixation of the pelvic organs may distort
the anatomical locations, as seen in our case where the uterus was small and retroverted, and the cervix
deviated anteriorly. It was also noted that the adnexal mass was adherent to the posterior aspect of the
uterus.

2. WHAT ARE YOUR DIFFERENTIAL DIAGNOSIS?

Follicular cyst
A follicular cyst is a benign lesion that usually presents as a cystic structure in the adnexa. It is the
most frequent cystic structure in the ovaries and may grow from 2.5 to 15 cm in size. These cysts are
translucent, thin-walled and are filled with a watery, clear to straw colored fluid. This can usually be found
in young, regularly menstruating women and is associated with high levels of gonadotrophins. However
these cysts are usually asymptomatic and may only present with occasional bleeding.

RULE IN
RULE OUT
Presence of a left cystic adnexal mass in
(-) Abnormal Uterine Bleeding
the posterior aspect of the uterus
Patient has severe dysmenorrhea and
8x6 cm in size
dyspareunia
Age of Patient: 28 (Reproductive Age)
Tender Nodulations at Cul-de-Sac
DECISION: RULED OUT

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Corpus Luteum Cyst

A corpus luteum cyst is the second most common benign cyst found in the ovaries. These cysts
are thin walled, unilocular, and have mixed echoes. These cysts can grow from 3-10 cm. Patients may
present with a dull, unilateral abdominal pain, the presence of adnexal mass and Halbans Triad which
consists of tenderness in the mass, delayed normal period and unilateral pelvic pain.

RULE IN
RULE OUT
Presence of a left cystic adnexal mass in
(-) Delay in normal period
the posterior aspect of the uterus
(-) Dull, Unilateral, Lower Abdominal Pain
8x6 cm in size
Patient has dysmenorrhea and
Mass is slightly tender
dyspareunia
Age of Patient: 28 (Reproductive Age)
Tender nodulation at cul-de-sac
DECISION: RULED OUT

Endometrioid Tumor
Endometrioid tumor is a form of ovarian neoplasm. It is histologically classified under the
epithelial tumors which account for at least 65% of ovarian neoplasms. It consists of cells resembling those
of the endometrium and is usually seen in patients 40-50 years old. This neoplasm is seen in conjunction
with other conditions such as endometrioisis and ovarian endometrioma.

RULE IN
RULE OUT
Severe dysmenorrhea
Age of the patient: 28 years old
Severe dyspareunia
Prominent GI symptoms following after
pelvic pain
Presence of a left cystic adnexal mass in
the posterior aspect of the uterus
8x6 cm in size
Mass is slightly tender
Tender nodulations at cul-de-sac.
Family History of a similar benign
condition detected at perimenopause
and was managed with TAHBSO
DECISION: RULED OUT

Endometrioma

RULE IN
Severe dysmenorrhea
Severe dyspareunia
Presence of a left cystic adnexal mass in
the posterior aspect of the uterus
8x6 cm in size
Mass is slightly tender
Tender nodulations at cul-de-sac
suggestive of a possible endometriosis
DECISION: CANNOT BE RULED OUT

RULE OUT

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3. WHAT ARE THE OTHER SIGNS AND SYMPTOMS OF WOMEN OF THIS CONDITION?
The symptoms of an endometrioma are mostly the same as with a regular ovarian cyst, just more
exaggerated. It may cause symptoms by several mechanisms in some cases but not others. Cysts of any
size may cause ipsilateral pain or no pain at all due to stretching of the ovarian cortex. If the ovary is
encased in adhesions that are stretched by growth of a cyst, then pain may occur. If an ovarian
endometrioma cyst leaks, the chocolate-colored fluid is a potential irritant to the pelvis, in which case,
patients may have an acute episode of severe pain that declines over several days, or even to the
diaphragm, in which case, chest or shoulder pain may occur. Because women with ovarian endometriosis
usually have other disease present, it is difficult to determine the precise contribution of the ovarian
disease to the constellation of symptoms possible with endometriosis.
These are the other/detailed characterization of the common symptoms of endometrioma:
1. Cramping in the abdomen and pelvis
2. Painful periods that get worse over time
3. Pain in the pelvis when urinating or having a bowel movement
4. Pain in the pelvis with exercise, stretching, or bending over
5. If the ovary twists, losing its blood supply, you may feel very intense pain
6. Severe pain with rupture of the cyst
7. Fever and vomiting with rupture
8. Spotting or bleeding between periods
9. Discharge that is dark in color

4. WHAT ARE THE DIFFERENT PATHOPHYSIOLOGIC MECHANISMS FOR YOUR DIAGNOSIS?

Sampson discovered endometrial cyst of the ovaries by observing that hemorrhagic cysts of the
ovary with some endometrial-like lining showed evidence of typical endometrial shedding when patients
undergo surgery during menstruation. He also suggested that chronic spillage may be the cause of
peritoneal endometriosis. In 1927, Sampson proposed that menstrual regurgitation may be the cause of
endometriosis. He postulated that endometrial tissues that develops on the ovarian surface causes
adhesions. These adhesions cause the fusion of the ovary to the uterus and thus an endometrial cavity is
developed. This theory of invagination was further confirmed by serial sectioning of the ovaries with the
endometrioma in situ and by endoscopic in situ inspection. Sampsons invagination theory is consistent
with the specific macroscopic, ovarioscopic, and microscopic features of endometrioma.
There are other theories and researchers that tried to postulate the specific pathology of the
development of the condition and some of them are: (1) invagination of ovarian cortex secondary to
bleeding of superficial implant; (2) invagination of ovarian cortex secondary to metaplasia of coelmic
epithelium in cortical inclusion cysts; and (3) endometriotic transformation of functional cyst. For the first
theory, it was suggested that endometrial implants located on the surface of the ovary causes
endometrioma. This theory was described by Hughesdon in 1957. In this theory, menstrual shedding and
endometrial implant bleeding are trapped and they cause a gradual invagination of the ovarian cortex
that result to the formation of a pseudocyst. This theory was further strengthened by Bronsens et al when
they reported to note menstrual shedding and blood accumulation at the site of the implants. The second
theory regarding the pathology of endometrioma suggests that it is secondary to metaplasia of coelmic
epithelium in cortical inclusion cyst. This theory was related to the recurrence of endometrioma after
excision. It postulates that the recurrence is due to the invagination of the endometriotic tissue into the
ovary and recommends vaporization of the cyst wall instead of excision to prevent recurrence. The third
theory was described by Nezhat el al in 1992 and it states that endometrioma is formed by endometriotic
transformation of functional cyst.

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5. WHAT DIAGNOSTIC TESTS WILL YOU REQUEST FOR?

The presence of symptoms of severe dysmenorrhea and dyspareunia and physical exam findings
of a tender left adnexal cystic mass adherent to the posterior aspect of the uterus and tender nodulations
at the cul-de-sac gives an impression of an endometrioma. This presentation warrants a more thorough
diagnostic plan to achieve the correct diagnosis.
Laboratory Tests
To exclude other causes of the patients pelvic pain, laboratory investigations are requested.
Included in the battery of tests to perform are a complete blood count (CBC), urinalysis and urine cultures,
vaginal cultures, and cervical swabs to exclude infections or sexually transmitted infections that may cause
pelvic inflammatory disease (Schorge et al., 2008).
Serum CA-125
Elevated levels of CA125 have been shown to positively correlate with the severity of
endometriosis. The assay, however, has poor sensitivity in detecting mild endometriosis. A meta-analysis
of studies assessing CA125 as a diagnostic marker for endometriosis revealed a sensitivity of 28% and a
specificity of 90%. This marker is said to be a better test in diagnosing stage III and IV endometriosis. The
role of this test in clinical practice, however, is still uncertain. It may be useful in the presence of an ovarian
cyst suggestive of an endometrioma detected sonographically (Schorge et al., 2008).
Ultrasound
To assess the mass, both transabdominal and the more sensitive transvaginal (TVS) sonographic
approaches can be used in the diagnosis of endometriosis. TVS is the mainstay in evaluating symptoms
associated with endometriosis and is accurate in the detection of endometriomas. Endometriomas can
be diagnosed via TVS with adequate sensitivity in most settings if they are at least 20 mm in diameter. The
sensitivity and specificity of TVS in diagnosing endometriomas range from 64 to 90% and 22 to 100%,
respectively. The ultrasound characteristics of endometriomas include cystic structures with low-level
internal echoes, and occasional thick septations, thickened walls, and echogenic wall foci (Lentz et al.,
2012; Schorge et al., 2008). In some studies, the appearance of a thick-walled cyst with a relatively
homogenous echo pattern that is somewhat echolucent is said to confer a greater than 95% positive
predictive value (Lentz et al., 2012). Color Doppler TVS often demonstrates pericystic flow but not
intracystic flow (Schorge et al., 2008).
Magnetic Resonance Imaging (MRI)
Another imaging modality that can be used is Magnetic Resonance Imaging (MRI). MRI has been
increasingly used as a noninvasive method for diagnosing endometriosis. Small nodules present as
hyperintense lesions on T1-weighted sequences, and plaque lesions have a similar appearance, having a
variable signal on T2-weighted sequences. An endometrioma presents as a hyperintense mass on T1weighted sequences, with a tendency towards hypointensity in T2-weighted sequences. Surrounding the
endometrioma is usually a hypointense ring, which is enhanced after contrast administration (Schorge et
al, 2008).
Diagnostic Laparoscopy
The primary method used for diagnosing endometriosis is diagnostic laparoscopy. Findings via this
method are variable and may include discrete endometriotic lesions, endometrioma, and adhesion
formation. Endometriomas are seen as cystic endometrial lesions contained within the ovary. They
typically have the appearance of smooth-walled, brown cysts filled with thick, chocolate-appearing liquid.
These masses may be unilocular, but are often multilocular when reaching >3cm in diameter.
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Laparoscopic visualization of ovarian endometriomas has a sensitivity and specificity of 97% and 95%,
respectively. Because of this high sensitivity and specificity, ovarian biopsy is rarely required for diagnosis
(Schorge et al., 2008).
Pathologic Analysis
Histologic evaluation is not required for the diagnosis of endometriosis according to current
guidelines, however, laparoscopic findings in the absence of histologic confirmation often results in
overdiagnosis. Histologic diagnosis requires the presence of both endometrial glands and stroma found
outside the uterine cavity. Hemosiderin deposition and fibromuscular metaplasia are frequently observed
(Schorge et al., 2008). Pressure atrophy may lead to the loss of architecture of the endometrial glands
(Lentz et al., 2012).

6. MANAGEMENT OF PATIENTS WITH THIS CONDITION.

The management for endometriosis in general aims to provide pain relief and promote fertility.
In the long run, its goal is to halt the progression or prevent recurrence of the disease. The treatment may
either be medical, surgical, or both.
In patients presenting with pelvic pain, the treatment plan should take into account the patients
age, future reproductive plans, location and extent of the disease, and severity of the symptoms. As
previously discussed, patients with endometriosis-associated pain often experience dysmenorrhea,
dyspareunia, dysuria, dyschezia, and non-menstrual pelvic pain.
As an empiric treatment for patients presenting with pelvic pain and high suspicion of
endometriosis, patients may use NSAIDs and other analgesics and hormonal medications even without
prior definitive laparoscopic diagnosis. If other gynecologic conditions such as pelvic inflammatory
diseases or neoplasia have been ruled out, gonadotropic-releasing hormone agonists may be given for
three months. Other hormonal medications include hormonal contraceptives, progestagens, antiprogestagens, and aromatase inhibitors (Dunselman, et al., 2014).
Medical treatment with hormonal therapy works by induction of amenorrhea, inhibiting growth
and promotion regression of the disease. One of the approved therapies is Danazol, which works by
binding to androgen and progesterone receptors, and sex hormone-binding globulin. The end-effect is
inhibition of several steroidogenic enzymes in the ovary and adrenals, ultimately decreasing circulating
steroid levels. Also, it promotes atrophy of the uterus and the endometrial implants, producing an
endometrial specimen that is comparable to a postmenopausal woman. Danazol may be taken as an
800mg tablet four times a day for six to nine months. In patients who are sexually active, they should be
advised to use barrier methods to prevent conception (as Danazol may cause pseudohermaphroditism).
It may be initiated as long as it is proven that the patient is not pregnant, and starting it earlier in the cycle
may cause less breakthrough bleeding during the first four to six weeks (Katz, et al., 2012).
The second approved drug is GnRH agonists, which produces a reduction in estrone, E2,
testosterone, and adrostenedione, creating medical oophorectomy. In comparison to Danazol, it does not
take effect on SHBG, thus it does not have androgenic side effects. However, its side effects mimic those
experienced in menopause, such as hot flushes, vaginal dryness, and insomnia. It also produces reversible
decrease in bone mineral density of the lumbar spine. In starting a GnRH agonist therapy, the clinician
may consider a hormonal add-back therapy to counter bone loss and hypoestrogenic symptoms during
the treatment. Clinical response depends on the timing of initiation. If it is started on the follicular phase,
response is expected by the third or fourth week of therapy and amenorrhea is induced in six to eight
weeks. On the other hand, amenorrhea is expected in four to five weeks if the therapy is started during
the luteal phase or if artificially manipulated by concurrent oral progestogen administration (Katz, et al.,
2012).
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Other medical treatments include high-dose combination oral contraceptives and progestins.
Similarly, they produce amenorrhea. The latter is more indicated in older women who has no desire for
childbearing, those who cannot tolerate the former, or those with contraindications to estrogen therapy.
Surgical therapy in patients with ovarian endometriomas depend on ovarian reserve prior to
treatment, cyst laterality, location and hindering effects, patient age, and prior treatment. It is significant
to note that though medical treatment is effective, it may be counterproductive in women who are trying
to conceive.
One of the surgical options include laparoscopic cystectomy, which is done by stripping the cyst
wall. It is associated with decreased recurrence rates, increased chance of spontaneous pregnancy, and
significant reduction in pelvic pain. However, it is associated with damage to, removal of, or postoperative inflammation of healthy ovarian cortex and follicles, thereby reducing ovarian reserve.
Aspiration is another option done through identification of cyst by transvaginal ultrasound, and needle
aspiration to remove the fluid. It is related with recurrence, infections, and adhesions. Overall, aspiration
alone is regarded as ineffective in the treatment of endometriomas, however, it is a less invasive
alternative for recurrent cases. Laparoscopic endometrial ablation is an invasive procedure using a carbon
dioxide laser, a tissue-sparing energy source with more controlled penetration than electrical energy
sources, to drain the cyst and destroy the cyst wall. Patients who underwent ablation has the same
recurrence rates and spontaneous pregnancy chances as those who underwent laparoscopic cystectomy.
Apart from the CO2 laser, other equipment such as the potassium-titanyl-phosphate (KTP) and plasma
laser may be used (Carnaha, et al., 2013).
The management of ovarian endometrioma may be a combination of several means, medical or
surgical, in achieving the aforementioned goals.

7. WHAT WOULD BE YOUR MANAGEMENT IN THIS PARTICULAR CASE?

It was found that endometriomas larger than 3 cm does no respond well medical treatment
(Alborzi et al., 2006). Surgery is considered to be the first line of treatment for pain in women with
endometriotic cyst. Because of the patient's presenting signs and symptoms including dysmenorrhea and
dyspareunia, the most effective treatment modality is cystectomy to prevent recurrence. Another
advantage of cystectomy is the ability to perform histologic examination to detect any neoplastic
processes.
Laparoscopic surgery is the first choice among women with endometriotic cysts. There are several
benefits of performing laparoscopic approach than laparotomy including decreased length of
hospitalization, lower use of analgesia post-operatively, and faster recovery time. Randomized control
trials exhibited that laparoscopic excision of cyst wall of an endometriotic cysts are superior to ablation in
terms of reduced recurrence, relief of pain and pregnancy rates. Considering that the patient is nulligravid
and on reproductive age group, studied have shown that the damage secondary to removal or normal
ovarian tissue during excisional procedure is usually minimal. Ablation therapy can induce thermal injury
to underlying ovarian cortex that can lead to functional loss in ovarian reserve as well as an increased cyst
recurrence rate. Another study even mentioned that there is increased pregnancy rate post-surgically via
excision. In this type of procedure, the inner lining of the cyst is dissected from the ovary by 2 atraumatic
grasping forceps that are pulled in opposite directions (Alborzi et al., 2006)

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