Diagnosis Of Endometrioma Research Articles

Surgical techniques for ovarian endometriosis

Key content: All patients with ovarian endometriosis should be offered an individualised, shared decision‐making approach informed by clinical history, symptoms and fertility status. Surgical management of ovarian endometriosis can be effective in treating endometriosis‐associated pelvic pain and infertility, but there is no current evidence that surgery for ovarian endometriosis increases the success of in vitro fertilisation (IVF) treatment. Ovarian reserve tests should be considered before any ovarian surgery and can help guide the patient towards the optimal treatment. The Endometriosis Fertility Index should be incorporated into pre‐operative consultations as a validated tool that estimates the likelihood of spontaneous conception following surgical intervention. Surgeons should be trained in different surgical techniques, types of diathermy and haemostatic agents that can minimise the risk of inadvertent injury to normal ovarian cortex. Learning objectives: To facilitate informed decision‐making regarding the treatment of ovarian endometriosis. To gain insight into the possible surgical techniques available to manage ovarian endometriosis and the evidence behind them. To understand the impact of each technique on endometriosis‐associated pain, fertility outcomes and recurrence rates. Ethical considerations: Should fertility preservation be offered to all women of reproductive age with fertility aspirations and a diagnosis of endometriomas? Should integrated care boards (ICBs) devise specific criteria to offer funding for fertility preservation as an option before surgery for ovarian endometriosis?

Perception and Comfort with Endometriosis Management Among OB/GYN Residents.

The diagnosis of endometriosis often takes several years, delaying appropriate care while patients suffer from pelvic pain, dysmenorrhea, and dyspareunia. Understanding whether residents in obstetrics and gynecology (OB/GYN) are being adequately exposed to and trained in the diagnosis and management of the disease is important for improving care. We conducted an online cross-sectional survey of OB/GYN residents to investigate their comfort level and familiarity with endometriosis diagnosis and management. Residency program directors and coordinators of 20 OB/GYN residency programs in California, USA were emailed to disseminate the 31-question, anonymous survey in January to February 2023. Responses were collected using Redcap and analysis was conducted using STATA. 67 residents answered at least one non-demographic question and were included. A resident response rate was not calculated because we were unable to determine how many programs distributed the survey. 84% of residents felt they could recognise symptoms of endometriosis but over 30% of senior residents were not comfortable with sonographic diagnosis of endometrioma. Approximately one third of residents felt comfortable managing hypoestrogenic symptoms, osteoporotic risks, and add-back progestin for certain hormonal therapies. Academic-hospital based residents had significantly more exposure to attendings prescribing long-acting reversible contraception, GnRH antagonists, and GnRH agonists but there were no significant differences in trainee prescribing practices or comfort. More respondents would feel comfortable medically managing endometriosis (52%) than surgically managing the disease (26%) if they were in practice today, with only 39% of PGY3-4 residents feeling comfortable surgically managing endometriosis. There is considerable room for improvement in the education of residents in the diagnosis and medical and surgical management of endometriosis.

Endometrioma Within the Anterior Abdominal Wall Causing Cyclic Abdominal Pain.

Lesions from endometriosis contain endometrial glands and stroma outside the uterine cavity. The lesions occur in the pelvis but are also found in the bowel, diaphragm, and pleural cavity. Endometriosis within the extraperitoneal abdominal wall is rare, though, and usually within c-section scars (incidence is .03%-.5%). The typical triad includes: mass in the abdominal wall, cyclical pain, and history of previous abdominal surgery. We present the case of a 28-year-old female with a past history of cesarean section and obesity (BMI = 31) who presented with approximately 3 years of abdominal pain which was "waxing and waning" in severity depending on her menstrual cycle. Multiple doctors and US imaging did not reveal a diagnosis. During consultation, she had a palpable 3cm mass several centimeters above and right of her abdominal incision. She underwent a CT showing an inflamed subcutaneous mass abutting her anterior rectus sheath. She underwent wide excision which confirmed the diagnosis of endometrioma. This case demonstrates the need for good history and physical exam skills, as well as proficiency in reviewing radiographic imaging. Due to habitus and pain, the physical exam was difficult. However, there was a firm mass upon deep palpation. Her initial imaging was "negative," but review of the images revealed only intraperitoneal views and further imaging revealed the mass. There must be high clinical suspicion for this disease because failure to remove all tissue (including the surrounding fibrosis and desmoplastic tissue) or biopsy can lead to spread of residual endometrial cells and recurrence.

Diagnosis of Endometriosis by Transvaginal Ultrasound: An Online Survey of Gynecologists Practising in Greece.

Accurate diagnosis and assessment of endometriosis by transvaginal ultrasound scan (TVS) can be challenging. We performed an online survey of specialist gynecologistswho perform TVS on a regular basisregarding their views as well as clinical experience on the use of TVS in the diagnosis of endometrioma and deep endometriosis (DE). We collected 64 responses. Sixty-one participants (95.31%) answered that they can confidently diagnose endometrioma by TVS "always" or "most of the time". With the exception of DE of the recto-vaginal septum/posterior vaginal vault, for all other DE locations, more than 50% of participants felt that they can "rarely" or "never" diagnose it by TVS in their own clinical practice. Forty-two participants (65.6%) stated that additional, specialized trainingis required for the diagnosis of endometrioma. When asked about a diagnosis of DE, 58 participants (90.6%)felt that the same is required. The only statistically significant association was between the number of TVSs performed per year and the clinician's ability to diagnose bowel DE in their practice. The answers to all other questions did not differ significantlybased on professional status, years of experience post-residency, or number of TVSs per year. Our results demonstrate the delayed adoption of novel diagnostic approaches in endometriosis and confirm the urgent need for specialized ultrasound training.

Comparison of immunohistochemical characteristics of endometriomas with non-endometriotic benign ovarian cysts.

The aim of the study was to investigate the existence of neuroendocrine cells and to compare the density of those in normal ovarian tissue, endometriotic and non-endometriotic benign ovarian cysts. Twenty patients with the diagnosis of endometrioma and 30 control subjects consisting of ovarian serous cystadenoma (n=10), ovarian mucinous cystadenoma (n=10) and normal ovarian tissue (n=10) were included. The tissues were prepared and assessed according to staining density by using the H-score method. Tissues with mucinous cystadenoma were significantly more stained with PAS and VanGieson, when compared to women with endometrioma. Macrophage deposition was higher in cyst samples with endometrioma and in normal ovarian tissue when compared to serous cystadenoma and mucinous cystadenoma. Normal ovarian tissue was significantly more stained with PGP9.5, NSE and SYN when compared to endometrioma and non-endometriotic benign ovarian cyst. PGP9.5 staining was higher in normal ovarian tissue when compared with endometriotic lesions (p<.001). Endometrioma samples were significantly more stained with p53 when compared to non-endometriotic cysts and normal ovarian tissue. c-Kit staining was mild and not statistically significant among all groups. During endometrioma transformation, expression intensity of neuroendocrine markers decreases compared to normal ovarian tissue and other benign ovarian cysts.

The Performance of the Uterine Artery Resistance Index following Stimulation of the Cervix in the Diagnosis of Endometriosis: A Prospective Study

Background: We speculated that stimulating the uterine cervix of patients may increase blood flow resistance of the uterine artery more significantly in women with endometriosis than those without. Accordingly, the resistance index (RI) of the uterine artery following stimulation of the cervix may offer a novel and promising non-invasive method for diagnosing endometriosis. In this prospective study, the aim was to determine the performance of the uterine artery resistance index (RI) following stimulation of the cervix in the diagnosis of endometriosis. Methods: This prospective cohort study included 270 patients with non-uterine diseases who were scheduled for laparoscopic surgery. Each patient underwent Doppler sonography for peak systolic velocity (PSV), end diastolic velocity (EDV), and RI before and after stimulation of the cervix, in addition to conventional ultrasound examination one day prior to laparoscopic surgery. The cervix was stimulated using a double convex array electronic vaginal probe for real-time tissue elastography. Results: Laparoscopic surgical evaluation revealed endometriosis in 91 (33.7%) patients. Following stimulation of the cervix, the RI of the uterine artery was significantly increased in the endometriosis group (p = 0.00), but no significant increase in the RI was observed in the control group (p = 0.45). The sensitivity and specificity of the post-stimulation RI for diagnosing endometriosis (using a cut off of 0.83) were 85.71% (95% confidence interval (CI): 76.45–91.88) and 88.83% (95% CI: 83.05–92.87), respectively. For peritoneal endometriosis (PEM), sensitivity and specificity were 86.96% (95% CI: 65.33–96.57) and 88.83% (95% CI: 83.05–92.87), respectively. The sensitivity and specificity of transvaginal ultrasonography (TVU) for diagnosing endometriosis were 63.74% (95% CI: 52.93–73.37) and 94.41% (95% CI: 89.68–97.14), respectively. The positive rate for TVU in diagnosing all endometrioses was 63.7%, and this was lower than that for the post-stimulation RI (84.6%, p = 0.001). Conclusions: Stimulation of the cervix leads to a significant decrease in uterine blood perfusion in women with endometriosis. TVU is a sensitive and specific method for the diagnosis of endometrioma, while the RI is a more sensitive parameter for diagnosing PEM than TVU. For the diagnosis of endometriosis, especially for PEM, the post-stimulation RI may prove to be a promising non-invasive diagnostic technique.

Laparoscopic treatment of a complex adnexal mass of the retroperitoneal space: A case report

Complex adnexal cystic masses in women of reproductive age should be carefully evaluated before the final diagnosis is set. Adnexal cystic masses are not necessary malignant. On the contrary, they usually refer to a benign and not cancerous pathology. A certain benign pathology behind adnexal masses is endometriosis. Endometriosis occurs in 10-15% of women of reproductive age and presents great diversity both in the way it manifests and in its location. We report a case of a multiparous woman of reproductive age that was referred to our clinic due to abdominal and back pain. The imaging examinations revealed a cystic mass of the left parametrium that was laparoscopically removed. The histopathology set the diagnosis of endometrioma. The aim of our work is to highlight the endometrioma of the retroperitoneal space as part of the differential diagnosis of the cystic masses of the parametrium.

Ruptured endometrioma in a nonpregnant patient: a case report

BackgroundEndometriomas are a type of ovarian cyst composed of degenerated blood products from hemorrhage of ectopic endometrial tissue. Endometriomas can rupture, causing hemoperitoneum, and present with signs and symptoms similar to other, more common abdominal emergencies. Therefore, they are not often diagnosed preoperatively. Ultrasound and cross-sectional imaging can assist in diagnosis of endometriomas. We present a case of ruptured endometrioma causing massive hemoperitoneum that was initially suspected to represent malignancy with carcinomatosis.Case presentationA 32-year-old Hispanic woman presented with sharp abdominal pain and 15-pound unintentional weight loss over 6 months. Laboratory work was significant for a negative pregnancy test and elevated cancer antigen-125. Computed tomography of the abdomen and pelvis demonstrated a 13-cm complex cystic mass in the left adnexa with moderate hyperdense ascites and omental nodularity. Ultrasound demonstrated a large left adnexal complex cystic structure with internal echoes, and chest computed tomography showed no signs of intrathoracic neoplastic or infectious processes. Her presentation was concerning for malignancy with carcinomatosis. Fluid from a paracentesis was sent for culture and cytology. Diagnostic laparoscopy revealed that the left ovary had been completely replaced by an endometrioma, which had a small ruptured area superiorly. Brown deposits of endometriosis were present on the cyst, omentum, and various peritoneal linings. Tissue samples of the endometrium, myometrium, cervix, ovaries, fallopian tubes, peritoneum, omentum, and paracolic spaces were taken and showed no hyperplastic, dysplastic, or malignant cells on pathology.ConclusionsRuptured endometrioma and ruptured hemorrhagic cyst should be included in the differential diagnosis when a premenopausal female presents with hemoperitoneum in combination with complex adnexal cystic masses in the absence of trauma. Cancer antigen-125 and cancer antigen 19-9 can be falsely elevated in the setting of ruptured endometrioma.

Impact of Surgical Management of Endometrioma on Ovarian Reserve

Objective: The aim of this study was to explore the outcome of surgical removal of endometriotic cyst on ovarian reserve.&#x0D; Materials and methods: This prospective observational study was carried out in Infertility Care and Research Centre, Dhaka, Bangladesh between January 2011 and December 2018. One hundred and fifty-five patients, who had an ultrasonographic diagnosis of endometrioma measuring ³3 cm and underwent surgical excision due to subfertility were the candidates for this study. The exclusion criteria were a) previous ovarian cystectomy, b) removal of one ovary, c) irregular menstrual cycle, d) polycystic ovarian syndrome e) endocrine disorder, f) low AMH (&lt;1ng/ml), g) history of taking medication for endometriosis that could affect ovarian function, e.g., GnRH analogues or oral contraceptives during the 6 months preceding scheduled surgery. To investigate the effect of surgery on ovarian reserve, their FSH, E2 and AMH were measured before and after surgery. Tests were done before surgery and repeated after 3 months and 6 months of surgery. A value of &lt; 0.05 was considered significant.&#x0D; Results: Mean age of the patients was 31.72 ±2.77 years. The baseline FSH, E2 and AMH were within normal limit. In 63.88% of the cases the cysts were unilateral and 83.22% of the cases the size of the cysts were within 10 cm. To assess the change of ovarian reserve FSH, E2 and AMH were measured in 3 and 6 months after surgery. There was marked declining of AMH level from baseline to both 3 months and 6 months after surgery p is &lt;0.0001. There was no significant change of FSH and AMH between 3 months and 6 months after surgery.&#x0D; Conclusion: Cystectomy in ovarian endometrioma significantly reduces ovarian reserve, which is menifested by reduced level of AMH.&#x0D; Bangladesh J Obstet Gynaecol, 2020; Vol. 35(2): 96-101

Correlation between endometriomas volume and Raman spectra. Attempting to use Raman spectroscopy in the diagnosis of endometrioma

The formation of the uterus lining, i.e. the endometrium, outside the uterus (ex. in the abdominal cavity,ovaries,or anywhere in the body) is called endometriosis. The presence of endometrial tissue present in the ovaries, thickens after menstruation, leading to menstrual-like bleeding and to the formation of chocolate cyst (Endometrioma) because of the accumulation of old, brown blood in the ovary. It is still unknown, what triggers the development ofendometrioma. However,it leads to excessive bleeding during menstrual periods or abnormal bleeding between periods and infertility. Endometriosis is often first diagnosed in those who seek medical attention for infertility. Therefore, new markers of endometrioma as well as new methods of its diagnosis are sought. In this study we used Raman spectra of serum collected from 50 healthy women and 50 women suffering from endometriosis. The obtained Raman data were used in multivariateanalysis to determine the Raman range, which can be used for endometriomadiagnostics. Partial Least Square (PLS), Principal Component Analysis (PCA) and Hierarchical Component Analysis (HCA) showed, that it is possible to distinguish between the serum collected from healthy and un-healthy women using the Raman range between 800 cm−1 and 1800 cm−1 and between 2956 cm−1 and 2840 cm−1, while the first range corresponds to the fingerprint region and the second one to lipids vibrations. Consequently, the Pearson correlation test showeda significantpositive correlation betweenvaluesoflipidintensity in Raman spectra and volume of endometriomas. Summarizing, Raman spectroscopy can be a helpful tool in endometrioma diagnosis and the lipid vibrations are candidates for being a spectroscopic marker of the disease being studied.

Comparison of diagnostic values of transvaginal sonography with laparoscopic and histological results in the evaluation of uterosacral ligaments' involvement in endometriosis patients.

Endometriosis is one of the most common gynecological disorders, which causes pain and reduces fertility. An accurate diagnostic technique would be helpful in the management of these patients preoperatively. The objective of this study was to do a comparative evaluation of uterosacral involvement in deep infiltrative endometriosis by transvaginal sonography (TVS) and laparoscopic biopsy. TVS and laparoscopy were done in all patients suspected to have endometriosis. TVS examination was carried out to identify endometriotic lesions, and in suspicious laparoscopic views, biopsy was done and laparoscopic findings were confirmed by pathologic report. Then, TVS and pathological findings in laparoscopy were compared and data analyzed by SPSS Version 23. In our study on 80 patients, the mean age was 34.47 ± 5.94 (mean ± SD) years. Comparison of ultrasound with laparoscopic examinations showed that ultrasound as the gold standard method, has sensitivity, specificity, and positive and negative predictive values of 93%, 65%, and 87%, and 78.9%, respectively, while in the diagnosis of increased uterosacral ligament thickness showed 82%, 100%, and 100% and 6.66%, respectively. While in the diagnosis of nodules in the uterosacral ligament, 100% for all four parameters in the diagnosis of endometrioma in the ovaries, and 71%, 96.4%, and 97.3% and 64.2%, respectively, in the diagnosis of rectal, bladder, and ureteral involvement. TVS can be used in the diagnosis of endometriosis by examining the increase in the thickness of the uterosacral ligament and the presence of hypoechoic nodules in it; also, this method demonstrates acceptable sensitivity and specificity in ovarian endometrioma.

P–749 Knowledge of women undergoing surgery for endometrioma regarding the impact of the disease and its treatment on ovarian reserve and fertility

Abstract Study question Do women undergoing surgery for endometrioma due to pain, a cyst and/or subfertility understand the impact of the disease and its treatment on ovarian reserve and fertility. Summary answer The majority of women treated in a fertility setting are well informed compared to those in a general medical setting. What is known already: Infertility affects 30% to 50% of women with endometriosis. Ovarian endometriomas are reported in 17–44% of infertile women with endometriosis and are typically associated with more severe disease. Endometriomas are associated with diminished ovarian reserve, due to the endometrioma per se or due to surgical interventions required to treat and excise the disease. ESHRE guidelines recommend that women should be informed pre-operatively of the potential reduction in ovarian reserve associated with surgery and that ovarian reserve tests should be performed when future fertility is a concern. Study design, size, duration In conjunction with our histopathology colleagues we identified a cohort of women with a histological diagnosis of one or more ovarian endometriomas who underwent surgery in our unit between 2010 and 2019. We developed a scoping questionnaire, targeted at women currently over the age of 40, who had previously undergone surgery for endometrioma under the age of 35. Patients were contacted by telephone and consent obtained to send an email with a survey link. Participants/materials, setting, methods We identified 47 women who had a histological diagnosis of endometrioma. Of these, 30 were contactable by telephone, of whom 29 consented to being sent information regarding the study and a link to the questionnaire. 21 women completed the survey. Respondents were divided into 2 groups for analysis. Group 1 cited ‘fertility’ or ‘both pain and fertility’ as an indication for their surgery while group 2 had ‘pain’ or ‘ovarian cysts’ but no fertility concerns. Main results and the role of chance: The majority (62%) of patients were diagnosed with endometriosis while aged 25–34. The indication for surgery was evenly divided between pain (32%), fertility (37%) and ovarian cysts (37%). 60% of women reported having endometriomas diagnosed preoperatively. Striking differences were noted between groups 1 and 2. Of the women who cited ‘fertility’ or ‘both pain and fertility’ (n = 9) as an indication for their surgery, 78% (n = 7) reported being aware of any possible negative impact of endometriosis on their fertility, with 78% also being aware of the possible negative impact of surgery for endometriosis on their fertility. This compared to only 36% (n = 4) and 27% (n = 3) respectively in Group 2. In group 1, 56% (n = 5) remembered having an AMH level checked pre operatively while 78% (n = 7) also had an ultrasound pre-operatively. In contrast, only 33% (n = 3) of Group 2 remember having an AMH level checked pre operatively though 64% (n = 7) had an ultrasound pre-operatively. Of those whose surgery was performed by a fertility specialist, 75% (n = 6) reported being aware of the impact of endometriosis and also the impact of surgery on ovarian reserve, compared to 44% (n = 4) of those who surgery was performed by a non-fertility specialist. Limitations, reasons for caution This is a retrospective study and the numbers are small. We were only able to identify women with an endometrioma via pathology records, so those with no excision of disease (eg those who had ablation of an endometrioma) were excluded from this analysis. Wider implications of the findings: This suggests the majority of patients treated in a fertility setting are counselled regarding the benefit of surgery but also the risk to ovarian reserve. This is not the case in other settings. It is time to disseminate guidelines such as those produced by ESHRE to our general gynaecology colleagues. Trial registration number Not applicable

Overexpressed MPS-1 contributes to endometrioma development through the NF-\u03baB signaling pathway

BackgroundEndometriosis is a benign gynecological disease that shares some characteristics with malignant tumors and affects approximately 10% of women of reproductive age. Endometrioma refers to endometriosis that appears in the ovary. Metallopanstimulin-1 (MPS-1) is a component of the 40S subunit of ribosomes that has extra-ribosomal functions that contribute to the development of diseases. This study aimed to explore the expression pattern and role of MPS-1 in endometrioma development.MethodsQuantitative real time polymerase chain reaction, western blotting, immunohistochemistry, and enzyme-linked immunosorbent assay were used to determine the expression of MPS-1 in patients with endometrioma. Following the successful knockdown of MPS-1 by siRNA, CCK-8 assays, flow cytometry, and transwell assays were performed to detect ectopic endometrial stromal cells (EcESCs) proliferation, the rate of apoptosis, and cell cycle, migration, and invasion, respectively. Western blotting was used to explore the effect of MPS-1 knockdown on protein levels in the NF-κB signaling pathway.ResultsThe expression of MPS-1 was significantly higher in endometrioma and the serum of endometrioma patients than in the patients without endometriosis. In addition, the downregulation of MPS-1 expression inhibited EcESCs proliferation, migration, and invasion. This downregulation led to the arrest of the EcESCs cycle in the G0/G1 phase and apoptosis and depressed the NF-κB signaling pathway.ConclusionMPS-1 can regulate EcESCs proliferation, motility, invasion, apoptosis, and cell cycle via the NF-κB signaling pathway in endometrioma. This may contribute to the formation or development of endometriotic foci. This study suggests the potential role of MPS-1 in the pathogenesis of endometriosis and enabled further research into the use of MPS-1 in the clinical diagnosis of endometrioma.

Ultrasonography in the Differentiation of Endometriomas from Hemorrhagic Ovarian Cysts: The Role of Texture Analysis.

The ultrasonographic (US) features of endometriomas and hemorrhagic ovarian cysts (HOCs) are often overlapping. With the emergence of new computer-aided diagnosis techniques, this is the first study to investigate whether texture analysis (TA) could improve the discrimination between the two lesions in comparison with classic US evaluation. Fifty-six ovarian cysts (endometriomas, 30; HOCs, 26) were retrospectively included. Four classic US features of endometriomas (low-level internal echoes, perceptible walls, no solid components, and less than five locules) and 275 texture parameters were assessed for every lesion, and the ability to identify endometriomas was evaluated through univariate, multivariate, and receiver operating characteristics analyses. The sensitivity (Se) and specificity (Sp) were calculated with 95% confidence intervals (CIs). The texture model, consisting of seven independent predictors (five variations of difference of variance, image contrast, and the 10th percentile; 100% Se and 100% Sp), was able to outperform the ultrasound model composed of three independent features (low-level internal echoes, perceptible walls, and less than five locules; 74.19% Se and 84.62% Sp) in the diagnosis of endometriomas. The TA showed statistically significant differences between the groups and high diagnostic value, but it remains unclear if the textures reflect the intrinsic histological characteristics of the two lesions.

Diagnostic value of susceptibility-weighted imaging for endometrioma: preliminary results from a retrospective analysis.

Endometrioma is a common manifestation of endometriosis that can be difficult to diagnose with conventional magnetic resonance imaging (MRI). Susceptibility-weighted imaging (SWI) may be more sensitive than conventional MRI in the detection of chronic, local hemorrhagic disease. To investigate whether signal voids in SWI sequences could be used in the preoperative diagnosis of endometrioma. This retrospective study included consecutive female patients with clinically suspected endometrioma. All patients underwent pelvic 3-T MRI (T1- and T2-weighted) and SWI within two weeks before laparoscopy. Two experienced radiologists blinded to the histopathologic/clinical diagnoses interpreted the images together, and any disagreements were resolved by consensus. The final analysis included 73 patients: 46 patients (mean age=37 years; age range=22-68 years) with 85 endometrioma lesions and 27 patients (mean age=34 years; age range=15-68 years) with 34 non-endometrioid cystic lesions (18 hemorrhagic corpus luteal cysts, three simple cysts, three mucinous cystadenomas, two mature teratomas, and one endometrioid cyst with corpus luteum rupture/hemorrhage). The presenting symptoms for patients with endometrioma were chronic pelvic pain (44.6%), dysmenorrhea (31.9%), infertility (12.8%), dyspareunia (6.4%), and menstrual irregularity (4.3%). MRI identified all 119 lesions observed laparoscopically. SWI visualized punctate or curvilinear signal voids along the cyst wall or within the lesion in 67 of 85 endometriomas (78.8%) and only 3 of 31 non-endometrioid cysts (8.8%). The use of SWI to look for signal voids in the cyst wall or within the lesion could facilitate the preoperative diagnosis of endometrioma.

Role of biomarkers CA-125, CA-15.3 and CA-19.9 in the distinction between endometriomas and ovarian neoplasms

Purpose To evaluate the utilisation of CA-125, CA-15.3 and CA-19.9 in differentiating between ovarian neoplasms and endometriomas, and the best cut-off value for these tumour markers in this differentiation. Materials and methods Preoperative serum values of CA-125, CA-15.3 and CA-19.9 were evaluated in 265 patients undergoing surgery for adnexal masses, being 32 non-neoplastic lesions, 134 benign neoplasms, 19 borderline tumours, 36 malignant neoplasms, and 44 endometriomas. ROC curves and Univariate and multivariate analyses were performed. Results Only CA-19.9 was useful in differentiating between endometriomas and ovarian neoplasms (benign and malignant tumours), being this marker found at higher levels in endometriomas. In multivariate analyses, CA-19.9 greater than 22.3 U/mL was considered an independent factor for the diagnosis of endometrioma, comparing endometrioma and ovarian cancer. Comparing endometrioma and all other groups, the clustering analysis using the combination CA-125 > 34.28 U/mL and CA-19.9 > 19.12 U/mL demonstrated that this association was considered an independent factor for the diagnosis of endometrioma. Conclusion CA-9.9 is useful in distinguishing between endometriomas and ovarian cancer, and its combination with CA-125 is useful in differentiating endometrioma from other ovarian lesions.

Hormonal treatments for preventing recurrence of endometriomas

: Endometriosis is a chronic condition determined by the presence of ectopic endometrial glands and stroma. The disease affects approximately 10% of women of reproductive age and 35-50% of women with chronic pelvic pain and/or infertility. Transvaginal ultrasonography is a very sensitive and specific instrument for the diagnosis of endometrioma. Surgical and/or medical therapies for endometriomas aim to control symptoms (in particular, chronic pelvic pain and dysmenorrhea) and prevent cyst growth; medical therapy may be employed to reduce recurrence rate after surgery. After surgical approach, the reported postoperative recurrence rate of endometriomas is high, ranging from 30% to 40%; therefore, several hormonal therapies, such as oral contraceptives (OC), progestins (PG), GnRH analogs (GnRHa), and antagonists, danazol, aromatase inhibitors, selective estrogen receptor modulators (SERMs) and selective progesterone receptor modulators (SPRMs), have been employed in order to prevent disease recurrence. The objective of this systematic review is to assess the impact of the adjuvant use of hormonal treatment on endometrioma recurrence. Two evaluators extracted from MEDLINE, EMBASE, and Cochrane Library and reviewed published studies on this topic, following pre-determined selection criteria. Finally, data were extracted from 16 selected prospective or retrospective studies, of which 8 were randomized controlled trial and 8 were cohort studies. Most of them reported a beneficial impact on endometrioma recurrence by the usage of OC, PG, and GnRH analogs (GnRHa); however, conflicting results exist in the current literature about this topic. The duration of adjuvant therapy seems to have a crucial role in this context, but it is still not clear which type of postoperative hormonal treatment represents the best choice.

Endometrioma surgery and possibilities of early disease control

Aim: The purpose of this study is to investigate the efficacy of surgical management in ovarian endometrioma for early disease control and long-term fertility preservation in adolescents and women of very young age. A history of cyclic pains in adolescents is highly associated with endometriosis. Sonography enables the diagnosis of small endometriomas 1-2 cm in diameter. Although it is obvious that the risk of damage to normal ovarian tissue is diminished when operating and removing a 2 cm endometrioma, it is not approved since there are currently no tools available to identify at-risk patients. Additionally, performing laparoscopic surgery with 5 mm instruments in patients with small endometriomas will likely cause more harm than benefit. Methods: A literature review was performed using key words for endometrioma surgery, in vitro fertilization (IVF), implantation rate, pregnancy rate and adolescents. The pros and cons of surgical removal prior to assisted reproductive therapy (ART), outcomes of endometrioma surgical treatment before IVF, and current recommendations for endometrioma removal were investigated. Results: The total patient population from articles supporting removal of endometrioma before assisted reproductive therapy and evidence against were 30,741 and 9983 respectively. However, the only study reporting a statistically significant result found an 8.2% implantation rate for the surgical removal group vs . 12% in the direct-to-IVF group, and 14.9% pregnancy rate in the surgical removal group vs . 24.9% in the direct-to-IVF group. Damage to ovarian reserve and function due to surgery is exacerbated by large cyst size, stripping of the pseudocapsule and older age. Larger endometrioma, ablation of the endometrioma base and younger age are associated with higher recurrence rate. Conclusion: The patient’s age, in addition to the size and type of endometrioma, can direct and indicate the timing of surgical management. Bilateral endometriomas and those larger than 7 cm are associated with more damage to ovarian reserve due to disease and surgery, as compared with unilateral lesions and those smaller than 7 cm. High-risk adolescents and very young women seeking fertility treatment can thus benefit from an early diagnosis of endometrioma. Treatment by trans vaginal hydro-laparoscopy of selected cases can probably be suggested for the treatment of small endometriomas, since 5fr instruments are used following microsurgery principles. Therefore, an early diagnosis of endometrioma, especially in young patients, must be encouraged, improved and standardized, through stepwise clinical reasoning and diagnostic testing.

Other imaging techniques: Double-contrast barium enema, endoscopic ultrasonography, multidetector CT enema, and computed tomography colonoscopy.

Double-contrast barium enema (DCBE), transrectal endoscopic ultrasonography (REU), multidetector computerized tomography enema (MDCT-e), and computed tomography colonoscopy (CTC) have been successfully used for the diagnosis of bowel endometriosis. DCBE provides a complete overview of the entire colon and allows detecting cecal nodules. The accuracy of DCBE is operator dependent and, thus, it may have low specificity. It does not allow identifying the cause of the mass effect. DCBE requires the administration of barium and exposure to radiation. REU precisely estimates the distance between the rectosigmoid nodule and the anal verge. However, it allows investigating only the distal part of rectosigmoid, it misses anterior pelvic lesions, and it has poor sensitivity for the diagnosis of endometriomas. MDCT-e is accurate and reproducible in diagnosing intestinal endometriosis and in assessing its characteristics: the largest diameter of the nodule, the distance between the distal part of the nodule and the anal verge, and depth of infiltration of endometriosis in the intestinal wall. MDCT-e requires the administration of iodinated contrast medium (CM) and the exposure to radiations. CTC has good performance in the diagnosis of rectosigmoid endometriosis. It allows estimating the degree of intestinal stenosis CTC, and the distance between the intestinal endometriotic nodule and the anal verge. It requires exposure to radiations, and it may require the administration of an iodinated CM.

Negative Sliding Sign during Dynamic Ultrasonography Predicts Low Endometriosis Fertility Index at Laparoscopy

Endometriosis fertility index (EFI) is a robust tool to predict the pregnancy rate in patients with endometriosis who are attempting non-in vitro fertilization conception. However, EFI calculation requires laparoscopy. Newly established imaging techniques such as sliding sign, which is used to diagnose pouch of Douglas obliteration, could provide a promising alternative. The objective of this study was to investigate the practicality of using ultrasound data to predict a low EFI (score ≤6). Observational study from a prospective registry (Endometriosis Pelvic Pain Interdisciplinary Cohort, clinicaltrials.gov #NCT02911090). Analyzed data were captured from December 2013 to June 2017. Tertiary referral center at British Columbia Women's Hospital. We analyzed data for 2583 participants from the Endometriosis Pelvic Pain Interdisciplinary Cohort. In this cross-sectional study, we included 86 women aged <40 years. Dynamic ultrasonography for the sliding sign testing and EFI calculation during laparoscopic surgery. Logistic regression was used to obtain receiver operating characteristic area under the curve (AUC) for the prediction models. Significance was p <.05. Patients with a negative sliding sign were older and had severe endometriosis and longer duration of infertility. Patients with a negative sliding sign had significantly lower total EFI scores and lower surgical factors scores than patients with a positive sliding sign. Logistic regression showed that a negative sliding sign and EFI historic factors score can predict an EFI score ≤6 (sensitivity = 87.9%, specificity = 81.1%, AUC = 0.93 [95% confidence interval, 0.88-0.98]). Adding the diagnosis of endometrioma to the previous prediction model resulted in AUC = 0.95 (95% confidence interval, 0.90-0.995), sensitivity = 84.8%, and specificity = 92.5%. The sliding sign could be a potential alternative to the EFI surgical factors, and it could be used in combination with EFI historic factors and the diagnosis of endometrioma to predict an EFI score ≤6 for patients who are not scheduled for immediate surgery.