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An endometrioma, also known as an endometriotic ovarian cyst, is one of the most common manifestations of endometriosis. Follow-up after the detection of an endometrioma depends on the associated symptoms, such as pain or infertility. Scientific guidelines emphasise that cysts smaller than 3 cm should not be operated on if the patient has no symptoms.
Although endometriomas are clearly visible on gynaecological ultrasound, it should be noted that the only way to confirm the diagnosis with 100% certainty is through the histological examination of a tissue sample, usually obtained during a laparoscopy, to determine the exact type of cyst.
If a woman is not in pain or infertile, there are some cases in which the cyst should still be operated on.
Surgical treatment of endometriomas is generally recommended when the cysts exceed 3–4 cm in diameter, although specific thresholds may vary between clinical guidelines. The larger the cyst, the greater the damage to normal ovarian tissue, and the more challenging it becomes to preserve healthy, fully functioning ovarian tissue during surgery.
Similarly, the surgical removal of endometriomas is recommended to prevent the need for emergency surgery in cases of cyst rupture or infection, and to exclude malignancy if ultrasound findings are suspicious or if the cyst is rapidly enlarging.
When an endometriotic cyst is identified, it is also important to rule out deep endometriosis, as this may impair the function of other pelvic organs. For example, endometriosis may cause gastrointestinal disturbances, while ureteral involvement can lead to kidney problems – though symptoms often only appear after a prolonged period.
If the patient has no symptoms, surgical treatment would be preferable in the following cases:
In cases where a woman has symptoms, treatment is needed, which may initially be medical if the patient does not yet want surgery. If surgery is postponed, the cyst should continue to be monitored under the guidance of an experienced specialist, and any symptoms should be followed up on. This is because, even with hormonal therapy (if prescribed) or after assisted reproduction procedures, endometriotic lesions can continue to progress.
While hormonal therapy can be effective for managing pain, it does not treat infertility. Assisted reproduction procedures may be considered for this purpose and can be performed even without the prior surgical treatment of small cysts (<3 cm). If medical treatment is ineffective, surgical management should be considered. When performed with precision, surgery is effective in relieving pain and may also improve the chances of natural conception.
When planning surgical treatment, careful consideration should be given to the patient’s symptoms, and a thorough evaluation is performed to determine the possible extent of endometriosis and the scope of surgery required. If a woman is found to have a small endometriosis cyst but is experiencing severe pain, it is likely that the real cause of the pain is some other endometriosis lesion, which may be difficult to find by ultrasound. So, for surgical treatment to be effective, both the cyst and the complete removal of all, especially the deep lesions, is necessary. Only removing the cyst can relieve the symptoms temporarily. Leftover lesions can not only cause pain, but even progress. This then requires additional surgery, which can be very difficult and unnecessarily increase the risk of complications.
Patients with symptoms require surgical treatment:
For some women with endometriosis, surgery will eventually become necessary. This may be due to medication-related side effects, lack of effectiveness (around 25% of women find drug therapy ineffective), the involvement of other organs, or the patient’s preference to avoid medical treatment. Surgical treatment can be highly effective for both pain relief and fertility, provided that all endometriotic lesions are completely excised during the initial operation. Surgical treatment achieves the best outcomes for both pain relief and fertility in young women undergoing their first operation for endometriosis. Therefore, it is particularly important to seek a specialist with extensive experience in endometriosis surgery. endometriozes ārstēšanā pieredzējušu speciālistu.
The case for the surgical treatment of endometriomas and endometriosis lesions:
Cases when cyst and lesion surgery is not recommended:
To achieve the desired result, the specialist’s experience in the complete excision of endometriosis lesions is important. In cases where the specialist does not have this experience, surgery would not be advisable, and we recommend that you seek the opinion of another, more experienced specialist.
Unfortunately, endometriosis lesions and cysts can recur. The risk of recurrence of endometriomas is ~5–10%, even with well-performed surgery. If pregnancy is not planned immediately, the risk of recurrence can be significantly reduced by prescribing long-term hormonal therapy following surgery.
Repeat surgery for endometriotic ovarian cysts carries particular risks for women seeking fertility treatment, those with bilateral cysts, and patients over the age of 38. It is known that repeated surgery can seriously reduce the natural follicle reserve and make it difficult to get pregnant, even with assisted reproduction.
A difficult decision has to be made in cases where only the cyst has been removed, but both the lesions and the pain remain. If only the cyst is removed, the ovaries may stick to the unremoved lesions after surgery, and there is a high risk of traumatising the blood supply to the ovaries during re-operation, even though the cyst is gone. Therefore, in order to keep the ovaries healthy in young women, we sometimes leave the lesions adjacent to the ovaries in the case of re-operations, so that the function of the ovary or the ovary itself is not lost.
It is important to warn patients before surgery about the risk of ovarian damage, as this risk is particularly high with repeated operations. For this reason, it is very important to discuss pregnancy plans with patients. If pregnancy is not planned immediately, egg freezing should be considered in some cases to increase the chances of becoming pregnant in the future.
The specialists at Vītola klīnika believe that one of the key factors for achieving the best treatment outcomes in symptomatic patients is timely surgery with the complete removal of all endometriotic lesions.
There is currently no one-size-fits-all answer to relieve the symptoms caused by endometriosis. Managing endometriosis requires a comprehensive, long-term approach that may include dietary modifications and lifestyle adjustments. It is also clear that effective surgery, followed by long-term medical therapy when pregnancy is not planned, plays a central role in disease management. It should be noted that some women will require assisted reproductive techniques, such as artificial insemination, to address infertility.
