Ovarian endometriosis, commonly known as a "chocolate cyst," is a prevalent form of endometriosis. It can occur alone or alongside deep endometriosis and other extra-pelvic locations. This condition significantly impacts fertility, affecting around 20-40% of those with endometriosis.
While ovarian endometriosis is often associated with severe pain, pain levels don't always correlate with cyst size. Large endometriomas may not always cause pain, and small cysts can sometimes be painful. Bilateral ovarian endometriosis, or "kissing ovaries," is common but isolated cases can also occur.
Symptoms may include chronic pelvic pain, dysmenorrhea, dyspareunia, irregular menstrual cycles, heavy bleeding, or infertility. However, extensive endometriosis does not always equate to severe symptoms, and some women may remain asymptomatic.
Diagnosis involves clinical examination, imaging, and sometimes surgical intervention. Transvaginal ultrasound is typically the first-line imaging method due to its accessibility and sensitivity. Magnetic Resonance Imaging (MRI) is useful for detecting deep infiltrating endometriosis, but a definitive diagnosis often requires laparoscopic surgery and histological examination of tissue.
Medical management alone cannot cure ovarian endometriosis due to its limited glandular component. For small endometriomas (less than 3 cm), continuous oral contraceptive pills or dienogest are often recommended. Larger or symptomatic endometriomas, particularly those over 5 cm, may require surgical intervention.
The preferred surgical method is laparoscopic surgery, which offers excellent depth perception and minimizes recurrence when performed expertly. While robotic surgery is available, it has not shown proven benefits over laparoscopic surgery and can be more expensive.
After surgery, patients should follow up annually for three years. Post-surgical medication may be necessary, especially if fertility preservation is a concern. Long-term oral contraceptive pills might be used to prevent recurrence, particularly in cases of multilocular endometriomas.
AMH (anti-Müllerian hormone) levels should be tested before surgery. Although AMH levels typically drop initially post-surgery, they usually recover. Preserving fertility requires expert surgical techniques to avoid damage. Egg freezing is an option for women to preserve fertility, with a recommendation to freeze 12 to 16 eggs.
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