Curr Obstet Gynecol Rep (2012) 1:16–24

DOI 10.1007/s13669-011-0002-3

DIAGNOSIS AND MANAGEMENT OF ADNEXAL MASS (H KATABUCHI, SECTION EDITOR)

Clinical Management of Ovarian Endometriotic

Cyst (Chocolate Cyst): Diagnosis, Medical
Treatment, and Minimally Invasive Surgery
Masaki Mandai & Ayako Suzuki & Noriomi Matsumura &
Tsukasa Baba & Ken Yamaguchi & Junzo Hamanishi &
Yumiko Yoshioka & Kenzo Kosaka & Ikuo Konishi

Published online: 7 January 2012

# Springer Science+Business Media, LLC 2012

Abstract In the clinical management of endometriotic cyst, Kyoto 606-8507, Japan

three major clinical disruptions need to be addressed ade- e-mail: mandai@kuhp.kyoto-u.ac.jp
quately: pain, infertility, and malignant transformation.
Symp- toms differ according to the patient’s age and her
life stage, and they should be managed individually. This
review dis- cusses the role of medical treatment with
currently available drug regimens as well as surgical
interventions for endometri- otic cyst in terms of each
symptom. Endometriosis-associated ovarian cancer is an
important issue in the management of endometriosis in
relatively elderly women, although it is not yet widely
recognized. The need for standard management of these
patients is also discussed.

Keywords Endometriotic cyst . Chocolate cyst . Ovarian

cyst . Pain . Infertility . ART. Endometriosis .
Management . Diagnosis . Ultrasound . MRI . Medical
treatment .
Laparoscopy . Minimally invasive surgery . Ovarian
cancer . Estrogen replacement

Introduction

Endometriosis, defined as the presence of endometrium-like

tissue outside the uterus, affects approximately 10% of women
of reproductive age [1, 2•]. The origin of ectopic
endometrium remains unresolved: some gynecologists believe
that it originates

M. Mandai (*) : A. Suzuki : N. Matsumura : T. Baba :

K. Yamaguchi : J. Hamanishi : Y. Yoshioka : K. Kosaka :
I. Konishi
Department of Gynecology and Obstetrics,
Kyoto University Graduate School of Medicine,
54 Shogoin Kawahara-cho, Sakyo-ku,
Curr Obstet Gynecol Rep (2012) 1:16–24 17
from endometrial tissue in the backflow of menstrual
bleeding, whereas others believe that it is a result of coelomic
metaplasia [1]. These discrepancies yield continuous debates
among gyne- cologists. Endometriosis affects many organs
and structures, including the ovary, fallopian tube, pelvic
serosa, rectum, retro- peritoneal structures (e.g., the ureter),
and more remote organs, including the lungs. The most
frequently affected organ is the ovary. Ovarian endometriosis
typically presents as an ovarian cyst containing old blood;
usually called a chocolate cyst or an endometriotic cyst, these
are diagnosed in about 17% to 44% of women with
endometriosis [2•].
Although the diagnosis of endometriosis is sometimes
dif- ficult, especially during early-stage disease, the
characteristic appearance of a typical ovarian
endometriotic cyst can be easily detected with MRI. After
a diagnosis of ovarian endo- metriotic cyst, there are
several management options, including careful follow-up,
medication, and surgical intervention. The efficacy of these
options is different according to the purpose of the
treatment; for instance, medication is more effective for
relieving pain than for recovering fertility.
Endometriosis causes three major clinical disruptions:
pain, infertility, and malignant transformation. The most
common symptom in younger patients is endometriosis-
associated pain including dysmenorrhea, which, if
mistreated, may lead to endometriosis-associated infertility.
Endometriosis-associated ovarian cancer has been
recognized recently. It generally affects elderly women,
especially postmenopausal women who are symptom-free
and have no childbearing plans. Be- cause the symptoms
and problems in patients with endometri- osis vary
according to the woman’s age, the severity of the disease,
and individual social requirements, the aim of treat- ment
should be specific to each patient (Fig. 1). In this review,
we summarize the updated management of endometriotic
cyst in several clinical situations.
 Younger age Reproductive age (Menopause) Elder age

Pain

Infertility

Malignant transformation

Preservation of ovarian function Curative (radical) treatment

Medical care Surgical intervention

Fig. 1 The symptoms and problems in patients with endometriosis vary according to the age of the patient, the severity of the disease, and
individual social requirements. Therefore, the aim of treatment should be specific to each patient

endometriotic cyst
Diagnosis of Endometriotic Cyst

The most useful diagnostic imaging modalities for endo-

metriotic cyst are ultrasonography (US) and MRI.

Exploratory Examination

Although plentiful information can be obtained from imag-

ing analyses, the importance of a physical examination,
especially an internal examination, should not be over-
looked. With the aid of transvaginal US, careful internal
examination by the experienced physician can identify the
site causing pelvic pain and estimate the presence or
absence of adhesions. Posttherapeutic improvement in
pelvic tender- ness detected by examination is as
informative as improve- ment detected by imaging
analysis.

Ultrasonography

US is used mainly in outpatient clinics for the screening of

an adnexal mass, following exploratory examination. Typi-
cally, an ovarian endometriotic cyst presents with a
diffuse, low-echoic appearance with occasional
hyperechoic foci in the wall of unilocular or multilocular
cysts 3 to 6 cm in diameter [3, 4] (Fig. 2).
Differential diagnosis includes a mature cystic teratoma
(or so-called dermoid cyst), which generally shows a more
echogenic internal structure with an acoustic shadow
reflect- ing hairballs and calcifications. Other differential
diagnoses include functional cysts, such as a lutein cyst or
a hemor- rhagic follicular cyst, a tubo-ovarian abscess, and
ovarian cancer [3]. Usually, differentiating an
from other ovarian cysts is not difficult, using a precise
evaluation of structural features and careful short-term
follow-up. However, it is occasionally difficult to exclude
other possibilities, especially when the cyst contains a
solid portion or shows a wall irregularity. This finding
most often represents a hemorrhagic clot, but it is difficult
to exclude malignancy (Fig. 3). Color Doppler US may be
useful for the differential diagnosis, but its effectiveness
remains un- certain [5]. In such cases, further examination
with MRI should be considered [3].
Because it is neither invasive nor expensive, US is also
useful in the follow-up of endometriotic cyst. Regular
check-ups every 6 months should be recommended. If any
alteration in the US appearance is noticed, a closer
follow-up or additional MRI examination is necessary.

Magnetic Resonance Imaging

MRI is one of the most powerful and informative

diagnostic tools for an endometriotic cyst. Typically, an
endometriotic cyst shows high intensity in both T1-
weighted and T2- weighted images, reflecting the blood
element in the cyst [3, 6] (Fig. 2). A “shading” or “shading
sign” refers to a T2 shortening in the cyst, corresponding
to a hyperintense portion on the T1 image, which is useful
to distinguish endometriotic cyst from other blood-
containing lesions, such as a hemor- rhagic corpus luteum
cyst [3, 4]. Although the hypointensity typically presents
either as a focal/diffuse area or a layering with a
hypointense fluid level, a significant proportion of cases
show only a complete loss of signal intensity [7]. Lack of
fat suppression helps to distinguish an endometriotic cyst
from a dermoid cyst [4]. In cases of endometriotic cyst
with a
18 Curr Obstet Gynecol Rep (2012) 1:16–24

Fig. 2 Typical images of an endometriotic cyst. a Ultrasonography (US), showing a unilocular cyst with a diffuse and low-level echo within it. b–
d On MRI scans, the contents of the cyst show high intensity in both T1-weighted and T2-weighted images, reflecting the blood element

solid portion, contrast enhancement is mandatory to finding can be easily misdiagnosed as a malignancy [10–
exclude malignancy, such as a clear cell carcinoma [3, 8]. 12]. In such
Malignant transformation of endometriotic cyst is the
most serious problem related to late-stage endometriosis. If
US screening shows atypical findings such as a nodular
portion, wall thickening, or a significant change in
appearance during follow-up, MRI is helpful not only to
rule out malignancies but also to estimate the histologic
subtype of malignancies (Fig. 3). For this purpose, various
parameters should be taken into account, such as maximum
diameter, the presence of shading, and the size and the
nature of the nodular portion. The most apparent risk factor
is enhancement of the nodular portion, although a benign
endometriotic cyst occasionally harbors an enhanced
nodule. According to a study by Tanaka et al. [9•], the
diameter of the cyst nodule is significantly correlated with
a malignant phenotype. Lack of shading is also an
important finding in the malignant transformation of
endometriosis, especially when MRI scans are repeated in
the same patient. Tanaka et al. [9•] reported that 81% of
benign endometriotic cysts showed shading on T2-
weighted images, but only 33% of malignant tumors
showed shading. It is most likely that a nonhemorrhagic
secretion by malignant cells may dilute the cyst’s contents,
causing the loss of shading. One of the difficulties in
diagnosing malignancy in endometriosis is a decidualized
endometriosis during pregnancy, which presents as a
rapidly growing nodular portion or wall thickening with
abundant vascularity in the endometriotic cyst. This
Curr Obstet Gynecol Rep (2012) 1:16–24 19
cases, expectant management with careful serial follow-
up is needed. MRI is also useful to estimate histologic
subtypes of cancer arising in endometriosis. In cases of
endometrioid cancer, MRI shows either a solid or cystic
pattern without shading [13]. The nodular portions in the
cyst tend to be multiple rather than single. In contrast, a
clear cell carcinoma tends to be more cystic and
unilocular, with one or several nodular portions [8].
One of the important roles of MRI in treating a patient
with an endometriotic cyst is the diagnosis of coexisting
extraovarian endometriosis, as it has similar symptoms,
such as pain and infertility. Diagnosing it is also helpful to
ensure adequate surgical intervention. Endometriotic
lesions fre- quently involve the surface of the peritoneum
and ovary. Fat-suppressed images are useful to identify
the lesion, but a diagnosis is relatively difficult, resulting
in poor diagnostic accuracy [5]. The characteristic MRI
pattern of superficial endometriosis is either high T1
intensity with low T2 inten- sity or high intensity in both
T1 and T2 imaging. Deep endometriosis, sometimes
referred to as posterior endome- triosis, often affects
retroperitoneal organs, including the ureter and rectum. It
frequently causes severe pelvic pain as a result of the
involvement of the uterosacral ligament. The sensitivity
of diagnosis of deep endometriosis by MRI is reported to
be 76% to 86% [3]. Adhesions caused by endometriosis
are also important as a cause of infertility and frequently
make operation difficult. Using MRI, adhesions are
typically identified by low-signal-intensity strands.
Fig. 3 Images of a case of clear cell carcinoma, which arose in the
weighted images (d, e) with several nodular portions. These nodular
same patient as Fig. 2 after an interval of 6 years. a ultrasonography
portions show isointensity to high intensity in the T2-weighted image
(US), showing that the cyst contains a solid portion and the cyst is
and low intensity in the T1-weighted images. e These portions also
larger than it was 6 years ago. b–e On MRI scans, the cyst is
show positive contrast enhancement (CE)
unilocular and shows high intensity both in T2-weighted images (b,
c) and T1-

Management of Endometriotic Cyst According OCs, and

to the Symptoms

The treatment options for ovarian endometriotic cyst are

either medical or surgical interventions. Observation is an-
other choice in some situations. Medical therapy typically
consists of androgens, progestogens, oral contraceptives
(OCs), and gonadotropin-releasing hormone (GnRH) ago-
nists. Surgical treatment for ovarian endometriotic cyst
varies from hysterectomy with salpingo-oophorectomy
(SO) to unilateral cystectomy with or without laparoscopy.
Treatment recommendations differ according to the
purpose of treatment and the symptoms of the patient.

Treatment of Endometriosis-Associated Pain

Although ovarian endometriotic cyst could be a cause of

pelvic pain, it is rare that endometriotic cyst is the only
cause of severe, chronic pain. Rather, accompanying extra-
ovarian endometriosis or resulting adhesions or inflamma-
tion may be responsible [14]. Various drugs have been
used to treat endometriosis-associated pain. A GnRH
agonist is the most popular treatment choice, and a number
of placebo- controlled randomized studies have shown that
these are effective [15•]. Other drugs, such as danazol,
gestrinone have also been shown to be effective, with
little difference from GnRH agonists [15•, 16, 17].
Dienogest, a selective progestin, was also as effective as
GnRH agonists [18]. There are few published data,
however, that indicate whether medical treatment
effectively alleviates pain in women with symptomatic
endometriotic cyst. Rana et al. reported that a GnRH
agonist or danazol is effective in reducing the size of an
endometriotic cyst and in controlling pelvic pain and
dysmenorrhea [19].
Surgery is thought to be the first line of treatment for
pain in women with endometriotic cyst [15•]. Surgical
treatment to conserve bilateral ovaries includes drainage,
sclerotherapy, diathermy, laser vaporization, and
cystectomy [20–22]. Drain- age guided by laparoscopy or
transvaginal US has reportedly resulted in a high
recurrence rate and is less effective for relieving
symptoms [20]. In addition, it can cause pelvic infection
or adhesions [20, 22]. Combining sclerotherapy using
ethanol, tetracycline, and methotrexate with aspiration
may reduce the rate of recurrence, although it can cause
severe adhesions, which may affect future fertility [22,
23]. Ovarian cystectomy is a more definite treatment for
endometriotic cyst. Although several studies found no
difference among various surgical procedures, including
drainage, ablation, and cystec- tomy, randomized trials
indicated a lower cumulative postop- erative rate of
recurrence of dysmenorrhea, dyspareunia, and
chronic pelvic pain in patients who underwent cystectomy disrupt fertility [34•]. For example, interleukins directly
compared with those who underwent drainage alone [21, affect sperm motility, and tumor necrosis factor (TNF)-α
22]. Another obvious advantage of cystectomy is that causes
histo- logic examination is available. Uterine nerve
ablation (UNA) was reported to be effective in relieving
pain in earlier studies [22], but in recent randomized
controlled trials, its effective- ness in alleviating symptoms
has been controversial. Several reports found no difference
in symptoms at 3 years after surgery between the women
who underwent laparoscopy alone and the women who
underwent laparoscopy with UNA [24, 25]. Several
authors reported modest clinical bene- fits of UNA [26,
27]. By contrast, many studies, including randomized
trials, showed that presacral neurectomy (PSN)
significantly improved symptoms [25, 27, 28], although
some patients suffered adverse effects from the procedure,
including constipation, bladder dysfunction, or
intraoperative hemor- rhage. Radical treatment options for
women who do not require fertility include oophorectomy
and hysterectomy with oophorectomy.
There are conflicting data on the role of postoperative
medical treatment. Randomized studies in which a GnRH
agonist or danazol was used postoperatively for 3 months
did not show a difference in the recurrence of pain
compared with a nontreated group [29, 30]. In contrast,
treatment with a GnRH agonist, danazol, or
medroxyprogesterone acetate (MPA) for 6 months after
operation showed a significant advantage against the
recurrence of pain in randomized con- trolled trials [31,
32]. These data suggest that postoperative medical
treatment should be administered for at least 6 months and
that treatment over a shorter period may not be beneficial
[22].

Treatment of Endometriosis-Associated Infertility

Because endometriosis is primarily a disease encountered in

women of reproductive age, infertility is one of its most im-
portant complications. The causal link between
endometriosis and infertility is not clearly defined [33]. It is
generally be- lieved that endometriosis impairs fertility in
multiple ways [33, 34•]. First, severe pelvic pain may
interfere with regular sexual intercourse in couples who are
trying to conceive. Second, endometriosis destroys the
pelvic anatomy as it progresses, thereby disrupting the
normal fertilization procedure. The most direct cause of
infertility associated with endometriosis is tubal obstruction.
Closure of the cul-de-sac, adhesions, and disloca- tion of the
ovary or fallopian tube also interfere with natural
conception. Third, in addition to these mechanical impair-
ments, endometriosis affects fertility chemically and biologi-
cally. Inflammation caused by endometriosis alters the pelvic
environment, with increases in inflammatory cytokines,
growth factors, and angiogenic factors, which significantly
DNA damage to the sperm [35–37]. These factors, along As regards surgical intervention, Tsoumpou et al. [41]
with reactive oxygen species (ROS) produced by performed a meta-analysis of five studies comparing
endometriosis, also impede sperm capacitation, oocyte- surgical treatment versus no treatment for ovarian
sperm interaction, and oocyte quality [33, 34•]. endometriotic cyst.
Whether the presence of ovarian endometriotic cyst
affects the normal ovarian function in terms of conception
is unclear. It is suggested that endometriosis does not
affect the quality of oocytes retained in the ovary. Rather,
surgical intervention in the endometriotic cyst may
damage ovarian function to some extent. In this view,
which surgical procedure is favorable for reproductive
ability is a matter of concern [38].
Treatment for endometriosis-associated infertility
consists of medical and surgical approaches, just as for
pain. However, because the purpose of treatment is
different, the treatment strategy differs. The type of
treatment may also be different for patients desiring
natural conception and for those undergoing assisted
reproductive technology (ART). Almost all medical
treatments for endometriosis are based on the hormonal
block- age of ovarian function and are thus contraceptive;
therefore, medical treatment is usually not the chosen
treatment for women pursuing spontaneous conception
[34•]. Evidence suggests that there is no improvement in
pregnancy rates with medical intervention for
endometriosis [39].
Although removal of an ovarian endometriotic cyst is
con- sidered to be effective in correcting disrupted pelvic
anatomy, it is still undetermined whether surgical
intervention for endome- triosis, especially endometriotic
cyst, contributes to natural conception [34•]. The presence
of endometriotic cyst may affect spontaneous ovulation
[40]. Surgery for various degrees of endometriosis appears
to improve the rate of natural con- ception, but determining
the optimal operative procedure for endometriotic cyst is
another issue. Several reports, including randomized
controlled trials, indicate that ovarian cystectomy by way of
laparoscopy is superior to drainage or vaporization in terms
of higher pregnancy rates and lower recurrence rates [21,
41]. Yazbeck et al. [23] suggested that ethanol sclerotherapy
may offer a better result because it causes less damage to the
remaining ovarian function.
For patients who plan to undergo in vitro fertilization
(IVF) after treatment for infertility associated with
endometriosis, the management policy is different. It is
estimated that 10–25% of patients undergoing IVF have
accompanying endometriosis, and 17–44% of them have
endometriotic cyst [38, 41]. The presence of endometriosis
and its severity may negatively impact the outcomes of
IVF, though the relationship is not definitively proven [42].
Medical treatment for endometriotic cyst prior to IVF
reduces the size of the cyst, and several randomized
controlled trials indicate that GnRH agonist treat- ment
before IVF in women with endometriosis significantly
increases pregnancy rates [43, 44].
The results showed no significant effect of treatment on cancer into account in managing endometriosis, especially in
IVF pregnancy rates and on ovarian response to elderly women. There are few guidelines, however, on how
stimulation, com- pared with no treatment. Nevertheless, to
the author mentioned that the decision regarding surgery
for endometriotic cyst in asymptomatic women before IVF
should take into account the anticipated difficulty in
accessing the follicles and the risk of pelvic infection if
inadvertent drainage of a large endometri- otic cyst occurs
at the time of retrieval. Expectant manage- ment of
endometriotic cyst before IVF presents risks that include
difficulty in monitoring follicular growth and sponta-
neous rupture and leakage, which may cause pelvic inflam-
mation, infection, and adhesion. On the other hand, surgery
may cause quantitative damage to ovarian reserves, as a
decrease in the number of eggs has been observed after
ovarian cystectomies, although the fertilization rates and
the quality of the embryos did not differ [22].

Management of Endometriosis in Terms of Development

of Ovarian Cancer

It is clinically evident that endometriosis gives rise to

ovarian cancer with a relatively high frequency, and it has
been shown that women with endometriosis have a higher
risk of ovarian cancer. According to a survey in Japan,
approximately 1% of cases of ovarian endometriosis
transform into ovarian cancer [45]. Importantly, this rate
significantly increases in elderly women. The risk of
ovarian cancer in patients with endome- triosis is reported
to be significantly higher than in the general population
(standardized incidence ratio [SIR], 1.4–1.9), and this risk
increases in women with a longer history of endome-
triosis (SIR, 2.2–4.3) [46•]. It is also well known that
ovarian cancers arising from endometriosis have a unique
histology: most are of a clear cell or endometrioid subtype,
relatively rare for ovarian cancer [47•].
Numerous pathologic and molecular biologic data
suggest that endometriotic epithelium is actually a
precursor of ovar- ian cancer [47•]. Continuation from
morphologically benign endometriosis to cancer is
frequently observed, and occasion- ally an intermediate
lesion, such as atypical endometriosis, is found nearby
[48]. The analysis of the loss of heterozygosity (LOH) and
genetic mutations also indicates that endometriosis shares
common genetic events with associated ovarian cancer
[49]. These findings clearly show that ovarian cancer
indeed develops from endometriosis, and that both
conditions have common molecular pathways in their
development. However, the precise mechanism involved in
the development of cancer in endometriosis is still unclear.
Various genetic events are implicated, as is the effect of the
microenvironment, such as endometriotic fluid containing
highly concentrated iron [50, 51].
Considering these facts, it is important to take the risk of
manage endometriosis as a precursor of ovarian cancer. to be a major risk for ovarian cancer. Together with their
This lack is partly because the risk factors for ovarian therapeutic effect on endo- metriosis, OCs may reduce the
cancer among women with endometriosis are not fully risk of malignant transformation
defined. Especially in the case of endometrioid
adenocarcinoma, and possibly in some cases of clear cell
and mixed-type carcinomas, estrogen plays an important
role not only in the growth and maintenance of
endometriosis, a precursor lesion of these cancers, but also
in the development of cancer [47•]. Mechanisms that may
be implicated in these conditions include unopposed
estrogen status, increased expression of estrogen α,
progesterone resis- tance, and increased aromatase activity,
but these should be further elucidated [46•]. In terms of
clinical relevance, several authors reported that estrogen
replacement therapy (ERT) in- creased the risk of ovarian
cancer, especially of the endome- trioid subtype [52].
Although it has not been directly shown that estrogen
increases the risk of endometriosis-associated cancer, this
possibility should be considered when introducing ERT in
women who have a history of endometriosis, even after
menopause [52]. There are several reports of endometrioid
adenocarcinoma in patients who underwent a hysterectomy
with bilateral oophorectomy for endometriosis with
subse- quent long-term estrogen use [53]. It is generally
recommen- ded to add a progestin if ERT is necessary after
menopause or after a hysterectomy with oophorectomy for
endometriosis [54].
Whether surgical intervention is indicated for cancer pre-
vention in women with endometriosis is an important issue
but is not clearly defined. It is unclear whether conservative
sur- gery, such as ovarian cystectomy or vaporization,
reduces the risk of malignant transformation of
endometriosis [47•]. As previously mentioned, several
surveys indicate that women who have a longstanding
history of endometriosis have a greater risk of developing
ovarian cancer [46•], which suggests that surgical
intervention somehow may reduce the risk of malignant
transformation. Interestingly, women who under- went a
hysterectomy after a diagnosis of endometriosis did not
show an increased risk of ovarian cancer, thus indicating
that hysterectomy and possibly tubal ligation may have
some protective role [46•]. For elderly women in whom
endometri- otic cyst has been diagnosed, early detection of
cancer is clinically important. It is generally accepted that
an endometri- otic cyst growing after menopause should
be resected. Kobayashi et al. [55] demonstrated that the
risk factors for malignant transformation of endometriotic
cyst are older age, postmenopausal status, and larger tumor
size. They recom- mended considering surgery in
postmenopausal women with an endometriotic cyst
measuring 9 cm or larger.
It is still unclear whether medical treatment for
endometri- osis reduces the risk of developing ovarian
cancer. Oral contra- ceptives are known to reduce ovarian
cancer risk partly by inhibiting ovulation, which is thought
of endometriosis, but there is not yet any conclusive study on cyst is superior to
this issue. The use of a GnRH agonist may reduce or increase
the risk of endometriosis-associated ovarian cancer because
although postmenopausal status increases the risk of ovarian
cancer, GnRH agonists suppress endometriosis itself. Newer
drugs such as dienogest may be used more frequently for
endometriosis, but no data are yet available on their effect on
cancer prevention. Clinical studies are needed on the effect of
medical care in preventing the development of endometriosis-
associated cancer.

Minimally Invasive Surgery for Endometriotic Cyst

As mentioned above, various surgical procedures are used to

manage various symptoms derived from endometriosis. Re-
cently, minimally invasive surgery under laparoscopy is
becom- ing the standard modality for the treatment of
endometriosis, especially in conservative therapy.

Laparotomy Versus Laparoscopy for Endometriosis

Whether laparotomy or laparoscopic surgery is superior as

a surgical management technique for endometriosis is an
im- portant issue. A number of reports, including
controlled trials, indicate that pregnancy rates, monthly
fecundity, and recurrence rates are comparable between
laparotomy and laparoscopy [56, 57]. On the other hand,
blood loss, length of hospitalization, and recovery time are
usually decreased after laparoscopy [57]. It is generally
thought that laparos- copy is technically difficult and has a
greater risk of surgical complications than laparotomy, but
a meta-analysis of pro- spective randomized trials showed
that laparoscopy and laparotomy exposed patients equally
to complications [58]. Therefore, except in cases with
special indications, laparo- scopic surgery is the first
choice among surgical procedures for infertile woman with
endometriotic cyst.
Laparotomy may be more applicable for women with
severe pelvic endometriosis if curative surgery is planned.
However, even in very radical operations, such as REHCR
(radical en bloc hysterectomy and colorectal resection),
lapa- roscopy is reported to be comparable or superior to
laparoto- my in terms of symptoms and improvement in
quality of life [59].

Excision Versus Ablative Surgery for Ovarian

Endometriosis

As previously mentioned, surgical procedures, including

lap- aroscopic procedures, include salpingo-oophorectomy
(with or without hysterectomy), ovarian cystectomy,
ablation, and drainage. Randomized trials clearly show that
laparoscopic excision of the cyst wall of an endometriotic
ablation in terms of reduced recurrence, relief of pain, and Diagnosis of endometriosis: pelvic endoscopy and imaging
pregnancy rates [60]. Damage caused by the removal of techniques. Best Pract Res Clin Obstet Gynaecol.
2004;18(2):285–303.
normal ovarian tissue in an excisional procedure is
usually minimal, but Donnez et al. [61] have
recommended using laser vaporization for the portion
close to the hilus.

Surgery for Recurrent Endometriotic Cyst

Vercellini et al. [62] reviewed the reports on the efficacy of

repeat surgery for recurrent endometriosis. Among 313
patients who wanted to conceive after repeat surgery, 81
women be- came pregnant, with no significant difference
between laparot- omy and laparoscopy. However, the
pregnancy rate after repeat surgery was significantly lower
than the rate after primary surgery.

Conclusions

The roles of medical treatment with currently available

drug regimens and of surgical interventions for treating
endometriosis-associated pain and infertility in women
with endometriotic cyst have been intensively
investigated and are by and large clear. In contrast, the
effect of medication and surgery on the development of
cancer in women with endo- metriosis is poorly
understood, and no standard management for
endometriosis in terms of reducing malignant transforma-
tion has been proposed. High-quality clinical trials are
needed to help in establishing a standard care for
endometriotic cyst, especially after menopause.

Disclosure No potential conflicts of interest relevant to this article

were reported.

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