Advertisement

The Ovarian Endometrioma: Clinical Setting and Ultrasound Findings

  • Stefano GuerrieroEmail author
  • Silvia Ajossa
  • Cristina Peddes
  • Maura Perniciano
  • Bruna Soggiu
  • Jasjit S. Suri
  • Luca Saba
  • Gian Benedetto Melis
Chapter

Abstract

Ovarian endometrioma is defined as a pseudocyst arising from growth of ectopic endometrial tissue. The typical features of endometriomas are diffuse low-level internal echoes (“ground glass”) in the absence of particular neoplastic features and with a clear demarcation from ovarian parenchyma. Several studies report very high values of specificity with values of sensitivity usually ranging from 87 to 77 %.

Keywords

Endometriosis Endometrioma Ovarian neoplasm Imaging Ultrasound Flow chart Ovarian mass 

References

  1. 1.
    Hachisuga T, Kawarabayashi T. Histopathological analysis of laparoscopically treated ovarian endometriotic cysts with special reference to loss of follicles. Hum Reprod. 2002;17(2):432–5.PubMedCrossRefGoogle Scholar
  2. 2.
    Alcázar JL, Guerriero S, Laparte C, Ajossa S, Ruiz-Zambrana A, Melis GB. Diagnostic performance of transvaginal gray-scale ultrasound for specific diagnosis of benign ovarian cysts in relation to menopausal status. Maturitas. 2011;68(2):182–8.PubMedCrossRefGoogle Scholar
  3. 3.
    Van Holsbeke C, Van Calster B, Guerriero S, Savelli L, Paladini D, Lissoni AA, Czekierdowski A, Fischerova D, Zhang J, Mestdagh G, Testa AC, Bourne T, Valentin L, Timmerman D. Endometriomas: their ultrasound characteristics. Ultrasound Obstet Gynecol. 2010;35(6):730–40.PubMedGoogle Scholar
  4. 4.
    Guerriero S, Mais V, Ajossa S, Paoletti AM, Angiolucci M, Melis GB. Transvaginal ultrasonography combined with CA-125 plasma levels in the diagnosis of endometrioma. Fertil Steril. 1996;65(2):293–8.PubMedGoogle Scholar
  5. 5.
    Mais V, Guerriero S, Ajossa S, Angiolucci M, Paoletti AM, Melis GB. Transvaginal ultrasonography in the diagnosis of cystic teratoma. Obstet Gynecol. 1995;85(1):48–52.PubMedCrossRefGoogle Scholar
  6. 6.
    Al-Fozan H, Tulandi T. Left lateral predisposition of endometriosis and endometrioma. Obstet Gynecol. 2003;101(1):164–6.PubMedCrossRefGoogle Scholar
  7. 7.
    Ulukus M, Yeniel AÖ, Ergenoglu AM, Mermer T. Right endometrioma is related with more extensive obliteration of the Douglas pouch. Arch Gynecol Obstet. 2012;285(5):1483–6.PubMedCrossRefGoogle Scholar
  8. 8.
    Vercellini P. Endometriosis: what a pain it is. Semin Reprod Endocrinol. 1997;15:251–6.PubMedCrossRefGoogle Scholar
  9. 9.
    Koninckx PR, Meuleman C, Demeyere S, Lesaffre E, Cornillie FJ. Suggestive evidence that pelvic endometriosis is a progressive disease, whereas deeply infiltrating endometriosis is associated with pelvic pain. Fertil Steril. 1991;55(4):759–65.PubMedGoogle Scholar
  10. 10.
    Khan KN, Kitajima M, Fujishita A, Hiraki K, Matsumoto A, Nakashima M, Masuzaki H. Pelvic pain in women with ovarian endometrioma is mostly associated with coexisting peritoneal lesions. Hum Reprod. 2013;28(1):109–18.PubMedCrossRefGoogle Scholar
  11. 11.
    Chapron C, Santulli P, de Ziegler D, Noel JC, Anaf V, Streuli I, Foulot H, Souza C, Borghese B. Ovarian endometrioma: severe pelvic pain is associated with deeply infiltrating endometriosis. Hum Reprod. 2012;27(3):702–11.PubMedCrossRefGoogle Scholar
  12. 12.
    Maneschi F, Marasá L, Incandela S, Mazzarese M, Zupi E. Ovarian cortex surrounding benign neoplasms: a histologic study. Am J Obstet Gynecol. 1993;169(2 Pt 1):388–93.PubMedCrossRefGoogle Scholar
  13. 13.
    Almog B, Shehata F, Sheizaf B, Tan SL, Tulandi T. Effects of ovarian endometrioma on the number of oocytes retrieved for in vitro fertilization. Fertil Steril. 2011;95(2):525–7.PubMedCrossRefGoogle Scholar
  14. 14.
    Ruiz-Flores FJ, Garcia-Velasco JA. Is there a benefit for surgery in endometrioma-associated infertility? Curr Opin Obstet Gynecol. 2012;24(3):136–40.PubMedCrossRefGoogle Scholar
  15. 15.
    Macleod D. Endometriosis; a surgical problem. Br J Surg. 1946;34(134):109–16.PubMedCrossRefGoogle Scholar
  16. 16.
    Nezhat F, Nezhat C, Allen CJ, et al. Clinical and histologic classification of endometriomas. Implications for a mechanism of pathogenesis. J Reprod Med. 1992;37:771–6.PubMedGoogle Scholar
  17. 17.
    Vercellini P, Somigliana E, Vigano P, Abbiati A, Barbara G, Fedele L. ‘Blood On The Tracks’ from corpora lutea to endometriomas. BJOG. 2009;116(3):366–71.PubMedCrossRefGoogle Scholar
  18. 18.
    Hughesdon PE. The structure of endometrial cysts of the ovary. J Obstet Gynaecol Br Emp. 1957;64(4):481–7.PubMedCrossRefGoogle Scholar
  19. 19.
    Brosens I, Puttemans P. Endometriosis and the ovary. In: Kurjak A, editor. Ultrasound and the ovary. New York: Parthenon Pub. Group; 1994. p. 157–63.Google Scholar
  20. 20.
    Donnez J, Nisolle M, Gillerot S, Anaf V, Clerckx-Braun F, Casanas-Roux F. Ovarian endometrial cysts: the role of gonadotropin-releasing hormone agonist and/or drainage. Fertil Steril. 1994;62(1):63–6.PubMedGoogle Scholar
  21. 21.
    Athey PA, Diment DD. The spectrum of sonographic findings in endometriomas. J Ultrasound Med. 1989;8(9):487–91.PubMedGoogle Scholar
  22. 22.
    Kupfer MC, Schwimer SR, Lebovic J. Transvaginal sonographic appearance of endometriomata: spectrum of findings. J Ultrasound Med. 1992;11(4):129–33.PubMedGoogle Scholar
  23. 23.
    Patel MD, Feldstein VA, Chen DC, Lipson SD, Filly RA. Endometriomas: diagnostic performance of US. Radiology. 1999;210(3):739–45.PubMedCrossRefGoogle Scholar
  24. 24.
    Mais V, Guerriero S, Ajossa S, Angiolucci M, Paoletti AM, Melis GB. The efficiency of transvaginal ultrasonography in the diagnosis of endometrioma. Fertil Steril. 1993;60(5):776–80.PubMedGoogle Scholar
  25. 25.
    Guerriero S, Mais V, Ajossa S, Paoletti AM, Angiolucci M, Labate F, Melis GB. The role of endovaginal ultrasound in differentiating endometriomas from other ovarian cyst. Clin Exp Obstet Gynecol. 1995;22(1):20–2.PubMedGoogle Scholar
  26. 26.
    Alcázar JL, Laparte C, Jurado M, López-García G. The role of transvaginal ultrasonography combined with color velocity imaging and pulsed Doppler in the diagnosis of endometrioma. Fertil Steril. 1997;67(3):487–91.PubMedCrossRefGoogle Scholar
  27. 27.
    Asch E, Levine D. Variations in appearance of endometriomas. J Ultrasound Med. 2007;26:993–1002.PubMedGoogle Scholar
  28. 28.
    Brown DL, Dudiak KM, Laing FC. Adnexal masses: US characterization and reporting. Radiology. 2010;254(2):342–54.PubMedCrossRefGoogle Scholar
  29. 29.
    Guerriero S, Ajossa S, Mais V, Risalvato A, Lai MP, Melis GB. The diagnosis of endometriomas using colour Doppler energy imaging. Hum Reprod. 1998;13:1691–5.PubMedCrossRefGoogle Scholar
  30. 30.
    Alcázar JL. Transvaginal colour Doppler in patients with ovarian endometriomas and pelvic pain. Hum Reprod. 2001;16(12):2672–5.PubMedCrossRefGoogle Scholar
  31. 31.
    Aleem F, Pennisi J, Zeitoun K, Predanic M. The role of color Doppler in diagnosis of endometriomas. Ultrasound Obstet Gynecol. 1995;5(1):51–4.PubMedCrossRefGoogle Scholar
  32. 32.
    Guerriero S, Alcazar JL, Pascual MA, Ajossa S, Gerada M, Bargellini R, Virgilio B, Melis GB. Diagnosis of the most frequent benign ovarian cysts: is ultrasonography accurate and reproducible? J Womens Health (Larchmt). 2009;18(4):519–27.CrossRefGoogle Scholar
  33. 33.
    Kurjak A, Kupesic S. Scoring system for prediction of ovarian endometriosis based on transvaginal color and pulsed Doppler sonography. Fertil Steril. 1994;62(1):81–8.PubMedGoogle Scholar
  34. 34.
    Volpi E, De Grandis T, Zuccaro G, La Vista A, Sismondi P. Role of transvaginal sonography in the detection of endometriomata. J Clin Ultrasound. 1995;23(3):163–7.PubMedCrossRefGoogle Scholar
  35. 35.
    Guerriero S, Ajossa S, Paoletti AM, Mais V, Angiolucci M, Melis GB. Tumor markers and transvaginal ultrasonography in the diagnosis of endometrioma. Obstet Gynecol. 1996;88(3):403–7.PubMedCrossRefGoogle Scholar
  36. 36.
    Sokalska A, Timmerman D, Testa AC, Van Holsbeke C, Lissoni AA, Leone FP, Jurkovic D, Valentin L. Diagnostic accuracy of transvaginal ultrasound examination for assigning a specific diagnosis to adnexal masses. Ultrasound Obstet Gynecol. 2009;34(4):462–70.PubMedCrossRefGoogle Scholar
  37. 37.
    Edwards A, Clarke L, Piessens S, Graham E, Shekleton P. Acoustic streaming: a new technique for assessing adnexal cysts. Ultrasound Obstet Gynecol. 2003;22(1):74–8.PubMedCrossRefGoogle Scholar
  38. 38.
    Van Holsbeke C, Zhang J, Van Belle V, Paladini D, Guerriero S, Czekierdowski A, Muggah H, Ombelet W, Jurkovic D, Testa AC, Valentin L, Van Huffel S, Bourne T, Timmerman D. Acoustic streaming cannot discriminate reliably between endometriomas and other types of adnexal lesion: a multicenter study of 633 adnexal masses. Ultrasound Obstet Gynecol. 2010;35(3):349–53.PubMedCrossRefGoogle Scholar
  39. 39.
    Raine-Fenning N, Jayaprakasan K, Deb S. Three-dimensional ultrasonographic characteristics of endometriomata. Ultrasound Obstet Gynecol. 2008;31(6):718–24.PubMedCrossRefGoogle Scholar
  40. 40.
    Guerriero S, Alcazar JL, Ajossa S, Pilloni M, Melis GB. Three-dimensional sonographic characteristics of deep endometriosis. J Ultrasound Med. 2009;28:1061–6.PubMedGoogle Scholar
  41. 41.
    Pascual MA, Guerriero S, Hereter L, Barri-Soldevila P, Ajossa S, Graupera B, Rodriguez I. Diagnosis of endometriosis of the rectovaginal septum using introital three-dimensional ultrasonography. Fertil Steril. 2010;94(7):2761–5.PubMedCrossRefGoogle Scholar
  42. 42.
    Guerriero S, Pilloni M, Alcazar JL, Sedda F, Ajossa S, Mais V, Melis V, Melis GB, Saba L. Tissue characterization in deep infiltrating endometriosis by using Mean Gray Value (MGV) analysis. Ultrasound Obstet Gynecol. 2013;41(4):459–64.PubMedCrossRefGoogle Scholar
  43. 43.
    Alcázar JL, Iturra A, Sedda F, Aubá M, Ajossa S, Guerriero S, Jurado M. Three-dimensional volume off-line analysis as compared to real-time ultrasound for assessing adnexal masses. Eur J Obstet Gynecol Reprod Biol. 2012;161(1):92–5.PubMedCrossRefGoogle Scholar
  44. 44.
    Alcázar JL, León M, Galván R, Guerriero S. Assessment of cyst content using mean gray value for discriminating endometrioma from other unilocular cysts in premenopausal women. Ultrasound Obstet Gynecol. 2010;35(2):228–32.PubMedCrossRefGoogle Scholar
  45. 45.
    Jacobs I, Bast Jr RC. The CA 125 tumour-associated antigen: a review of the literature. Hum Reprod. 1989;4(1):1–12.PubMedGoogle Scholar
  46. 46.
    Pittaway DE, Fayez JA, Douglas JW. Serum CA-125 in the evaluation of benign adnexal cysts. Am J Obstet Gynecol. 1987;157(6):1426–8.PubMedCrossRefGoogle Scholar
  47. 47.
    Guerriero S, Ajossa S, Caffiero A, Mais V. Relationship between abnormally high levels of plasma CA 125 and resolution of acute pelvic pain in two women with endometrioma. Gynecol Obstet Invest. 1995;40(1):61–3.PubMedCrossRefGoogle Scholar
  48. 48.
    Paoletti AM, Serra GG, Mais V, Ajossa S, Guerriero S, Orrù M, Melis GB. Involvement of ovarian factors magnified by pharmacological induction of multiple follicular development (MFD) in the increase in Ca125 occurring during the luteal phase and the first 12 weeks of induced pregnancies. J Assist Reprod Genet. 1995;12(4):263–8.PubMedCrossRefGoogle Scholar
  49. 49.
    Koninckx PR, Riittinen L, Seppala M, Cornillie FJ. CA-125 and placental protein 14 concentrations in plasma and peritoneal fluid of women with deeply infiltrating pelvic endometriosis. Fertil Steril. 1992;57(3):523–30.PubMedGoogle Scholar
  50. 50.
    Alcázar JL, Guerriero S, Mínguez JÁ, Ajossa S, Paoletti AM, Ruiz-Zambrana A, Jurado M. Adding cancer antigen 125 screening to gray scale sonography for predicting specific diagnosis of benign adnexal masses in premenopausal women: is it worthwhile? J Ultrasound Med. 2011;30(10):1381–6.PubMedGoogle Scholar
  51. 51.
    Kobayashi H, Sumimoto K, Moniwa N, Imai M, Takakura K, Kuromaki T, Morioka E, Arisawa K, Terao T. Risk of developing ovarian cancer among women with ovarian endometrioma: a cohort study in Shizuoka, Japan. Int J Gynecol Cancer. 2007;17(1):37–43. PubMed PMID: 17291229.PubMedCrossRefGoogle Scholar
  52. 52.
    Kobayashi H, Sumimoto K, Kitanaka T, Yamada Y, Sado T, Sakata M, Yoshida S, Kawaguchi R, Kanayama S, Shigetomi H, Haruta S, Tsuji Y, Ueda S, Terao T. Ovarian endometrioma – risks factors of ovarian cancer development. Eur J Obstet Gynecol Reprod Biol. 2008;138(2):187–93. Epub 2007 Dec 26.PubMedCrossRefGoogle Scholar
  53. 53.
    Testa AC, Timmerman D, Van Holsbeke C, Zannoni GF, Fransis S, Moerman P, Vellone V, Mascilini F, Licameli A, Ludovisi M, Di Legge A, Scambia G, Ferrandina G. Ovarian cancer arising in endometrioid cysts: ultrasound findings. Ultrasound Obstet Gynecol. 2011;38(1):99–106.PubMedCrossRefGoogle Scholar
  54. 54.
    Van Holsbeke C, Van Belle V, Leone FP, Guerriero S, Paladini D, Melis GB, Greggi S, Fischerova D, De Jonge E, Neven P, Bourne T, Valentin L, Van Huffel S, Timmerman D. Prospective external validation of the ‘ovarian crescent sign’ as a single ultrasound parameter to distinguish between benign and malignant adnexal pathology. Ultrasound Obstet Gynecol. 2010;36(1):81–7.PubMedCrossRefGoogle Scholar
  55. 55.
    Barbieri M, Somigliana E, Oneda S, Ossola MW, Acaia B, Fedele L. Decidualized ovarian endometriosis in pregnancy: a challenging diagnostic entity. Hum Reprod. 2009;24(8):1818–24. Epub 2009 Apr 10.PubMedCrossRefGoogle Scholar
  56. 56.
    Guerriero S, Ajossa S, Piras S, Parodo G, Melis GB. Serial ultrasonographic evaluation of a decidualized endometrioma in pregnancy. Ultrasound Obstet Gynecol. 2005;26:304–6.PubMedCrossRefGoogle Scholar
  57. 57.
    Somigliana E, Berlanda N, Benaglia L, Viganò P, Vercellini P, Fedele L. Surgical excision of endometriomas and ovarian reserve: a systematic review on serum antimüllerian hormone level modifications. Fertil Steril. 2012;98(6):1531–8.PubMedCrossRefGoogle Scholar
  58. 58.
    Raffi F, Metwally M, Amer S. The impact of excision of ovarian endometrioma on ovarian reserve: a systematic review and meta-analysis. J Clin Endocrinol Metab. 2012;97(9):3146–54.PubMedCrossRefGoogle Scholar
  59. 59.
    Exacoustos C, Zupi E, Amadio A, Szabolcs B, De Vivo B, Marconi D, Elisabetta Romanini M, Arduini D. Laparoscopic removal of endometriomas: sonographic evaluation of residual functioning ovarian tissue. Am J Obstet Gynecol. 2004;191(1):68–72.PubMedCrossRefGoogle Scholar
  60. 60.
    Exacoustos C, Zupi E, Amadio A, Amoroso C, Szabolcs B, Romanini ME, Arduini D. Recurrence of endometriomas after laparoscopic removal: sonographic and clinical follow-up and indication for second surgery. J Minim Invasive Gynecol. 2006;13(4):281–8.PubMedCrossRefGoogle Scholar
  61. 61.
    Zanetta G, Lissoni A, Dalla Valle C, Trio D, Pittelli M, Rangoni G. Ultrasound-guided aspiration of endometriomas: possible applications and limitations. Fertil Steril. 1995;64(4):709–13.PubMedGoogle Scholar
  62. 62.
    Zhu W, Tan Z, Fu Z, Li X, Chen X, Zhou Y. Repeat transvaginal ultrasound-guided aspiration of ovarian endometrioma in infertile women with endometriosis. Am J Obstet Gynecol. 2011;204(1):61.e1–6.CrossRefGoogle Scholar
  63. 63.
    Hsieh CL, Shiau CS, Lo LM, Hsieh TT, Chang MY. Effectiveness of ultrasound-guided aspiration and sclerotherapy with 95% ethanol for treatment of recurrent ovarian endometriomas. Fertil Steril. 2009;91(6):2709–13. Epub 2008 Jun 20.PubMedCrossRefGoogle Scholar
  64. 64.
    Alcázar JL, Olartecoechea B, Guerriero S, Jurado M. Expectant management of adnexal masses in selected premenopausal women: a prospective observational study. Ultrasound Obstet Gynecol. 2013;41(5):582–8.PubMedCrossRefGoogle Scholar
  65. 65.
    Guerriero S, Ajossa S, Lai MP, Mais V, Paoletti AM, Melis GB. Transvaginal ultrasonography in the diagnosis of pelvic adhesions. Hum Reprod. 1997;12(12):2649–53.PubMedCrossRefGoogle Scholar
  66. 66.
    Guerriero S, Ajossa S, Gerada M, D’Aquila M, Piras B, Melis GB. “Tenderness guided” transvaginal ultrasonography: a new method for the detection of deep endometriosis in patients with chronic pelvic pain. Fertil Steril. 2007;88:1293–7.PubMedCrossRefGoogle Scholar
  67. 67.
    Guerriero S, Ajossa S, Gerada M, Virgilio B, Angioni S, Melis GB. Diagnostic value of transvaginal ‘tenderness-guided’ ultrasonography for the prediction of location of deep endometriosis. Hum Reprod. 2008;23(11):2452–7. Epub 2008 Jul 29. PubMed PMID: 18664469.PubMedCrossRefGoogle Scholar
  68. 68.
    Saba L, Guerriero S, Sulcis R, Pilloni M, Ajossa S, Melis G, Mallarini G. MRI and “tenderness guided” transvaginal ultrasonography in the diagnosis of recto-sigmoid endometriosis. J Magn Reson Imaging. 2012;35(2):352–60. doi: 10.1002/jmri.22832. Epub 2011 Oct 27. PubMed PMID: 22034232.PubMedCrossRefGoogle Scholar
  69. 69.
    Guerriero S, Piras B, Peddes C, Paladino E. Transvaginal sonography in diagnosis of vesicoperitoneal fistula due to deep infiltrating endometriosis as a cause of uroperitoneum. Ultrasound Obstet Gynecol. 2012;40(6):727–9. doi: 10.1002/uog.11198. PubMed PMID: 22648704.PubMedCrossRefGoogle Scholar
  70. 70.
    Guerriero S, Ajossa S, Garau N, Alcazar JL, Mais V, Melis GB. Diagnosis of pelvic adhesions in patients with endometrioma: the role of transvaginal ultrasonography. Fertil Steril. 2010;94(2):742–6. Epub 2009 Apr 14. PubMed PMID: 19368917.PubMedCrossRefGoogle Scholar
  71. 71.
    Ghezzi F, Raio L, Cromi A, Duwe DG, Beretta P, Buttarelli M, Mueller MD. “Kissing ovaries”: a sonographic sign of moderate to severe endometriosis. Fertil Steril. 2005;83(1):143–7.PubMedCrossRefGoogle Scholar
  72. 72.
    Exacoustos C, Zupi E, Carusotti C, Rinaldo D, Marconi D, Lanzi G, Arduini D. Staging of pelvic endometriosis: role of sonographic appearance in determining extension of disease and modulating surgical approach. J Am Assoc Gynecol Laparosc. 2003;10(3):378–82.PubMedCrossRefGoogle Scholar
  73. 73.
    Holland TK, Yazbek J, Cutner A, Saridogan E, Hoo WL, Jurkovic D. Value of transvaginal ultrasound in assessing severity of pelvic endometriosis. Ultrasound Obstet Gynecol. 2010;36(2):241–8.PubMedCrossRefGoogle Scholar
  74. 74.
    Bazot M, Darai E. Value of transvaginal sonography in assessing severe pelvic endometriosis. Ultrasound Obstet Gynecol. 2010;36(2):134–5.PubMedCrossRefGoogle Scholar
  75. 75.
    Reid S, Lu C, Casikar I, Reid G, Abbott J, Cario G, Chou D, Kowalski D, Cooper M, Condous G. Can we predict pouch of Douglas obliteration in women with suspected endometriosis using a new real-time dynamic transvaginal ultrasound technique: the “sliding sign”. Ultrasound Obstet Gynecol. 2013;41(6):685–91.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  • Stefano Guerriero
    • 1
    • 2
    Email author
  • Silvia Ajossa
    • 1
  • Cristina Peddes
    • 1
  • Maura Perniciano
    • 1
  • Bruna Soggiu
    • 1
  • Jasjit S. Suri
    • 3
    • 4
  • Luca Saba
    • 5
  • Gian Benedetto Melis
    • 1
  1. 1.Department of Obstetrics and GynecologyUniversity of CagliariCagliariItaly
  2. 2.Dipartimento Chirurgico Materno Infantile e di Scienze delle ImmaginiUniversità di CagliariCagliariItaly
  3. 3.CTO, Global Biomedical TechnologiesRosevilleUSA
  4. 4.Department of Biomedical EngineeringIdaho State University (Aff.)PocatelloUSA
  5. 5.Department of RadiologyUniversity of CagliariCagliariItaly

Personalised recommendations