Ovarian endometriosis is extremely common. Ovarian involvement is an important part of the overall staging process to account for the degree of pelvic endometriosis. From a symptomatic perspective, it accounts for a lot of the issues causing chronic pelvic pain as well as concerns regarding infertility.
Patients with ovarian endometriosis invariably describe a fixed or pulling sensation on either side of the pelvis, almost always commencing with ovulation. In more severe cases, this pain might continue until menstruation for that month concludes. Patients with ovarian endometriosis often also have co-existent bowel problems and back pain.
Pelvic ultrasound scans can certainly establish the presence of thick walled cysts containing material of a ‘ground glass’ appearance. This is a hallmark feature of an endometrioma. The cysts are associated with substantially reduced fertility (until they are carefully removed), as well as the strong likelihood of other deposits of deep pelvic endometriosis.
Patients with endometriomas will have reduced fertility due to:
- reduction in ovarian volume/reserve by compression from the expanding cyst
- pelvic inflammation/local adhesion formation surrounding the ovary (and other pelvic organs)
- associated blockage of fallopian tubes (often in association with the endometrioma cysts).
Treatment options are variable. The use of an oral contraceptive pill will delay further rapid change in expansion of an endometrioma. More powerful medications (Zoladex, Synarel) can reduce the cyst size by 30% to 40%, but will not ’dissolve‘ the endometriosis completely. Such treatments are only available for a maximum of six months.
In the longer term, surgery to remove the ovarian endometriosis will address issues of chronic pain management and fertility. The aim of this laparoscopic surgery is to carefully restore anatomy while preserving as much ovarian tissue as possible. Equally important is the need to remove the ’nodules‘ of endometriosis tissue to which the ovary attached; leaving this tissue behind will only lead to further endometriosis formation in the future.
Once surgery is completed it is important to minimise the risk of ovarian adhesions. There are a number of adhesion barriers that have been trialled (Adept, SurgiCell), but the preferred option utilised by Dr Gordon is ’oophoropexy‘. This is a procedure completed at the end of all surgery, where the ovary is ’hitched‘ with a dissolving suture that lasts for just two to three weeks – enough time for healing to be well advanced, and therefore minimising attachment of the ovary to other organs or tissues. Since introduction of this laparoscopic technique, Dr Gordon’s patients have had virtually no problems with local ovarian adhesions.
Occasionally, some patients have such severe endometriosis involving an ovary that removal of the ovary is deemed necessary. Paradoxically, removing the complete ‘diseased ovary’ actually improves fertility chances by taking away all local inflammation. If ever indicated (and only following a long discussion) the ovary can be removed laparoscopically, along with all pelvic endometriosis. In the fertile population, this ovarian tissue can be harvested and stored thru Monash IVF.
Chronic endometriosis with ovarian endometrioma formation can lead to some concerns regarding ovarian cancer. In 20 years, with many patients referred for procedures involving large endometriomas, Dr Gordon has only ever identified two women with cancer developing within endometriosis. The reported risk is <1:10,000 for both endometrioid and clear-cell ovarian cancers. In other words, the risk of cancer developing in an endometriosis-affected ovary is very, very low.