Endometrioma

Changed by Dr Henry Knipe on 18 Dec 20:32

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Endometriomas,also known as a chocolate cysts or endeometriotic cysts, are a localised form of endometriosis and are usually within the ovary. They are readily diagnosed on ultrasound, with most demonstrating classical radiographic features. 

Epidemiology

It affects women of reproductive age.

Pathology

Endometriomas contains dark degenerated blood products following repeated cyclical haemorrhage. The cysts may be up to 20 cm in size although they are usually smaller (2-5 cm).

Location

Typical locations include:

  • ovaries: ~75%
  • anterior/posterior cul-de-sac: ~70% 
  • posterior broad ligament: ~50% 
  • uterosacral ligaments: ~35%
  • uterus: ~10 %
  • colon: ~5% 

Radiographic features

Plain film

Not usually helpful in diagnosis.; ~10% of endometriomas can calcify.

Ultrasound

In the typical situation there is acoustic enhancement with diffuse homogenous low-level internal echoes as a result of the haemorrhagic debris. This appearance occurs in 95% of cases and is considered the classic finding on ultrasound examination. Features of multi-locularity and hyper-echoic wall foci may be present. Anechoic cysts may occur, but they are rare.

MRI

Signal characteristics vary according to the age of any complicating haemorrhage 6:

  • T1: typically, lesions appear hyperintense while acute haemorrhage occasionally appears hypointense
  • T2
    • typically hypointense owing to the presence of deoxyhaemoglobin and methaemoglobin
    • old haemorrhage occasionally appears hyperintense

A shading sign 3 may be seen and is very suggestive of an endometrioma.

Treatment and prognosis

Although endometriomas are usually a benign entity, there is an ~1% rate of malignant transformation4. It is seen, seen mostly in women >40 years after several years of latency, with endometriomas larger than 9 cm 4-5.  Malignant transformation is uncommon in masses <6 cm.

If not surgically excised, follow-up should be at least yearly 4. GnRH agonists may be used for medical management.

Differential diagnosis

General imaging differential considerations include:

  • -<p><strong>Endometriomas</strong>,<strong> </strong>also known as a <strong>chocolate cysts</strong> or <strong>endeometriotic cysts</strong>, are a localised form of <a href="/articles/endometriosis">endometriosis</a> and are usually within the <a href="/articles/ovaries">ovary</a>.</p><h4>Epidemiology</h4><p>It affects women of reproductive age.</p><h4>Pathology</h4><p>Endometriomas contains dark degenerated blood products following repeated cyclical haemorrhage. The cysts may be up to 20 cm in size although they are usually smaller (2-5 cm).</p><h5>Location</h5><p>Typical locations include:</p><ul>
  • +<p><strong>Endometriomas</strong>,<strong> </strong>also known as a <strong>chocolate cysts</strong> or <strong>endeometriotic cysts</strong>, are a localised form of <a href="/articles/endometriosis">endometriosis</a> and are usually within the <a href="/articles/ovaries">ovary</a>. They are readily diagnosed on ultrasound, with most demonstrating classical radiographic features. </p><h4>Epidemiology</h4><p>It affects women of reproductive age.</p><h4>Pathology</h4><p>Endometriomas contains dark degenerated blood products following repeated cyclical haemorrhage. The cysts may be up to 20 cm in size although they are usually smaller (2-5 cm).</p><h5>Location</h5><p>Typical locations include:</p><ul>
  • -</ul><h4>Radiographic features</h4><h5>Plain film</h5><p>Not usually helpful in diagnosis. ~10% of endometriomas can calcify.</p><h5>Ultrasound</h5><p>In the typical situation there is acoustic enhancement with diffuse homogenous low-level internal echoes as a result of the haemorrhagic debris. This appearance occurs in 95% of cases and is considered the classic finding on ultrasound examination. Features of multi-locularity and hyper-echoic wall foci may be present. Anechoic cysts may occur, but they are rare.</p><h5>MRI</h5><p>Signal characteristics vary according to the age of any complicating haemorrhage <sup>6</sup>:</p><ul>
  • +</ul><h4>Radiographic features</h4><h5>Plain film</h5><p>Not usually helpful in diagnosis; ~10% of endometriomas can calcify.</p><h5>Ultrasound</h5><p>In the typical situation there is acoustic enhancement with diffuse homogenous low-level internal echoes as a result of the haemorrhagic debris. This appearance occurs in 95% of cases and is considered the classic finding on ultrasound examination. Features of multi-locularity and hyper-echoic wall foci may be present. Anechoic cysts may occur, but they are rare.</p><h5>MRI</h5><p>Signal characteristics vary according to the age of any complicating haemorrhage <sup>6</sup>:</p><ul>
  • -</ul><p>A <a href="/articles/shading-sign">shading sign</a> <sup>3</sup> may be seen and is very suggestive of an endometrioma.</p><h4>Treatment and prognosis</h4><p>Although endometriomas are usually a benign entity, there is an ~1% rate of malignant transformation <sup>4</sup>. It is seen mostly in women &gt;40 years after several years of latency, with endometriomas larger than 9 cm <sup>4-5</sup>.  Malignant transformation is uncommon in masses &lt;6 cm.</p><p>If not surgically excised, follow-up should be at least yearly <sup>4</sup>. GnRH agonists may be used for medical management.</p><h4>Differential diagnosis</h4><p>General imaging differential considerations include:</p><ul>
  • +</ul><p>A <a href="/articles/shading-sign">shading sign</a> <sup>3</sup> may be seen and is very suggestive of an endometrioma.</p><h4>Treatment and prognosis</h4><p>Although endometriomas are usually a benign entity, there is an ~1% rate of malignant transformation, seen mostly in women &gt;40 years after several years of latency, with endometriomas larger than 9 cm <sup>4-5</sup>.  Malignant transformation is uncommon in masses &lt;6 cm.</p><p>If not surgically excised, follow-up should be at least yearly <sup>4</sup>. GnRH agonists may be used for medical management.</p><h4>Differential diagnosis</h4><p>General imaging differential considerations include:</p><ul>

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Cases and figures

  • Case 1
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  • Case 2: endometrioma, fibroid and ovarian cyst
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  • Case 3
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  • Case 4
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  • Case 5
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  • Case 6
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  • Case 7: chocolate cyst in right adnexa
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  •  Case 8
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  • Case 9: T1 C+ fat sat
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  • Case 10: MRI T1
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  • Case 11
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  • Case 12
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  • Case 13
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  • Case 14
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  • Case 15: bilateral ovarian
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  • Case 16
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  • Case 17
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  • Case 18
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  • Case 19: MRI signs
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  • Case 20
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  • Case 21: shading sign
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  • Case 22: ruptured endometrioma
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  • Case 23
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  • Case 24
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