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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,three major clinical disruptions need to be addressed ade-

quately: pain, infertility, and malignant transformation. Symp-

toms differ according to the patients 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 thatit originates

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 achocolate cystor 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 characteristicappearance 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-associatedovarian 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 womans 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.

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,

Kyoto 606-8507, Japan

e-mail: [email protected]

Curr Obstet Gynecol Rep (2012) 1:1624

DOI 10.1007/s13669-011-0002-3


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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 internalexamination 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 endometriotic cyst

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

Infertility

Pain

(Menopause) Elder ageYounger age Reproductive age

Medical care

Curative (radical) treatmentPreservation of ovarian function

Malignant transformation

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

Curr Obstet Gynecol Rep (2012) 1:1624 17


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solid portion, contrast enhancement is mandatory to exclude

malignancy, such as a clear cell carcinoma [3,8].

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 cysts 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 finding

can be easily misdiagnosed as a malignancy [1012]. In such

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. 2 Typical images of an endometriotic cyst.aUltrasonography (US), showing a unilocular cyst with a diffuse and low-level echo within it.bdOn

MRI scans, the contents of the cyst show high intensity in both T1-weighted and T2-weighted images, reflecting the blood element

18 Curr Obstet Gynecol Rep (2012) 1:1624


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Management of Endometriotic Cyst According

to the Symptoms

The treatment options for ovarian endometriotic cyst areeither 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, OCs, and

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 indicatewhether 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 [2022]. 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

Fig. 3 Images of a case of clear cell carcinoma, which arose in the

same patient as Fig. 2 after an interval of 6 years. a ultrasonography

(US), showing that the cyst contains a solid portion and the cyst is

larger than it was 6 years ago.beOn MRI scans, the cyst is unilocular

and shows high intensity both in T2-weighted images (b, c) and T1-

weighted images (d, e) with several nodular portions. These nodular

portions show isointensity to high intensity in the T2-weighted image

and low intensity in the T1-weighted images. e These portions also

show positive contrast enhancement (CE)



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chronic pelvic pain in patients who underwent cystectomy

compared with those who underwent drainage alone [21,

22]. Another obvious advantage of cystectomy is that 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 aftersurgery 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 postoperativemedical 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

disrupt fertility [34]. For example, interleukins directly affect

sperm motility, and tumor necrosis factor (TNF)- causes

DNA damage to the sperm [3537]. These factors, along with

reactive oxygen species (ROS) produced by endometriosis,

also impede sperm capacitation, oocyte-sperm interaction,

and oocyte quality [33,34].

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 inthe 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 forwomen 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 1025% of

patients undergoing IVF have accompanying endometriosis,

and 1744% 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].

As regards surgical intervention, Tsoumpou et al. [41]

performed a meta-analysis of five studies comparing surgical

treatment versus no treatment for ovarian endometriotic cyst.



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The results showed no significant effect of treatment on IVF

pregnancy rates and on ovarian response to stimulation, com-

pared with no treatment. Nevertheless, 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], 1.41.9), and

this risk increases in women with a longer history of endome-

triosis (SIR, 2.24.3) [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

cancer into account in managing endometriosis, especially in

elderly women. There are few guidelines, however, on how to

manage endometriosis as a precursor of ovarian cancer. This

lack is partly because the risk factors for ovarian cancer among

women with endometriosis are not fully 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 beimplicated in these conditions include unopposed estrogen

status, increased expression of estrogen , 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 hysterectomywith 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 to be a major risk for

ovarian cancer. Together with their therapeutic effect on endo-

metriosis, OCs may reduce the risk of malignant transformation



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of endometriosis, but there is not yet any conclusive study on

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 ofmedical 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 cyst is superior to

ablation in terms of reduced recurrence, relief of pain, and

pregnancy rates [60]. Damage caused by the removal of

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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