Pathophysiology proposed as the basis for modern management of the ovarian endometrioma

Ivo Brosens, Stephan Gordts, Patrick Puttemans, Giuseppe Benagiano

Reproductive BioMedicine Online (2014)

Pathophysiology proposed as the basis for modern management of the ovarian endometrioma

Le principali linee guida internazionali indicano che solo gli endometriomi di diametro superiore a 3 cm devono essere asportati. Tuttavia, questo dogma contrasta con le moderne teorie fisiopatologiche della malattia che confermano che l’endometrioma ha un’aggressività biologica intrinseca che non dipende dalle dimensioni. Sono ormai numerosi gli studi che dimostrano che anche cisti endometriosiche di piccolo volume determinano danno ovarico e che le stesse possono essere agevolmente trattate risparmiando gran parte del parenchima ovarico. Posticipare l’intervento, intervenendo quindi solo nelle cisti di maggiori dimensioni, comporta che necessariamente bisognerà sacrificare più tessuto ovarico funzionante. Pertanto, una diagnosi e un trattamento ablativo(rimanda ad articoli Laser) precoce rappresentano la terapia di scelta allo scopo di preservare la normale funzionalità ovarica.

Abstract
Present management of the ovarian endometrioma focuses on the size of the cyst and dictates that surgery should not be performed unless this exceeds 3 cm, which neglects the complex pathology of this condition. Studies of ovaries with the endometrioma in situ show progressive smooth muscle cell metaplasia and fibrosis of the cortical layer as the main ovarian lesion. There is no correlation between the size of the endometrial cyst and the degree of ovarian pathology: it is the mere presence of an ovarian endometrioma that has a detrimental impact on the cortical layer’s follicle reserve. Cystectomy in young patients with an endometrioma may be particularly detrimental to follicle reserve, with the ovarian parenchyma loss at the time of surgery being related to the cyst’s diameter. An underutilized diagnostic procedure, transvaginal hydrolaparoscopy with in-situ inspection of the cyst wall by ovarioscopy, allows careful diagnosis of ovarian pathology and selection of appropriate surgery with minimal invasiveness. Thus, available evidence shows that expectant management may not be the best choice when an endometrioma is suspected. On the contrary, early diagnosis through a minimally invasive technique, followed by early ablative surgery whenever indicated, represents the management of choice to preserve normal ovarian function.

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