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Dan C. Martin, MD
UT Medical Group, Inc.

University of Tennessee Health Science Center (UTHSC)

UTHSC Academic Office

Daniel Clyde Martin, M.D.
UT Medical Group, Inc.
Infertility and Gynecology
Reproductive Surgery
Germantown Office Building
7945 Wolf River Boulevard
Suite 320
Germantown, Tennessee
TN 38138-1733

(901) 347-8331
(901) 347-8188 fax
Directions to Office

Updated information is at
UTMG 2006

Click for information on:
Glenn Ann Martin, Ph.D.
Clinical Psychologist

Ovarian Endometriosis

Adapted from "Recognition of Endometriosis" in
Laparoscopic Appearance of Endometriosis, Lecture Supplement
Martin DC (ed), Resurge Press, Memphis, (c)1991

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Of interest, the first reported case of microscopic endometriosis was in the ovary and was recognized on a pathology slide but not at the time of surgery. (Russell, 1899) Similar deep unrecognized ovarian endometriosis has been more recently been documented by Candiani(Candiani, Vercellini, & Fedele, 1990) and Vercellini. (Vercellini, Vendola, Bocciolone, Rognoni, Carinelli, & Candiani, 1991) These hidden areas appear to contribute to the 14% to 59% under-diagnosis rate in surgical procedures. (Martin, Ahmic, El-Zeky, Vander Zwaag, Pickens, & Cherry, 1990) (Table 4)

Surface lesions of the ovary can have the same appearance as any peritoneal lesion. Although small clear and red lesions on the surface will be hard to biopsy due to the dense stroma beneath them, these are easy to coagulate or vaporize.

Some lesions appear to infiltrate the stroma, others invaginate, (Hughesdon, 1957; Martin & Berry, 1990) and others may infiltrate corpus lutea. (Nezhat, Nezhat, Allan, Metzger, & Sears, 1992; Sampson, 1921) When the lesions invaginate into the cortex, an inner cortex is developed which is the inner margin of a developing ovarian endometrioma. (Hughesdon, 1957) When these ovarian endometriomas are opened, confirmation is common in small red excrescences on a white background or red excrescences on a mottled brown and white background. These reddish excrescences are often polypoid fronds of endometriosis arising from the wall whereas the brown areas are more commonly hemosiderin-laden and nonspecific but may have an endometrial epithelial lining at the surface. The flat white area is more commonly nonspecific scarring. This scarring appears to be a reaction to the endometriosis and forms the pseudocapsule of the endometriomas. (Martin & Berry, 1990) The type of collagen in the ovarian pseudocapsule suggests a metaplastic process. (Khare, Martin, & Eltorky, 1996)

The diagnosis of an endometrioma is based on both clinical and pathologic findings. When Vercellini examined endometriomas that fit an appearance with four suggestive criterion, he was able to document histologic evidence of endometriosis in 97% of 218 cysts diagnosed as endometrioma at laparotomy. His criteria were size = 12 cm, adhesions to pelvic side wall or broad ligament, powder burn with red or blue spots on the surface, and thick,tarry, chocolate-colored fluid contained within in the cyst. (Vercellini, et al., 1991) On the other hand, not all cystic endometriomas meet the four criterion used in Vercellini's study. Adhesions are irregular, the surface can be smooth, powderburn lesions may not be noted on the surface, and the fluid can be a clear yellow in uncommon circumstances.

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Basing the prospective diagnosis on chocolate fluid alone in patients with evidence of peritoneal endometriosis, Martin found that 61% of chocolate cysts were endometriomas whereas 27% were corpus lutea. Of the corpus lutea, 15% were diagnosed clinically and 12% only on the basis of histology. Retrospectively, irregular red and brown surface lesions on the inner surface of a white fibrotic capsule was the finding most commonly confirmed. (Martin & Berry, 1990) Patients with peritoneal endometriosis may have an increased chance of symptomatology in hemorrhagic corpus lutea. In a retrospective review of 206 patients with a laparoscopic or histologic diagnosis, 178 (92%) of 194 ovarian endometriomas diagnosed at laparoscopy were histologically confirmed. There were an additional 12 endometriomas diagnosed by pathology but not at the time of laparoscopy. (Canis, Mage, Pouly, Wattiez, Manhes, & Bruhat, 1994) The false diagnoses at laparoscopy included functional cysts, serous cysts, mucinous cyst, dermoid and benign clear cysts. But, not all researchers have been able to find endometrial epithelium, glands or stroma in the walls and lining of the cyst. Fayez reported finding no histologic evidence of endometriosis in 50 patients undergoing surgery for 66 endometriomas. (Fayez & Vogel, 1991) 

Although the endometrioma wall can be stripped out in its entirety for complete analysis, biopsy followed by coagulation or vaporization and with or without follow-up medical suppression therapy may be used. The techniques of biopsy and coagulation may limit the degree of destruction of healthy ovarian tissue. A second look laparoscopy or laparotomy would be carried out if there is evidence of persistence or recurrence. (Donnez, Nisolle, Karaman, Wayemberg, Bourgonion, Clerckx, et al., 1989) Sutures are avoided in the care of ovarian endometriomas as well as in the care of peritoneal endometriosis. (Martin & Diamond, 1991) 

Although ovarian cystectomy is preferable in women who desire future fertility, oophorectomy may be indicated. This is particularly true when the combination of CA-125 levels and sonography suggest an increased risk of malignancy. This possibility is evaluated preoperatively using a combination of serum CA-125 levels and sonography. The finding of septi, internal echoes and solid areas associated with a high CA-125 level increases the chance of malignancy and indicates a need for preoperative planning with the patient regarding surgical care should cancer be found at laparoscopy or laparotomy. (Morales & Murphy, 1992) However, endometriomas have been associated with elevated CA-125 levels; and multicystic, cystic and solid appearing masses on sonography have been endometriomas at surgery. Herrmann (Herrmann, Locher, & Goldhirsch, 1987) noted that 58% of benign cysts had cystic and solid components on sonography as opposed to 93% of malignant cysts. There is concern regarding spill of malignant ovarian cysts, dermoids and mucinous adenomas. (Hsiu, Given, & Kemp, 1986; Kindermann, Maassen, & Kuhn, 1996; Maiman, Seltzer, & Boyce, 1991) Spill can be limited by bagging the ovary and exteriorizing the bag prior to opening the cyst. (Quinlan, Townsend, & Johnson, 1997) An additional immediate concern is to avoid delay in therapy of an unexpected ovarian cancer. (Kindermann, et al., 1996; Maiman, et al., 1991; Trimbos, Schueler, van Lent, Hermans, & Fleuren, 1990)

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Bibliography

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Candiani, G. B., Vercellini, P., & Fedele, L. (1990). Laparoscopic ovarian puncture for correct staging of endometriosis. Fertil Steril, 53, 994-997.

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Canis, M., Mage, G., Pouly, J. L., Wattiez, A., Manhes, H., & Bruhat, M. A. (1994). Laparoscopic diagnosis of adnexal cystic masses: a 12-year experience with long-term follow-up. Obstet Gynecol, 83, 707-712.

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Donnez, J., Nisolle, M., Karaman, Y., Wayemberg, M., Bourgonion, D., Clerckx, F., & Casanas-Roux, F. (1989). CO2 laser laparoscopy in peritoneal endometriosis and in ovarian endometrial cyst. J Gynecol Surg, 5, 361-366.

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Fayez, J. A., & Vogel, M. F. (1991). Comparison of different treatment methods of endometriomas by laparoscopy. Obstet Gynecol, 78, 660-665.

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Herrmann, U. J., Locher, G. W., & Goldhirsch, A. (1987). Sonographic patterns of ovarian tumors: prediction of malignancy. Obstet Gynecol, 69, 777-781.

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Hsiu, J., Given, F., & Kemp, G. (1986). Tumor implantation after diagnostic laparoscopy biospy of serous ovarian tumors of low malignant potential. Obstet Gynecol, 68, 905-935.

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Hughesdon, P. E. (1957). The structure of endometrial cysts of the ovary. J Obstet Gynaecol Br Emp, 64, 481-487.

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Khare, V. K., Martin, D. C., & Eltorky, M. (1996). A comparative study of ovarian and pelvic wall-infiltrating endometriosis. J Am Assoc Gynecol Laparoscopists, 3, 235-239.

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Kindermann, G., Maassen, V., & Kuhn, W. (1996). Laparoscopic management of ovarian tumors subsequently diagnosed as malignant. J Pelvic Surg, 2, 245-251.

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Maiman, M., Seltzer, V., & Boyce, J. (1991). Laparoscopic excision of ovarian neoplasms subsequently found to be malignant. Obstet Gynecol, 77, 563-565.

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Martin, D. C., Ahmic, R., El-Zeky, F. A., Vander Zwaag, R., Pickens, M. T., & Cherry, K. (1990). Increased histologic confirmation of endometriosis. J Gynecol Surg, 6, 275-279.

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Martin, D. C., & Berry, J. D. (1990). Histology of chocolate cysts. J Gynecol Surg, 6, 43-46.

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Martin, D. C., & Diamond, M. P. (1991). The role of sutures in reconstructive pelvic surgery. Fertil Steril (Letters-to-the-Editor), 56, 792.

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Morales, A. J., & Murphy, A. A. (1992). Operative laparoscopy in gynecology. Curr Probl Obstet Gynecol Fertil, March/April, 73-102.

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Nezhat, F., Nezhat, C., Allan, C. J., Metzger, D. A., & Sears, D. L. (1992). Clinical and histologic classification of endometriomas. Implications for a mechanism of pathogenesis. J Reprod Med, 37, 771-776.

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Quinlan, D., Townsend, D. E., & Johnson, G. H. (1997). Safe and cost-effective laparoscopic removal of adnexal masses. J Am Assoc Gynecol Laparoscopists, 4, 215-218.

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Russell, W. W. (1899). Aberrant portions of the Mullerian duct found in an ovary. Johns Hopkins Hosp Bul, 94-96(January, February, March), 8-10.

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Sampson, J. A. (1921). Perforating hemorrhagic (chocolate) cysts of the ovary. Their importance and especially their relation to pelvic adenomas of the endometrial type ("adenomyoma" of the uterus, rectovaginal septum, sigmoid, etc.). Arch Surg, 3, 245-323.

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Trimbos, J. G., Schueler, J. A., van Lent, M., Hermans, J., & Fleuren, G. J. (1990). Reasons for incomplete surgical staging in early ovarian carcinoma. Gynecol Oncol, 37, 374-377.

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Vercellini, P., Vendola, N., Bocciolone, L., Rognoni, M. T., Carinelli, S. G., & Candiani, G. B. (1991). Reliability of the visual diagnosis of ovarian endometriosis. Fertil Steril, 56, 1198-1200.

Adapted from "Recognition of Endometriosis" in
Laparoscopic Appearance of Endometriosis, Lecture Supplement
Martin DC (ed), Resurge Press, Memphis, (c)1991

The color illustrations that accompanied this paper are in the Color Atlas.

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