16th Annual Patient Day
Your Mother Should Know, Your Doctor Should Know Better!
Patient Day - March 2, 2025
Einhorn Auditorium
Lenox Hill Hospital, New York City
Scientific Director
Dan Martin, MD
Program Director
Tamer Seckin, MD
All right, so I wanted to talk about something that probably a lot of women experience in the room. It is a slightly short time, so I want to talk about endometriomas, but I think in order to even get to endometriomas, we should talk about physiologic cysts, sort of how cysts form something like hemorrhagic cysts. So lemme just get started. Alright, so I have no disclosures related to this talk. Before we start with cysts, let's quickly talk about the ovaries. Okay, so remember the ovaries, they're typically paired endocrine organs, meaning they produce hormones. They're positioned on either side of the uterus. They actually weigh only four to eight grams each. These are normal ovaries, and they measure roughly one by two by three centimeters. So they're sort of the size of almonds. If you think about that, you have two almonds that are very, very powerful in generating a lot of this. So during puberty, remember the brain stimulates the ovary to cause maturation of follicle. So these are eggs, okay? Menarchy is the age at your first period. So on average that is about 12. For the majority periods become regular after three to four years. And we know that the average age of menopause in the US is about 50 to 51. So this is, I dunno if it's a fun fact, but it's a fact. Women have about 400 to 500 periods in their lifetime, and that's equal to about six years of their lives.
So this is a depiction of an ovary. It's sort of a ovary sort of through the menstrual cycle. So if you start here on this upper right hand corner, what you're seeing there is sort of the early follicles. If you follow that counterclockwise, what you're going to do is you're sort of following the ovary through the follicular phase. So remember during the follicular phase, estrogen is rising. You're recruiting eggs. In the beginning you have quite a few eggs towards what we call ovulation typically. So the midpoint of the cycle, we are selecting what's called a dominant follicle. So sort of the best egg of the bunch. And remember, for ovulation to happen, that egg is released. That egg is released, potentially it travels down the tube for implantation to meet the sperm for implantation. So the site of ovulation then regress it. Well then it becomes something called the corpus lium, which is very, very important. This is also a hormonally active structure, and unfortunately, if it doesn't see fertilization and plantation, it becomes something called the corpus albicans, which is honestly very challenging to see, but you can see it on things like pathology reports.
Okay, so the corpus luteum, remember this is a normal structure. So temporary endocrine organ, it secretes progesterone, other hormones, it protects the egg, allows time for fertilization implantation. If fertilization happens, then the egg is going to make its own hormone, beta, HCG, keep that corpus lutetium talking, producing progesterone, and then the placenta will take over around nine to 10 weeks. So this is what a corpus lium looks like on ultrasound. And there's a couple of appearances, but on average it measures about two centimeters. It's this round hypo coic, meaning low echo structure. It has something called peripheral vascularity. So that means it has vessels on the outside. So it has this sort of ring of fire sign. It can also look like this. So this is sort of what it looked like in the drawing. So it's thick wall. Those walls tend to be irregular, poorly defined.
It looks like it's collapsing in on itself, right? Okay. So remember, those are the things that are normally happening anyways. Okay? Now 20 to 30% of women will have an ovarian cyst in their lifetime. But of course we know the actual prevalence is unknown because most of those cysts are going to be asymptomatic, potentially benign, but a lot will resolve before they're even found. Okay? 4% of women will be admitted to the hospital for ovarian cyst by the time they're 65. And the common symptoms unfortunately are very common. So they overlap with a lot of other conditions, but they include bloating, nausea, abdominal pressure, painful periods, urinary symptoms, painful intimacy, back pain.
Now the first type of cyst, okay, so this is a follicular cyst, okay? So this type of cyst basically occurs when the follicle continues to grow and it doesn't rupture, so you don't ovulate. It keeps growing. And so on ultrasound, it's typically bigger than three centimeters because a normal mature follicle measures around two and a half centimeters. So it has these very specific characteristics. Most typically it's ocular, meaning it's like one loculation, one area, and a coic meaning no echoes and it's smooth walled. So basically if you ever are looking over at what the stenographer is doing, it basically looks like a black water balloon.
So a corpus lium cyst occurs when the corpus luteum fails to go away. So it fails to involute and it actually just keeps getting bigger. So this is more common in women using a RT, meaning assisted reproductive technology, IVF egg freezing. And then this is what is important as well. So both of these types of cysts, they have vessels in them, they have vascularity, I just talked about this ring of fire. So they can both become something on the right hand side called a hemorrhagic cyst. And some people may be more familiar with this because a hemorrhagic cyst looks very similar to an endometrioma on sonogram. So after some internal bleeding, this has this sort of lacy reticular pattern that you can see here. Unfortunately, hemorrhagic cysts also have a pretty variable appearance. They can look like that. They can also have this sort of dense, solid, dense, solid nature.
They can have what's on the bottom. So it has mixed sort of cyst solid patterns. It's more commonly found in the second phase of your cycle. But the important thing to know here is that hemorrhagic cysts, all of these cysts tend to go away. So they tend to resolve. Okay, so then that actually brings us finally here. So this is our endometrioma. Okay? This is our chocolate cyst. So of course I'll speed up too. So this forms really from the seeding of the uterine lining to the ovary, and it causes this repetitive cyclic hemorrhage process. It creates this very, very pathognomonic, sort of like Hershey's chocolate cyst fluid. 25% of endometriosis roughly okay, will form an endometrioma. And about 25% of those are going to be bilateral, and they have this very classic appearance. We call it ground glass. Oops, that's the wrong thing. Same thing, ground glass appearance.
But you can see how it kind of looks similar to that hemorrhagic cyst that we just saw. Okay, aside from the actual symptoms, which I won't go into right now, what impact does having an endometrioma have? So one of the big ones is unfortunately it decreases your ovarian reserve, your ovarian function. How do we think that happens? There's a couple of mechanisms here that sort of the two biggest one is number one, we think. Imagine now that ovary I just talked about, the size of an almond. If you think you have a five centimeter endometrioma, unfortunately that cyst is so large, we imagine there's compression of that healthy ovarian tissue impairs the circulation can cause some ischemia overall, unfortunately damaging the ovarian reserve. Also, of course, the cyclic inflammation causes scar tissue and damage over time. Okay, so very important here. So how do we measure the ovarian reserve?
So some of you might be familiar with this. We use a number of measures, but these are two of the most common. So hormone a blood test, sorry, is called the anti-malaria hormone, A MH. It's a hormone produced by your growing follicles. The reis, the fertility specialists tend to use antral follicle count as well where they're actually counting the number of the follicles. But what we do know very generally is that sort of the larger the endometrium that you have, the lower your A MH, so the lower your ovarian reserve. They also did a good study where they took women with endometrium as women with without, and they measured their AM MH over time. So they saw, okay, the women with endometriomas, their decline in A MH is also faster. So just by nature of the size and how long they're having them there is impacting the ovarian reserve.
I use this chart a lot with my patients, but they looked at almost 3000 patients and looked at sort of the mean A MH for age. So if you're age 25, the median A MH is about 5.4. If you're 30, that median is about 3.5 35, 2 0.5, and at 41.2. So again, this is a surrogate marker. This obviously taken contextually with a patient, but it gives us a very rough estimate, especially if fertility is very big on a patient's mind, if they're at maybe the 10th percentile or lower for their age. In the context of endometriomas, it could be a very important time to have some counseling in general, not just endometriomas, but endometriosis in general does have a decrease in spontaneous fertility. So we typically say fecundity as the chance of conceiving each cycle. Normal fecundity is about 15 to 25%, depending on your age. And rates of fecundity are extrapolated to be anywhere from two to 10% with endometriosis. So it's not that you cannot get spontaneously pregnant. Okay? It's just that it may be more challenging. And obviously there are things that delay time to pregnancy in our modern world.
Can an endometrium resolve spontaneously? So typically no, we don't think they can. So if sometimes I have women say, oh, I had an endometrium three years ago, they saw it on my ultrasound, but it went away. Sometimes two things. One is perhaps it was a hemorrhagic cyst. It's really hard to tell, especially with old imaging. The other is that potentially that endometrioma ruptured or leaked, which is its own host of problems. But in general we say no, they don't typically resolve can hormonal medication help? So also this we say generally, no, it's not going to resolve the endometrioma, but it can prevent growth. It's actually a very, very important part of recurrence risks that I'm about to talk about, and it can shrink them moderately. So if you have a very small endometrioma, you may be a candidate for medical management. So our best options, unfortunately, the first one is not available in the us.
That's est. And the second one is north syndrome, which is a very strong progestin, probably many of you're familiar with it. Unfortunately, it does have a pretty strong side effect profile. So, alright, very quickly, surgical options, and this is again a generalization, but the first two ovarian drainage where the cyst is ruptured, drained, and then sometimes burned is what some practitioners are doing. The second is an ovarian cystectomy. We actually take the wall of the cyst, fully peel it out and repair the ovary. The last one is something called ovarian sclerotherapy. It's gaining a little bit of traction, I think more in Europe. We don't have so much time talk about it, but it essentially involves putting the ovarian bed, sort of the cyst wall basically in ethanol, since it's not standard of care right now, I'm not going to go too much into it, but people are trying to develop ways to reduce the risk of damage to the ovary anytime we do surgery. So people again, are still even on the surgical front and they're pushing very hard on the medical front, but trying to find ways to make our surgeries better.
This is a picture of the pelvis at the time of laparoscopy, and this is a very nice looking pelvis. There's a uterus in the middle. Okay, that's the central structure. And if you look on just below that, on either side are the ovaries, those white structures, and then you're going to see fallopian tubes just lateral to that. So this is an example of an endometrioma, and you can sort of appreciate this implant that's already seeded itself. You can see this increased vascularity. This looks like the, I dunno, this just looks angry. And inside you will find that very classic chocolate cyst fluid. You can actually, if you have a keen eye, you can see there's actually an adhesion already forming back here. And actually look at where we are. This ovary is actually already pulled medially, so it's already pulled to the rectum. So this process is starting this repetitive cyclic process, inflammatory process. And then unfortunately, if you leave these things unchecked, you could develop more bilateral endometrioma. Unfortunately, in this patient you can see not just that obliteration of the normal sort of pelvis, but if you look carefully here too, you can actually see that tube going into this space. So unfortunately, this tube was already too involved at that time. And this one is just a slightly bit more dilated, but looked fine.
Okay, good. Last slide. So should you give hormonal therapy to prevent recurrence? There's a little bit of controversial it is, but in general, yes. Okay. Ovarian endometriomas, if you do not do anything, will recur in about 27 to 30% of patients in only two years. So you really don't want to keep doing this type of surgery over and over again. I mean, medication is not perfect, but it's better than nothing. They did a very nice study in 2010. They took about 240 women who underwent cystectomy and they followed them out for 24 months. So they found a similar rate. So if you didn't use any birth control, the recurrence rate was about 29% if you use birth control, but you took it cyclically, meaning you took that placebo pill, your recurrence rate was better, but it was still 15%. So it was only with continuous use where you're taking hormones every day that they got the recurrence rate down to about 8%.
The good thing that we noted too was that if you were taking some form of hormonal pills, if you did have a recurrence, at least that recurrence was smaller. So that was a really important point. Of course, women have different and independent risk factors. It's not just medication. So early age, if you make bilateral endometriomas, if you make more than one endometrium in an ovary, those are all risk factors and obviously the type of surgery you have. Okay. Just hit okay. In summary, so each menstrual cycle, a dominant follicle and a corpus lutetium form. Okay. Functional cysts. Okay. Cysts that happen physiologically are follicular cysts, corpus lutetium cysts, and they can both create hemorrhagic cysts. Unlike endometrium, as these cysts tend to go away. Endometriomas unfortunately cause a decline in ovarian function and spontaneous fertility. We will have some very good fertility talk later today. Endometrioma should be treated with cystectomy rather than ablation and drainage. And then medical management and follow-up is important for endometriomas given their recurrence risk. These are some references. Okay. I want to thank everyone for coming.
