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'Blood on the Tracks' from Corpora Lutea to Endometriomas*

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'Blood on the Tracks' from Corpora Lutea to Endometriomas* DOI: 10.1111/j.1471-0528.2008.02055.x General gynaecology www.blackwellpublishing.com/bjog ‘Blood On The Tracks’ from corpora lutea to endometriomas* P Vercellini,a,b,c E Somigliana,b,c P Vigano,c A Abbiati,a,c G Barbara,a L Fedelea a Universita` degli Studi di Milano, Milan, Italy b Fondazione Ospedale Maggiore Policlinico Mangiagalli e Regina Elena, Milan, Italy c Center for Research in Obstetrics and Gynecology, Milan, Italy Correspondence: Dr P Vercellini, Department of Obstetrics and Gynaecology, Istituto ‘Luigi Mangiagalli’, University of Milan, Via Commenda 12, 20122 Milan, Italy. Email [email protected] Accepted 20 October 2008. Objective To detect a direct transition from a haemorrhagic Main outcome measure Sonographic identification of corpus luteum to an endometriotic cyst by serial transvaginal progression from a haemorrhagic corpus luteum to a recurrent ultrasonographic scans. endometriotic cyst. Design Prospective observational study. Results A haemorrhagic corpus luteum was identified in 13 women. Serial ultrasonographic scans demonstrated transition to Setting An academic tertiary care and referral centre for women an endometriotic cyst in 11 (85%) instances and resorption in two. with endometriosis. A unilateral endometriotic cyst without previous detection of Population One hundred and nine women younger than 40 years, a cystic corpus luteum was observed in 14 women. with regular menstrual cycles, undergoing first-line surgery for Conclusions Bleeding from a corpus luteum appears to be endometriomas, and not wanting postoperative oral contraception. a critical event in the development of endometriomas. Methods Three-monthly transvaginal ultrasonography during the Keywords Corpus luteum, endometrioma, endometriosis, luteal phase for 2 years after surgery. ovulation. Please cite this paper as: Vercellini P, Somigliana E, Vigano P, Abbiati A, Barbara G, Fedele L. ‘Blood On The Tracks’ from corpora lutea to endometriomas. BJOG 2009;116:366–371. Introduction which subsequently undergoes metaplasia in typical glandular epithelium and stroma. The pathogenesis of ovarian endometriotic cysts is controver- A possible role of functional cysts in the pathogenesis of sial. Based on serial sections of ovariectomy specimens, endometriomas was originally suggested by Sampson.6 Hughesdon1 suggested that endometriomas are the result of Nezhat et al.7,8 maintain that ‘primary’, small endometriomas progressive invagination and duplication of the ovarian cor- originate from endometriotic cells that adhere to the ovary, tex secondary to adhesion of the gonad to the pelvic sidewall. bleed inside, and expand, whereas ‘secondary’, large endome- Brosens et al.2,3 confirmed that adhesions are caused by super- triomas derive from functional cysts that are invaded by pla- ficial endometriotic implants observed on the anterior or lat- ques of endometriosis that bleed inside the cyst. Finally, Jain eral side of the ovary4 in correspondence with the site of and Dalton9 observed at serial transvaginal ultrasonography inversion. that ovarian follicles can develop into endometriotic cysts. At odds with the above theory, Nisolle and Donnez5 According to the above theories, the typical tarry, thick hypothesised that the pathogenesis of endometriotic cysts is fluid content of endometriomas is formed by accumulation different from that of peritoneal implants, as the former do of menstrual debris from shedding and bleeding of active not derive from regurgitated endometrium but, rather, from implants. However, if this were true, ‘chocolate’ fluid should invagination of the superficial ovarian coelomic epithelium, be found in all endometriotic lesions, whereas it is specific of ovarian disease. Accordingly, a relation between ovulation and endometriomas appears plausible, as both are exclusive *Bob Dylan: Blood On The Tracks. Columbia Records LTD, USA, 1975. ovarian occurrences. Hence, chocolate fluid may be regarded 366 ª 2009 The Authors Journal compilation ª RCOG 2009 BJOG An International Journal of Obstetrics and Gynaecology From corpora lutea to endometriomas as a clue to the pathogenesis of endometriotic cysts. In fact, confirm the diagnosis of endometrioma recurrence. Two a possible alternative source of entrapped blood is a cystic highly qualified sonographers with extensive experience in corpus luteum developing along an ovarian cortex adherent the detection of endometriotic lesions performed all the scans. to the pelvic sidewall. Clinical characteristics of women who completed the study, Given this background, we performed a serial ultrasono- were withdrawn, or were lost to follow up were compared by graphic follow-up study after surgery for ovarian endometrio- means of analysis of variance or chi-square test, as appropriate. mas with the aim of verifying the existence of a sequential evolution from corpora lutea to recurrent endometriotic cysts. Results Methods Of the 212 subjects originally enrolled, 36 (17%) were lost to follow up. A total of 109 women completed the study as 67 of The objective of this prospective observational study was to them were withdrawn for various reasons (Figure 1). No detect ultrasonographically a direct transition from a haemor- significant difference was observed in the considered clinical rhagic corpus luteum to an endometriotic cyst in women with characteristics of the women who, respectively, completed the surgically diagnosed endometriosis and postoperative normal study, were withdrawn, or were lost to follow up (Table 1). ovaries. Women undergoing laparoscopic excision of endo- A haemorrhagic corpus luteum was identified in 13 metriotic ovarian cysts, evaluated in our tertiary care referral women. In all women, no other concomitant ovarian cysts centre for women with endometriosis, were considered for were observed. Serial ultrasonographic scans demonstrated inclusion in this study. Selected subjects were younger than transition to an endometriotic cyst in 11 instances (85%, 40 years, with regular menstrual cycles, undergoing conserva- Figures 2 and 3) and resorption in two. The endometrioma tive first-line laparoscopic surgery for endometriomas, and was on the left ovary in seven (64%) women and on a pre- refusing any type of postoperative hormonal contraception. viously operated ovary in six (55%) women. A unilateral Details of the technique adopted for cyst removal have been endometriotic cyst without previous detection of a haemor- described elsewhere.10,11 Disease was staged according to the rhagic corpus luteum was observed in 14 women, being on American Society for Reproductive Medicine classification.12 the left side in 9 (64%) of them and on a previously operated At hospital discharge, women were offered follow-up visits ovary in 8 (57%). Bilateral cysts were not detected. The mean during the luteal phase of the cycle, 1 month after surgery and ± SD corpus luteum cyst diameter at initial observation was every 3 months afterwards for 2 years. Scheduling of the 4.4 ± 1.1 cm. The mean ± SD diameter of the endometriotic appointments was based on date of the last menstrual period. cysts was 3.9 ± 1.5 cm in those that developed from a haemor- On these occasions, women underwent clinical assessment, rhagic corpus luteum and 3.7 ± 1.4 cm in those detected as vaginal and rectal examination, and transvaginal ultrasonog- ‘primary’ endometriomas. raphy. Women were excluded if ovarian endometriomas were The ultrasonographic diagnosis of endometriotic cyst was identified at the first postoperative evaluation to avoid inclu- confirmed by histology in each of the 19 women who under- sion of subjects with persistent, rather than recurrent, endo- went second-line surgery (9/11 in the haemorrhagic corpus metriotic cysts. luteum group and 10/14 in the ‘primary’ endometrioma Haemorrhagic corpus luteum cyst was defined as an ovar- group). At 2-month follow-up transvaginal ultrasonography, ian cyst with a diameter of more than 3 cm, thin, well defined, the diagnosis of endometrioma was confirmed in all the regular walls, posterior enhanced through-transmission, with remaining six women who did not undergo repeat laparoscopy. either a fishnet wave or reticular appearance due to fine inter- digitating septations without flow or an anechoic content Discussion with triangular or curvilinear echogenic areas and occasional fluid–debris levels.13 Ovarian endometrioma was diagnosed Brosens et al.4 defined the endometrioma as an ‘extraovarian when a round-shaped cystic mass with a minimum diameter pseudo-cyst’ because the majority of these lesions are not of 2 cm, with thick walls, regular margins, homogeneous low intraovarian but extraovarian, and the wall of the cyst is lined echogenic fluid content with scattered internal echoes, and by gonadal cortex. This is the consequence of a process begin- without papillary proliferations was observed.14 ning with implantation of regurgitated endometrial cells Whenever a haemorrhagic corpus luteum cyst was along the pelvic sidewall and lateral ovarian aspect, resulting detected, serial transvaginal ultrasonographic scans were per- in adhesion between the gonad and the peritoneum of the formed weekly, until either postmenstrual resorption or con- ovarian fossa and broad ligament.2 Subsequently, the cortex version to an endometriotic cyst was demonstrated. In the invaginates and active ovarian implants are usually found at latter case, when immediate surgery was not deemed neces- the site of inversion.2 sary (e.g. in the presence of a complex adnexal cyst), trans- The missing link of this pathogenetic
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