The purpose of this study was two-fold, first to investigate the association between endometriosis and the risk of benign gynecologic tumors and, secondly, to evaluate the distribution of endometrioma and ovarian cysts in women with endometriosis. The medical and pathological reports of 1,000 women with endometriosis were retrospectively reviewed. The incidence of ovarian cysts, uterine leiomyomas and adenomyosis, as well as the side of ovarian cysts were further compared. A total of 295 cases of endometriomas, 172 cases of adenomyosis, 173 cases of ovarian cysts and 89 cases of uterine leiomyomas were confirmed histologically in patients with endometriosis. Serous cysts represented the most frequent diagnosis (n=81, 8.1%) in women with ovarian cysts, followed by dermoid cysts (n=15, 1.2%). In women with unilateral endometriomas, the observed proportion of left-sided cysts was found in 65.6% (164 of 250), significantly higher compared with right-sided cysts (86 out of 250, 34.4%) (P<0.001). Moreover, patients with other ovarian cysts were recognized as left-sided in 60% (96 out of 160) of cases, significantly higher compared with right-sided cysts (64 out of 160, 40%) (P<0.01). On the whole, the current study indicates that endometriosis may be associated with an increased risk of benign gynecological tumors, such as ovarian cysts, adenomyosis and leiomyomas. The results of this study confirm a left lateral predisposition of endometriomas and ovarian cysts.
Endometriosis is a common, yet enigmatic gynecological disorder affecting 3–43% women of reproductive age. Endometrioma is defined as the formation of an ovarian cyst with epithelial lining resembling the ectopic endometrium. It is observed in 17–44% of women suffering from endometriosis and represents 35% of benign ovarian cysts requiring surgery (
Adenomyosis is a common gynecological disorder which is not yet well understood; it is a myometrial lesion characterized by the presence of ectopic endometrial glands and stroma located deep within the surrounding myometrium with adjacent myometrial hyperplasia and hypertrophy (
We have previously reported a left lateral predisposition of endometrioma in two different countries (
The records of all patients with endometriosis treated at the Yale University Hospital from 1995 to 2005 and from the Departments of Obstetrics and Gynecology of the University Hospital of Crete and Venizeleio General Hospital from 1990 to 2016, were reviewed. In total, 1,000 women with endometriosis who underwent surgical treatment by laparoscopy or laparotomy in two different geographical locations were investigated. The data were collected by clinicians and pathologists. The stage of endometriosis was scored according to the revised classification of the American Fertility Society (
The study protocol was approved by the human subjects review boards at the two field centers. The Human Committee of Yale University School of Medicine approved the study for this evaluation (HIC #12590), as well as the Department of Obstetrics and Gynecology of the University of Crete and the Obstetrics and Gynecology of the Venizeleio General Hospital of Crete. The Ethics Committee for Human Research of Venizeleio Hospital also approved the study (ECHR #46/6686). All patients provided written informed consent prior to participation.
Data were recorded, including age, symptoms, stage of endometriosis, side (location, left or right side) and classification of cysts. Moreover, the information of the histological type of benign gynecological tumors was obtained from pathological records. In cases where two or more cysts were presented in the same gonad, we included the cases with the largest diameter (
Among the 1,000 females with endometriosis, endometriomas were mostly observed (29.5%), followed by adenomyosis and uterine leiomyomas (17.2 and 8.9%), respectively (
Endometriosis, ovarian cysts, adenomyosis and uterine myomas are benign diseases that commonly affect women of reproductive age. Inflammatory, environmental and genetic factors play a role in the development of these benign tumors and sometimes may be found in the same women (
Previous studies have suggested that a comorbidity association exists between endometriosis and many benign gynecological tumors (
The complexity of the disease and the limited progress in identifying its exact cause explain the reason for the existence of so many controversies in the literature regarding the most effective modality to treat endometriomas. In our series, we observed that endometriomas represented the most common type (29.5%), followed by ovarian cysts (20.3%), adenomyosis (17.2%) and uterine leiomyomas (8.9%). The current data indicate that women with endometriosis should be counseled about the future risks of developing these benign gynecological diseases. To the best of our knowledge, this is the first study on 1,000 women with endometriosis and the simultaneous co-existence of benign gynecological tumors. Despite the various theories developed to explain the establishment of endometriosis, there is a great deal of evidence to suggest that endometriosis is result of a poly-parametric system with multiple origins. In the current study, we found unilateral endometrioma was more frequent on the left-sided (65.6%) than the right-sided (34.4%) ovary. Moreover, in women with other ovarian cysts, the location site was were observed to be mostly on the left side (60%), significantly higher compared with the right side (40%).
Our results are in agreement with those of our previous study, in which it was reported that the majority of endometriomas were located in the left ovary. In that study, we suggested a new mechanical theory of implication, the female varicocele theory, which could play an important role in the development of ovarian endometriosis or endometriomas (
Considering that endometriosis arises from the interplay between genetic and environmental factors, various studies (described below) have attempted to elucidate whether any shared genetic factors exist for endometriosis, leiomyoma and adenomyosis or the genetic basis is very specific for each condition.
Various scenarios have been suggested thus far regarding the histogenesis of adenomyosis and the molecular pathways involved in this procedure. Thus, a study focusing on adenomyosis tissue reported that specific uterine marker molecules are expressed, such as oxytocin receptor (OTR), vasopressin receptor (VPR), estrogen receptor (ER) and progesterone receptor (PR) (
The peroxisome proliferator-activated receptor-γ (
Taken together, the aforementioned findings point out that some genetic factors may exhibit a pleiotropic effect concerning these conditions, thus being common risk factors for more than one of them.
In conclusion, the present study demonstrates that endometriosis is linked with an increased risk of benign gynecological tumors, such as ovarian cysts, adenomyosis and uterine leiomyomas. Additionally, the present data confirmed a left lateral predisposition of endometrium and other ovarian cysts. Overall, further research and investigations are required to elucidate the correlation between endometriosis and benign gynecological morbidities.
The authors would like to thank all the clinicians and the pathologists for providing the data and pathology reports used in this study.
Confirmation of benign gynecological conditions in 1,000 women with endometriosisa.
Condition | No. (%) |
---|---|
Ovarian or paraovarian of cyst | |
Endometrioma | 295 (29.5) |
Serous cysts | 81 (8.1) |
Mucinous cysts | 14 (1.4) |
Dermoid cysts | 15 (1.5) |
Brenner tumors | 13 (1.3) |
Miscellaneous | 28 (2.8) |
Paraovarian cysts | 22 (2.2) |
Endometrioma and other cysts | 11 (1.1) |
Uterine leiomyomas | 89 (8.9) |
Adenomyosis | 172 (17.2) |
Endometrial polyps | 16 (1.6) |
Adenomyosis and leiomyomas | 111 (11.1) |
Leiomyomas and cysts | 16 (1.6) |
Adenomyosis and cysts | 16 (1.6) |
Adenomyosis, leiomyomas and cysts | 15 (1.5) |
Out of the 1,000 women diagnosed with endometriosis, 914 were confirmed to suffer from benign conditions. The remaining women, had endometriosis with other (not benign) conditions.
Clinical characteristics and lateral distribution of endometrioma and ovarian cysts in the women studied.
Characteristic | Endometrioma n=295 (29.5% of total no. of women studied) | Ovarian cysts n=173 (17.3% of total no. of women studied) | Leiomyomas n=89 (8.9%) of total no. of women studied) | Ademyosis n=172 (17.2% of total no. of women studied) |
---|---|---|---|---|
Age (years) | 36±5.8 | 38±6.2 | 41±4.5 | 42±3.6 |
Main complaints (%) | ||||
Pelvic pain | 120 (40.6%) | 40 (19.7%) | 35 (39.2%) | 92 (53.5%) |
Infertility | 141 (47.8%) | 12 (5.9%) | 9 (10.1%) | 62 (36%) |
Adnexal mass | 34 (11.6%) | 141 (69.4%) | 45 (50.7%) | 18 (10.5%) |
Left-sided | 164/250 (65.6%) | 96/160 (60%) | ||
Right-sided | 86/250 (34.4%) | 64/160 (40%) | ||
Bilateral | 45 | 15 |
Values are presented as the means ± standard deviation or n (%).