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Ultrasonographic Assessment of Ovarian Endometrioma

Article  in  Journal of Medical Ultrasound · December 2008

DOI: 10.1016/S0929-6441(09)60001-1

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 R E V I E W
A R T I C L E

Ultrasonographic Assessment of
Ovarian Endometrioma
Meng-Hsing Wu*, Yueh-Chin Cheng, Fong-Ming Chang

Endometriosis is a common gynecologic disease that affects about 10% of women of

reproductive age. Most women with endometriosis experience pelvic pain, dysmenorrhea,
dyspareunia and infertility, all of which reduce their quality of life. Ultrasound examination
is an easy and noninvasive method in the differential diagnosis of endometriosis, and is
useful in planning surgical intervention of ovarian endometrioma, as well as preoperative
and postoperative medical therapy. With advances in ultrasonography, the application of
higher-frequency scanning probes can evaluate ovarian endometrioma to improve diag-
nostic accuracy. This includes morphologic assessment with two-dimensional ultrasound
and other various ultrasound modalities such as three-dimensional sonography, color
Doppler, and power ultrasound imaging. The aim of this review will focus on the ultra-
sonographic findings of ovarian endometrioma during diagnosis, in differentiating vari-
ous benign and malignant tumors, and their functional role during treatment.

KEY WORDS — endometrioma, ovary, ultrasonography

■ J Med Ultrasound 2008;16(4):241–248 ■

Introduction [1]. Retrograde menstruation with additional fac-

Endometriosis, which is defined as ectopic pres-
ence of endometrial tissue outside the uterus, is a
common gynecologic disease that affects about
10% of women of reproductive age. Most women
with endometriosis experience pelvic pain, dys-
menorrhea, dyspareunia and infertility, all of which
reduce their quality of life. Although the mechanism
responsible for the development of endometriosis
remains unclear, several hypotheses have been pro-
posed to investigate the etiology of endometriosis
tors, such as aberrant production of steroids from
ectopic endometriotic lesions, and alteration and/or
dysfunction of the immune system (especially mac-
rophages) in the peritoneal microenvironment in-
creases the susceptibility of endometriosis. Ovarian
endometrioma is considered to be one entity of nu-
merous component endometriotic lesions, and its pa-
thogenesis may be either implantation or metaplasia
theory from histogenesis of ovarian endometrio-
mas. Continuum between the flat cells of the ovar-
ian surface mesothelium and the endometrial-type

Received: September 1, 2008 Accepted: September 9, 2008

Department of Obstetrics and Gynecology, National Cheng Kung University Hospital and College of
Medicine, National Cheng Kung University, Tainan, Taiwan.
*Address correspondence to: Dr. Meng-Hsing Wu, MD, PhD, Department of Obstetrics and Gynecology, College
of Medicine, National Cheng Kung University, Tainan 70428, Taiwan.
E-mail: mhwu68@mail.ncku.edu.tw

©Elsevier & CTSUM. All rights reserved. J Med Ultrasound 2008 • Vol 16 • No 4 241
 M.H. Wu, Y.C. Cheng, F.M. Chang
epithelium of the endometrioma has been histol-
ogically confirmed [2].
Conventional two-dimensional (2D) gray-scale
ultrasound is a valuable diagnostic technique in the
clinical practice of gynecology. The use of three-
dimensional (3D) ultrasound can further help in the
analysis of morphological anatomy and the mea-
surement of the volume of the internal genital
organs. Three-dimensional sonography with image
reconstruction is less invasive than hysterosalpin-
gography for the assessment of uterine anatomy,
and it can visualize both the uterine cavity and the
myometrium on a 3D scan. This facilitates the diag-
nosis of uterine anomalies, especially in the dif-
ferentiation of septate from bicornuate uteri for
preoperative surgical planning [3]. In the assessment
of the ovaries, three perpendicular planes of the
ovaries can be rotated to obtain the largest dimen-
sions, increasing the ability to evaluate the ovary
and follicles, especially in women with polycystic
ovary syndrome [4]. The evaluation of stroma and
volume determinations can be obtained more accu-
rately by 3D images than by traditional 2D ultra-
sonography. Three-dimensional power Doppler
ultrasound can also reveal blood flow and vascular-
ity in the target organ or the region of interest, and
quantify these for further evaluation. Such applica-
tions have been proved to be beneficial in the field
of infertility and reproductive endocrinology [5].
Ultrasound examination is an easy and non-
invasive method in the differential diagnosis of
endometriosis, and is useful in planning surgical
intervention of ovarian endometrioma, as well as
preoperative and postoperative medical therapy. It
is important to differentiate between the various
gynecologic conditions arising from endometriosis
due to the high prevalence of endometriosis with
clinical symptoms. With the advance of ultrasonog-
raphy, the application of higher-frequency scan-
ning probes is providing greater resolution and
improving the ability to evaluate ovarian endo-
metrioma. Morphologic assessment with 2D ultra-
sound is the foundation of the evaluation of ovarian
endometrioma. The use of various ultrasound mo-
dalities, such as 3D sonography, color Doppler, and
242 J Med Ultrasound 2008 • Vol 16 • No 4
power ultrasound imaging, in evaluating ovarian en-
dometrioma will improve diagnostic accuracy. The
aim of this review will be to focus on the ultrasono-
graphic findings of ovarian endometrioma in the
diagnosis differentiating different benign and malig-
nant tumors, and in the functional role of power
Doppler ultrasound during various treatments.
The Findings of Ultrasound in the
Diagnosis of Ovarian Endometriomas
Endometriosis without the presence of endometri-
omas is almost invisible when viewed by ultrasono-
graphy. When an endometrioma is suspected with
ultrasonography, the most characteristic finding is a
cyst with diffuse homogeneous hypoechoic (ground-
glass) appearance (Fig. 1). The cyst may be second-
ary to a hemorrhage. Ectopic endometriotic tissue
is shed with menstruation and will increase the size
and content of the cyst but will not disappear with
each period. It is described as a chocolate cyst. The
cyst may present in a solitary or multiple form in the
ovaries (Fig. 2). Endometrioma may contain a fluid-
fluid level (Fig. 3), which needs to be differentiated
from a hemorrhagic functional cyst with heteroge-
neous content which shows as fine linear strands
(“fish-net”) (Fig. 4). The ovaries will fix with adjacent
Fig. 1. An endometrioma in a 34-year-old woman viewed
with Doppler ultrasound. This cyst demonstrated diffuse low-
level internal echoes without any normal ovarian tissue on this
transvaginal sonogram. It had poor vascularity around the cyst
without any solid or papillary mass.

Fig. 2. A multiloculated endometrioma in a 28-year-old woman.
The transabdominal sonogram demonstrated a cystic adnexal
mass with hypoechoic content and internal septations.
Fig. 3. Transvaginal sonogram showing an endometrioma in a
30-year-old woman. The lesion is shown with low-level echoes
with fluid-fluid level (arrowheads).
pelvic structures, even demonstrating the ‘kissing
ovaries’ feature on the ultrasonography. When pres-
sure is applied to the ovaries with a transvaginal
probe, the ovaries are not movable. Endometrioma
will contain solid-appearing echoic nodulations (sec-
ondary to reactive fibrosis) without vascularity on
color Doppler imaging. Using color Doppler ultra-
sound imaging evaluation of vessel distribution, a
round-shaped homogeneous hypoechoic ‘tissue’ of
low-level echoes without papillary proliferations asso-
ciated with ‘poor’ vascularization, or a round-shaped
homogeneous hypoechoic cyst with an echogenic
portion without vascular flow detected indicates the
likely presence of ovarian endometrioma [6]. The
typical vascular pattern of ovarian endometrioma
Ultrasonographic Assessment of Ovarian Endometrioma
Fig. 4. Transvaginal sonogram showing a hemorrhagic corpus
luteal cyst with heterogeneous content and fine linear with fish
net-like strands.
Fig. 5. Transvaginal sonogram showing a vascularity pattern of
an endometrioma. It was presented as a pericystic flow at the
level of the ovarian hilius (arrowhead).
is presented as a pericystic flow at the level of the
ovarian hilius (Fig. 5) [7]. However, the use of color
Doppler imaging does not improve the diagnostic
accuracy of transvaginal ultrasonography alone in
the diagnosis of ovarian endometrioma.
Ovarian Endometrioma and Infertility
There is still controversy over whether endometrio-
sis is associated with infertility and the outcome of
pregnancy. The mechanism of infertility associated
with endometriosis may include hormonal, chemical,
and immunological changes leading to impaired folli-
culogenesis, luteal phase defects, reduced fertilization
J Med Ultrasound 2008 • Vol 16 • No 4 243
 M.H. Wu, Y.C. Cheng, F.M. Chang
and abnormal embryogenesis [8]. The gold standard
for the diagnosis of endometriosis is laparoscopic
examination. Surgical removal of endometriomas
and/or in vitro fertilization (IVF) is indicated for
women who desire pregnancy. Surgery may lead
to a decreased ovarian reserve, but it does not impair
fertility outcomes of IVF in women previously oper-
ated for ovarian endometriomas [9]. Conversely,
direct controlled ovarian hyperstimulation and IVF
treatment is suggested in women with asymptom-
atic ovarian endometriomas, because removal of
endometriomas before IVF does not improve fertil-
ity outcome [9]. Lower peak estrogen levels, higher
gonadotropin injection doses, lower oocyte yield, and
a higher cancellation rate of IVF cycles are demon-
strated in women with advanced-stage endometri-
osis who have undergone previous surgery compared
with tubal-factor infertility subjects, but no differ-
ences in fertilization, cleavage, implantation, preg-
nancy, miscarriage, and delivery rates are found
between two groups [10]. However, the IVF outcome
is significantly affected in women who previously
underwent bilateral endometriomas cystectomy
[11]. It still needs higher doses of gonadotrophins
during controlled ovarian hyperstimulation and
has a higher withdrawal rate for poor response, but
the follicular number of follicles, oocytes retrieved,
embryos obtained, clinical pregnancy rate and de-
livery rate per cycle are all significantly lower than
in women without surgery [11]. In our previous
study, lower body mass index, higher LH levels in
baseline day 2 data, lower oocyte retrieval numbers
and lower pregnancy rates were found in women
with endometriosis [12]. Nearly half of our cases
had large endometriomas and bilateral involve-
ment [12]. The clinical pregnancy rate per started
cycle in our endometrioma cases was slightly higher
than women operated on for bilateral ovarian endo-
metriomas [11]. Although fertilization rates were
similar, our results suggested that embryo quality
and uterine receptivity may still affect women with
large and/or bilateral endometriomas [12].
We used 3D power Doppler ultrasonography to
investigate the differences of ultrasound findings
between cases with endometriosis and control [12].
244 J Med Ultrasound 2008 • Vol 16 • No 4
There were significantly decreased intra-ovarian
stromal blood flow parameters, including vascular-
ization index (VI), flow index (FI) and vascularization
flow index (VFI), in the patients with endometrio-
sis who did not have any evident difference in total
ovarian volume on the day of human chorionic go-
nadotropin. There was also significantly decreased
uterine artery velocimetry (RI and PI) values as deter-
mined by Doppler analysis between two groups.
Therefore, a deficient intra-ovarian vascularity poten-
tially may be an initial marker of a reduced ovarian
reserve before the increase of serum follicle stimu-
lating hormone (FSH) levels in early follicular phase,
and an important predictor of ovarian response.
The above results all demonstrated that women
who underwent previous conservative surgery for
endometriomas showed signs of a diminished ovar-
ian reserve. Ovarian damage during surgery may lead
to decreased intra-ovarian vascularity in the endo-
metriosis group. It was interesting that there were
no significant differences in stromal blood flow pa-
rameters of 3D power Doppler ultrasound between
the endometriomatous ovaries post-endometrioma
surgery and the contralateral control ovaries in the
same individuals, which may be compatible with
decreased ovarian reserves in both ovaries of the
patients with previous endometriomas after surgery
in our study [12]. Therefore, 3D power Doppler can
be used to demonstrate the dynamic vascularity of
the IVF process and may provide a prognostic tool
for IVF outcomes in patients with endometriomas.
It is possible that restricted blood supply to the
ovarian stroma in endometrioma after conservative
surgery might be associated with impaired embryo
quality. Leptin is considered an angiogenic factor
and may serve as a sensitive marker of IVF outcomes.
The angiogenic effect of leptin is equivalent to that
of vascular endothelial growth factor (VEGF), but
the angiogenic response is evident earlier compared
with VEGF [13]. It means leptin plays a possible role
in conditions where new blood vessel growth is cru-
cial, such as a decreased ovarian reserve in patients
with endometriosis after surgery. Elevated levels of
serum leptin are associated with poor ovarian re-
sponse, as well as decreased follicle maturation,

embryo quality and pregnancy outcomes [12,14].
In our previous study, follicular fluid leptin (14.38 ±
1.74 ng/ml) was higher than serum samples (5.36 ±
1.37 ng/ml) examined on ovum pick up day in
normal control, which is compatible with the data
from Anifandis et al [14], but there were no signif-
icant differences in follicular fluid or serum leptin
concentrations between the patients with endo-
metriosis and the control group [12]. The value of
follicular fluid leptin demonstrated a negative cor-
relation with ovarian stromal FI in the control group,
but there was an absence of this effect in the endo-
metriosis group in our study [12]. Reduced blood
flow (such as decreased FI in our study) through
the ovarian stroma may lead to a follicular hypoxia
followed by the secretion of several angiogenic
factors, such as leptin, in ovarian follicles. The re-
duced ovarian response may then be found through
negative feedback of leptin to the ovaries. Loss of
the negative correlation between follicular fluid
leptin and intra-ovarian FI in the endometriosis group
may represent deficient angiogenic responses in
ovarian cortices after surgery.
Postmenopausal Endometrioma
Endometriosis is uncommon in postmenopausal
women, because it depends on estrogenic stimula-
tion for its continued growth during reproductive
ages. In asymptomatic postmenopausal women, the
risk of malignancy of simple adnexal cysts is low
(0.6%). Almost half of these women, whose meno-
pause tended to occur more recently and they ten-
ded to be younger, resolve spontaneously during close
ultrasound follow-up and avoid unnecessary surgical
intervention for physiological cysts [15]. However,
many cysts still persist and/or remain unchanged.
Color Doppler ultrasound is usually recommended
for screening for ovarian cancer. Vuento et al sug-
gested that the evaluation criteria for abnormal
ovarian findings in asymptomatic postmenopausal
women were an ovarian volume of 8 cm3 or greater,
nonuniform echogenicity, and/or a pulsatility index
(PI) of the ovarian artery or tumor vessel, if present, of
Ultrasonographic Assessment of Ovarian Endometrioma
1.0 or less [16]. The conventional 2D sonography
seems to be sufficient as a primary screening modal-
ity when a malignant tumor is suspected. However,
they found that transvaginal color Doppler ultra-
sound is an effective method for detecting ovarian
cysts in asymptomatic postmenopausal women. In
our previous study, 3D power Doppler sonography
has proved that the flow intensity of the ovarian
stroma, including VI, FI and VFI, decreased in the
order of the aging process: premenopause, peri-
menopause, then postmenopause [17]. There were
a significant increase in ovarian stromal flow indices
in postmenopausal women receiving continuous-
combined hormone replacement therapy, but not in
the control group [18]. Introducing 3D ultrasonog-
raphy with power Doppler facilities as a secondary
screening test for ovarian cancer in asymptomatic
peri- and postmenopausal women will further im-
prove the accuracy of ovarian cancer screening stud-
ies. Kurjak et al detected malignant tumors early and
accurately using 3D ultrasonography and power
Doppler imaging, in multiloculated, complex or
solid ovarian mass, or persistently cystic mass > 5 cm
in diameter, in which the echo architecture and/or
blood flow pattern was not highly suggestive of
a benign histology according to 2D morphologic
and Doppler ultrasonic criteria of the ovarian ma-
lignancy and related cut-off scores [19]. Up until
this point there has been little discussion in the dif-
ferential diagnosis of ovarian endometrioma with
malignancy in postmenopausal women using 3D
ultrasonography.
Accuracy of Ultrasonography in the
Differential Diagnosis of Suspected
Adnexal Tumors
Sometimes, the clinical features and biological be-
havior of ovarian cancer might be closely related to
endometrioma and/or endometriosis. About 0.7% of
ovarian endometriosis cases demonstrate malignant
transformation [20]. In contrast, the frequency of
endometriosis that occurred in benign, borderline
malignant, and malignant ovarian tumors is 9.7%,
J Med Ultrasound 2008 • Vol 16 • No 4 245
 M.H. Wu, Y.C. Cheng, F.M. Chang
12.5%, and 11.4%, respectively [21]. The most
frequent ovarian cancer closely related with endo-
metriosis is endometrioid adenocarcinoma. It is im-
portant in clinical practice that surgeons should be
aware of the possibility of ovarian cancer employing
careful preoperative evaluation when laparotomy or
laparoscopic surgery is arranged in ovarian endome-
trioma cases.
Ultrasound examination is a useful tool for pre-
operative differential diagnosis of adnexal lesions.
The gray-scale ultrasound parameters for predicting
malignancy include the size of the largest solid
component, wall irregularity and lesion size, with a
sensitivity of 100% and a false positive rate of 10%
[22]. The presence of normal ovarian tissue adjacent
to the ovarian cyst (the ‘ovarian crescent sign’) on
an ultrasound scan is also a useful morphological
feature to exclude the possibility of an invasive
ovarian malignancy in the preoperative evaluation
[23]. Ovarian cancer is diagnosed with a sensitivity
of 96% and a specificity of 76% when no normal
ovarian tissue is demonstrated by ultrasound. Several
parameters are used in the evaluation of adnexal
masses by transvaginal color Doppler sonography,
including a number of vessels detected in each
tumor, tumor vessel location (central vs. peripheral),
peak systolic velocity, lowest resistance index, mean
resistance index, lowest pulsatility index and mean
pulsatility index [24]. Most parameters demonstrate
an overlap between benign and malignant tumors
with a high false-positive rate. The parameters which
best differentiate malignant cancers from benign
tumors are the lowest resistance index with a cut-
off value of 0.45 (sensitivity 100%; false-positive rate
11.4%) and central tumor vessel location (sensitivity
90%; false-positive rate 11.4%). Using 3D ultra-
sonography, the central localization of vessels in an
adnexal mass can be easily observed (Fig. 6). In
addition, the mean gray index and the flow index
are potentially important parameters in differential
diagnosis [25]. The use of 3D power Doppler ultra-
sound can help to discriminate between benign and
malignant ovarian tumors. VI in a 5 cm3 ovarian tu-
mor improves diagnostic performance in the 3D flow
index, and is superior to that of the color content
246 J Med Ultrasound 2008 • Vol 16 • No 4
Fig. 6. The complex ovarian mass with an irregular wall in a case
of clear cell adenocarcinoma in a patient who had a serial follow-
up for suspected ovarian endometrioma. The central localization
of vessels in intracystic solid tissue are observed by Doppler
sonogram on the last visit before operation (arrowhead).
of the tumor scan (with sensitivity 93% vs. 78%,
and a false positive rate 16% vs. 27%) [22].
Furthermore, borderline malignant tumors in-
crease the diagnostic difficulties with only 47% being
correctly classified as malignant [26]. About 8% of
pelvic masses are difficult to correctly classify on the
basis of ultrasound findings. Papillary projections,
ten or more locules existing in a cyst without solid
components, low-level echogenicity of cyst fluid, and
moderate vascularization as assessed subjectively at
color Doppler examination are independent ultra-
sound variables associated with unclassified mass.
The diagnostic findings of ultrasound in borderline
ovarian tumors are highly specific using the tumor
pattern recognition method [27]. The morphologic
features viewed through ultrasonography are a
unilocular cyst with a positive ovarian crescent sign
and extensive papillary projections arising from the
inner wall, or a cyst with a well defined multilocular
nodules. However, typical ultrasound features are
only present in two thirds of cases, the others being
misdiagnosed as benign lesions. The most frequent
diagnostic ultrasound feature of borderline ovarian
tumors is the presence of papillae, defined as a small
number of solid tissue projections into the cyst cavity
from the cyst wall measuring 1–15 mm in height
and 1–10 mm in both width (base) and length
(base) [28]. Intracystic solid tissue measuring more

than 15 mm in height or 10 mm in width or length
would favor invasive malignant masses.
Serum CA-125 for Ovarian
Endometrioma
CA-125 levels are often used in differentiating
ovarian endometriomas from adenxal masses. The
levels are significantly higher in patients with endo-
metriotic masses, and increase with the stages of
endometriosis [29]. Recently, a multiple-marker
screening test for endometriosis involving a four-
marker panel consisting of CA-125, macrophage
chemotactic protein-1, leptin, and macrophage
migration inhibitory factor, could diagnose 48% of
subjects as to the presence of endometriosis with
93% accuracy, which may be useful in the workup
of patients with suspected endometriosis [30].
Using a cut-off at ≥ 35 U/mL, elevated CA-125 lev-
els demonstrates 79.3% sensitivity, 84.6% specificity,
79.3% positive predictive value, and 84.6% nega-
tive predictive value in the diagnosis of ovarian
endometrioma in patients scheduled for surgery
[7]. In our department’s previous study in women
undergoing surgery for endometriosis [29], CA-125
levels higher than 65 IU/mL, with a sensitivity of
76%, a specificity of 71%, a positive predictive value
of 76%, and a negative predictive value of 93.2%,
might help in the preoperative diagnosis of advanced
stages of endometriosis or severe pelvic adhesions
in women undergoing surgery for endometriosis,
meaning that these patients require preoperative
bowel preparation. The serum level of CA-125,
which is also considered as a useful parameter to
predict follicular loss before surgery in patients with
ovarian endometrioma, is directly correlated to the
histologic score and to cyst diameter [31]. How-
ever, transvaginal ultrasonography used alone is a
more cost-effective method in the preoperative
differential diagnosis of ovarian endometrioma
than tumor marker values, such as CA-19.9 and
CA-125 plasma levels [32]. Pattern recognition,
using color Doppler ultrasound examinations, can
further correctly discriminate between benign and
Ultrasonographic Assessment of Ovarian Endometrioma
malignant adnexal masses, and is also superior to
serum CA-125 [33].
Conclusion
Ultrasound examination is an easy and noninvasive
tool in the evaluation of ovarian endometriomas. It is
useful in the analysis of morphologic anatomy and
conventional 2D sonography seems to be sufficient
as a primary screening test for ovarian endometrio-
mas, even when a malignant tumor is suspected.
Color Doppler and 3D power sonography will pro-
vide substantial assistance in detecting the functional
role of ovarian endometriomas, and in discriminat-
ing ovarian endometriomas from malignant adnexal
masses in preoperative differential diagnosis.
Acknowledgments
The authors are grateful for the financial support provided
by grants from the National Science Council, R.O.C. and
National Cheng Kung University Hospital.
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