Does Size Matter? Investigating the Association Between Endometrioma on Pre-Operative Imaging and AAGL Endometriosis Stage

Study Objective

To investigate the association between the size of endometriomas on pre-operative imaging and the stage and extent of endometriosis based on laparoscopic findings according to the AAGL 2021 Endometriosis Classification.

Design

Retrospective cohort study.

Setting

High-volume academic gynecologic surgical practice.

Patients or Participants

Sixty-nine patients with endometriomas on pre-operative imaging undergoing surgical management of endometriosis from June 2022 to April 2024.

Interventions

Preoperative assessment of endometrioma size and laterality on ultrasound and/or MRI.

Measurements and Main Results

Sixty-nine patients met the inclusion criteria. The median of days elapsed from imaging date to the date of surgery was 81 [40, 136] days. The mean age of patients was 34±7.3 years. The majority of patients self-reported as Black (17.4%) or White (75.4%) and the mean BMI was 27.8±6.8 kg/m². The most commonly reported symptom was dysmenorrhea (95.7%) while dyschezia (37.7%) and infertility (20.3%) were less common. On pelvic exam, 39.1% had myofascial tenderness, 21.7% had uterosacral nodularity or thickening, and 5.8% had reduced uterine mobility.

Pre-operative imaging showed median endometrioma size of 49 [30, 62] mm on ultrasound (N=42) and 50 [23, 54] mm on MRI (N=27). Surgical AAGL endometriosis staging found that no patients had stage 1 disease while 79.7% had stage 4 disease. Patients who had endometriomas ≥ 40 mm often had higher surgical complexity as compared to those with smaller endometriomas, including more frequent cul-de-sac obliteration (71.4% vs 48.1%), rectovaginal septum disease (35.7% vs 18.5%), and appendiceal involvement (38.1% vs 11.1%).

Conclusion

In this sample, endometriomas on pre-operative imaging, regardless of size, were most frequently connected to stage III or IV endometriosis. For endometriomas ≥40 mm, a higher degree of surgical complexity was frequently encountered. Gynecologic surgeons operating on patients with endometriomas should be prepared to treat complex endometriosis. Understanding this relationship may aid clinicians considering referral to a gynecologic surgical specialists.