European Journal of Obstetrics & Gynecology and Reproductive Biology 215 (2017) 220–223

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European Journal of Obstetrics & Gynecology and

Reproductive Biology
j o u r n a l h o m e p a g e : w w w. e l se v i e r. c o m / l o c at e / e j o g r b

Full length article

Incidence of ovarian endometrioma among women with peritoneal

endometriosis with and without a history of hormonal contraceptive
use
Shahryar K. Kavoussia,*, Kate C. Odenwalda, Sawsan As-Sanieb, Dan I. Lebovicc

a Austin Fertility & Reproductive Medicine/Westlake IVF,300 Beardsley Lane, Bldg B, Suite 200, Austin, TX, 78746, United States
b
Department of Obstetrics & Gynecology, University of Michigan Healthcare System, Ann Arbor, MI, 48109, United States c Center for
Reproductive Medicine, 2828 Chicago Ave., Suite 400, Minneapolis, MN 55407, United States

ARTICLEINFO Study design: Retrospective case-control study of women who were patients at a fertility center and had
first laparoscopy from 2009 through 2015 showing, at minimum, evidence of peritoneal endometriosis
Article history: (n = 136). Chart review was conducted for history of prior birth control use as well as operative and
Received 25 February 2017 pathology notes of surgeries. Study subjects were grouped as follows: women with peritoneal
Received in revised form 12 June endometriosis diagnosed by laparoscopy who had a history of hormonal contraceptive use (n = 93) and
2017 women with peritoneal endometriosis diagnosed by laparoscopy who had never used hormonal
Accepted 18 June 2017 contraceptives (n = 43). The main outcome measure was the incidence of ovarian endometrioma
among women with peritoneal endometriosis who had a history of hormonal contraceptive use as
compared to women with peritoneal endometriosis who had a history of no hormonal contraceptive
Keywords:
use. Results: Among women with peritoneal endometriosis who had a history of hormonal
Hormonal contraceptive
contraceptive use, 17/93 (18.3%) were found to have endometriomas. Among women with peritoneal
Endometrioma
Endometriosis endometriosis who had a history of no hormonal contraceptive use, 21/43 (48.8%) were found to have
Pathogenesis endometriomas. The chi-square statistic was 13.6 (P-value < 0.001).
Endometrioma formation Conclusion(s): Among women with peritoneal endometriosis, those with a history of hormonal
ABSTRACT contraceptive use had a lower incidence of ovarian endometrioma than those with a history of no
hormonal contraceptive use. Possible mechanisms of action include reducing the risk of a corpus

Objective(s): To determine if, luteum formation and subsequent transformation into an ovarian endometrioma or reducing the risk of
among women with peritoneal ectopic endometrium implantation into the ovary via the diminution of retrograde menstruation.
endometriosis, the incidence of Although larger, prospective studies are needed, the findings of this study suggest that the use of
ovarian endometrioma at first hormonal contraception may decrease the likelihood of ovarian endometrioma formation among
laparoscopy differs between women with peritoneal endometriosis.
those with and without a history © 2017 The Author(s). Published by Elsevier Ireland Ltd. This is an open access article under the CC
of hormonal contraceptive use. BY-NCND license
(http://creativecommons.org/licenses/by-nc-nd/4.
0/).
Intro http://dx.doi.org/10.1016/j.ejogrb.2017.06.028
ducti invagination of these superficial endometriotic implants into
on the ovary [2]. Another theory is known as coelomic metaplasia
which consists of the invagination of ovarian cortical tissue and
The pathogenesis of ovarian endometriomas has been metaplasia of coelomic epithelium [3,4]. The theory of
controversial [1]. Theories of endometrioma formation include transformation of functional cysts into endometriomas has
the retrograde menstruation of endometrial glands and stroma been posited as well [5,6,7].
onto the ovarian surface where these cells adhere with In line with the theory of functional cyst transformation into
subsequent an endometrioma, a recent hypothesis raises the possibility that
a cystic corpus luteum, developing along the ovarian cortex
which is adherent to the pelvic sidewall’s peritoneum, results in
entrapped blood within the cyst which may transform the
* Corresponding author at: 300 Beardsley Lane, Bldg B, Suite 200, Austin, Texas,aforementioned
78746,
States.
E-mail address: austinfertility@gmail.com (S.K. Kavoussi).
0301-2115/© 2017 The Author(s). Published by Elsevier Ireland Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-ncnd/4.0/).
S.K. Kavoussi et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 215 (2017) 220–
221

corpus luteum cyst into an ovarian endometrioma [8]. Prior studies Table1

Characteristics among subjects in Group A

(women with peritoneal endometriosis have supported this possibility by showing a decreased risk of and a history of hormonal
contraceptive use) and Group B (women with peritoneal
endometrioma recurrence in women using cyclic, oral contra-
endometriosis and a history of no hormonal
ceptives post-operatively [9,10,11]. In addition, a prospective, randomized trial of 239
GROUP A (n = 93) GROUP B (n = 43) P value
women who had undergone ovarian cystectomy of endometriomas showed the efficacy of
long-term cyclic and continuous postoperative use of oral contraceptives in the reduction of Average Agea
size and delayed recurrence of endometriomas [12]. Although a prior publication showed no 0.086b
association between hormonal contraceptive use and endometriomas [13], a more recent 32.2 0.460 33.7 0.822
paper reported a decreased likelihood of ovarian endometriotic lesions among current users Parity
of hormonal contraceptives when compared with those who had not used hormonal 0 72 (77.4%) 33 (76.7%) 0.931c
contraceptives for greater than 3 months prior to surgery, suggesting a protective effect of 1 14 (15.1%) 10 (23.3%) 0.243c
hormonal contraceptives [14]. In the latter study, some patients had isolated endometriomas 2 70 (7.5%) 0 (0.0%)

whereas others had concomitant peritoneal endometriotic disease as well. The aim of our
>2 0 (0.0%) 0 (0.0%)
study was to determine if, among women with peritoneal endometriosis, the incidence of
ovarian endometrioma at first laparoscopy differed between those with a history of
Ethnicity
hormonal contraceptive use and those who had never used hormonal contraception. African-American 4 (4.3%) 1 (2.3%) 0.569c
Asian-American 2 (2.1%) 7 (16.3%) 0.002c
Materials and methods Caucasian 70 (75.3%) 19 (44.2%) 0.000 c
Hispanic 16 (17.2%) 14 (32.6%) 0.045 c
This retrospective chart review included women who had their first laparoscopy Other 1 (1.1%) 2 (4.6%) 0.187 c
showing, at minimum, evidence of peritoneal endometriosis (n = 136) at a single private- Dysmenorrhea
practice fertility center, Austin Fertility & Reproductive Medicine, from January 2009 Yes 75 (80.6%) 32 (74.4%) 0.410c
through December 2015. All laparoscopies had been performed by the same surgeon No 18 (19.4%) 11 (25.6%)
(SKK). Institutional review board approval was obtained from the Austin Multi-
Institutional Review Board. Data such as patient age at time of laparoscopy, history and Deep dyspareunia
duration of prior hormonal contraceptive use, and type of hormonal birth control used
were abstracted from the medical record and the fertility center’s New Patient Yes 42 (45.2%) 21 (48.8%) 0.690 c
Questionnaire, which is routinely given to all patients at the time of the first patient visit.
Operative findings and histopathology of surgical specimens were collected. Group A No 51 (54.8%) 22 (51.2%)

was defined as women with peritoneal endometriosis at first laparoscopy who had a
Stage of endometriosis
history of hormonal contraceptive use (n = 93); Group B was defined as women with
peritoneal endometriosis at first laparoscopy who had a history of no hormonal 1 56 (60.1%) 15 (34.9%) 0.006 c
contraceptive use (n = 43). The primary outcome measure was the presence or absence
of an endometrioma. Those 2 17 (18.3%) 5 (11.6%) 0.327 c
IUS = intrauterine system.
with endometrioma and no evidence ofperitoneal endometriosis a 3 10 (10.8%) 9 (20.9%) 0.111 c
Data are presented as mean standard error of the mean.
b 4 10 (10.8%) 14 (32.6) 0.002 c
(n= 3)were excluded. Pre-operative imaging ofthe ovaries such as Student t-test.
c
transvaginal sonogram (TVS), pelvic magnetic resonance Presence of endometrioma
imaging, Chi-square test. Yes 17 (18.3 %) 21 (48.8 %) <0.001 c
or No 76 (81.7 %) 22 (51.2 %)
recent reports of such imaging studies
were available prior to # of endometriomas
surgery. These imaging studies made it less likely that a small Among 0 76 (81.7%) 22 (51.2%) < 0.001 c
women with peritoneal endometriosis who had a 1 10 (10.8%) 11 (25.5%) 0.026 c
2 4 (4.3%) 7 (16.3%) 0.017 c
endometrioma or cyst would be missed during subsequent >2 3 (3.2%) 3 (7.0%) 0.322 c

history ofhormonal contraceptive use, 17/93 (18.3%) were foundto Hormonal contraceptive types
laparoscopic surgery. Student t-test and Chi-square test were have Oral pills only 69 (74.2%) N/A
endometriomas (Fig. 1).Among women with peritoneal Transdermal patch only 1 (1.1%) N/A
used
for statistical analyses between groups where appropriate. A endometriosis who Transvaginal ring only 0 (0.0%) N/A
had a history ofno hormonal contraceptive
Long-acting injectable only 3 (3.2%) N/A

Levonorgestrel-IUS only 1 (1.1%) N/A

More than 1 modality 19 (20.4%) N/A

 P-value of <0.05 was considered to be statistically significant. use, 21/43 (48.8%) were found to have endometriomas (Fig. 1). The
chi-square statistic was 13.6 (P-value <
0.001).
Results
Comment
The mean age of women in Group A was 32.2 (range: 21–41) and the mean age of women in Group B was 33.7 (range: 20–
44). In this study, women with peritoneal endometriosis who had a

Characteristics among women in Group A and Group B are shown history ofhormonal contraceptive use had a lower
incidence of
in Table 1.
With regards to duration of hormonal contraceptive use, ovarian endometriomas than women with a history no prior

80/93 (86%) of the subjects in Group A had responded to this hormonal contraceptive use. Although retrograde
menstruation

question of which 74 had specified the timeframe with an average with implantation of ectopic endometrial glands and stroma onto
duration of use of 7.73 years, whereas the remaining 6 who had the ovarian surface and subsequent invasion into ovarian
cortex or

responded to this question did sowith nonspecific terms such as coleomic metaplasia may be mechanisms ofaction ofovarian
“years” or “months”. endometrioma formation, the
concept of functional cyst

222 S.K. Kavoussi et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 215 (2017) 220–223

Fig. 1. Among women with peritoneal endometriosis who have history of hormonal contracpetive use (Group A) vs those with a history of no hormonal contraceptive
use (Group B), the incidence of presence of endometrioma was 18.3% vs 48.8%, respectively (Chi-Square statistic = 13.6; P-value < 0.001).
transformation into an endometrioma was has been described subsequent transformation into an ovarian endometrioma or
and it has been studied in prior publications as well. Bleeding reducing the risk of ectopic endometrium implantation into the
from a corpus luteum appears to be instrumental in the ovary via the diminution of retrograde menstruation. Larger
development of endometriomas as suggested by a prospective studies with prospective design are necessary and, if our study’s
observational study of 109 women who underwent first surgery findings are validated, determine whether or not a certain
for endometriomas. The study subjects did not take oral duration of hormonal contraceptive use is associated with a
contraceptive pills postoperatively and had serial transvaginal reduction in the incidence of primary ovarian endometrioma
sonograms (TVS), every 3 months, during the luteal phase for 2 formation orpostoperative recurrence.
years after surgery. TVS showed a hemorrhagic corpus luteum
cyst in 13 women, of which 11 had TVS that showed
transformation into an endometriotic cyst [8]. Fund
One of the strengths of our study was the availability of
operative and pathology reports for the diagnoses of pelvic ing
endometriosis and ovarian endometriomas. Another strength
of the study was information regarding history of prior sour
hormonal contraceptive use. This is specifically asked within
the new patient questionnaires and during the new patient ce
encounter if it had not initially been filled out by a given patient.
One limitation of our study was its retrospective nature. Non
Another limitation was that not all patients listed the duration of
hormonal birth control use and this was not specifically asked e.
about during all of the new patient encounters. In addition,
although the presence of endometrioma is more common in Ackn
Group B in this study and may be due to never use of hormonal
birth control, deep infiltrating disease may be a potential owle
confounder as such disease has been associated with ovarian
disease as well.
dge
The findings of the present study suggest that women with
peritoneal endometriosis who had a history of hormonal
men
contraceptive use had a lower incidence of ovarian
endometrioma than those with a history of no hormonal
contraceptive use. Because all patients included in this study ts
had peritoneal endometriosis, our findings suggest a lower
Non
incidence of ovarian endometrioma among those with a history
of hormonal contraceptive use. Possible mechanisms of action
e.
include reducing the risk of a corpus luteum formation and
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