Ultrasound features of ovarian endometriomas

The purpose of the study was a detailed evaluation of the ultrasound features of the ovarian endometriomas (endometrioid cysts) in pre- and postmenopause.

Material and methods. 155 patients (150 premenopausal and 5 postmenopausal) with morphologically proven endometrioid cysts were examined. A total of 259 endometriomas in premenopause and 6 endometriomas in postmenopause were found in 155 patients. Lesions described in accordance with the recommendations of the IOTA group. Prospective risk stratification of endometrioma malignancy was performed using the O-RADS v2022 ultrasound classification. Statistical processing of the data was carried out using standard statistical methods.

Results. In more than 15% of cases of ovarian endometriosis in premenopause, two or more endometriomas can be found in the involved ovary, and in every third patient, both ovaries are involved in the process. The following ultrasound signs characterized the majority of endometriomas in premenopause: a unilocular lesion with smooth internal contours with "ground glass” internal contents ± dotted echogenic foci in the wall ± solid/papillary avascular component. In approximately every tenth premenopausal endometrioma, other types of internal contents may be determined rather than “ground glass” (anechoic, rare echogenic suspension, liquid-liquid level, mixed echogenicity). In most postmenopausal endometriomas, mixed echogenicity, solid components with vascularization, septations with vascularization, and an irregular internal contour are very common.

Conclusions: Most endometriomas in premenopausal women have typical signs that allow them to be confidently diagnosed by ultrasound. However, it can be exceedingly challenging to distinguish postmenopausal endometriomas from malignant lesions since they commonly lack the typical signs. Thus, an ultrasound conclusion of the presence of endometrioma in postmenopausal women is inappropriate.

1. Kratochwil A., Altmann G., Wollmann G. Ultraschalldiagnostik von Adnextumoren [Ultrasonic diagnosis of ovarian tumours (author's transl)]. Wien. Klin. Wochenschr. 1978; 90 (15): 569–575. PMID: 676317 (In German)

2. Goldman S.M., Minkin S.I. Diagnosing endometriosis with ultrasound: accuracy and specificity. J. Reprod. Med. 1980; 25 (4): 178–182. PMID: 7431366

3. Zykin B.I. Ekhografiia v diagnostike genital'nogo éndometrioza [Echography in the diagnosis of genital endometriosis]. Sov. Med. 1981; 11: 51–54. (In Russian) PMID: 7336244

4. Kupfer M.C., Schwimer S.R., Lebovic J. Transvaginal sonographic appearance of endometriomata: spectrum of findings. J. Ultrasound. Med. 1992; 11 (4): 129–133. https://doi.org/10.7863/jum.1992.11.4.129

5. Fried A.M., Rhodes R.A., Morehouse I.R. Endometrioma: analysis and sonographic classification of 51 documented cases. South. Med. J. 1993; 86 (3): 297–301. PMID: 8141859

6. Kurjak A., Kupesic S. Scoring system for prediction of ovarian endometriosis based on transvaginal color and pulsed Doppler sonography. Fertil. Steril. 1994; 62 (1): 81–88. https://doi.org/10.1016/s0015-0282(16)56820-4

7. Bulanov M.N. Prospective use of O-RADS and ADNEX ultrasound systems for risk stratification of ovarian malignancies. Ultrasound and Functional Diagnostics. 2023; 1: 23–55. https://doi.org/10.24835/1607-0771-2023-1-23-55 (In Russian)

8. Volpi E., De Grandis T., Zuccaro G., La Vista A., Sismondi P. Role of transvaginal sonography in the detection of endometriomata. J. Clin. Ultrasound. 1995; 23 (3): 163–167. doi: 10.1002/jcu.1870230303

9. Guerriero S., Mais V., Ajossa S. et al. The role of endovaginal ultrasound in differentiating endometriomas from other ovarian cysts. Clin. Exp. Obstet. Gynecol. 1995; 22 (1): 20–22. PMID: 7736636

10. Demidov V.N., Gus A.I., Volkov N.I. Ultrasound diagnosis of endometriosis. III. Image options for endometrioid ovarian cysts. Ultrasound Diagnostics. 1996; 2: 17–21. (In Russian)

11. Patel M.D., Feldstein V.A., Chen D.C. et al. Endometriomas: diagnostic performance of US. Radiology. 1999; 210 (3): 739–745. https://doi.org/10.1148/radiology.210.3.r99fe61739. Erratum in: Radiology. 1999; 213 (3): 930. PMID: 10207476

12. Timmerman D., Valentin L., Bourne T.H. et al. Terms, definitions and measurements to describe the sonographic features of adnexal tumors: A consensus opinion from the International Ovarian Tumor Analysis (IOTA) group. Ultrasound Obstet. Gynecol. 2000; 16: 500–505.

13. Aleem F., Pennisi J., Zeitoun K., Predanic M. The role of color Doppler in diagnosis of endometriomas. Ultrasound Obstet. Gynecol. 1995; 5 (1): 51–54. https://doi.org/10.1046/j.1469-0705.1995.05010051.x

14. Alcázar J.L., Laparte C., Jurado M., López-García G. The role of transvaginal ultrasonography combined with color velocity imaging and pulsed Doppler in the diagnosis of endometrioma. Fertil. Steril. 1997; 67 (3): 487–491. https://doi.org/10.1016/s0015-0282(97)80074-x

15. Pascual M.A., Tresserra F., López-Marín L. et al. Role of color Doppler ultrasonography in the diagnosis of endometriotic cyst. J. Ultrasound. Med. 2000; 19 (10): 695–699. https://doi.org/10.7863/jum.2000.19.10.695

16. Zykin B.I., Bulanov M.N. Tumor-like lesions of the ovaries. In: Dopplerography in gynecology / Eds Zykin B.I., Medvedev M.V. 1st ed. M. RAVUZDPG, Real Time. 2000. 99–107. (In Russian)

17. Clarke L., Edwards A., Pollard K. Acoustic streaming in ovarian cysts. J. Ultrasound Med. 2005; 24 (5): 617–621. https://doi.org/10.7863/jum.2005.24.5.617

18. Van Holsbeke C., Zhang J., Van Belle V. et al. Acoustic streaming cannot discriminate reliably between endometriomas and other types of adnexal lesion: a multicenter study of 633 adnexal masses. Ultrasound Obstet. Gynecol. 2010; 35 (3): 349–353. https://doi.org/10.1002/uog.7537

19. Asch E., Levine D. Variations in appearance of endometriomas. J. Ultrasound Med. 2007; 26 (8): 993–1002. https://doi.org/10.7863/jum.2007.26.8.993

20. Mascilini F., Moruzzi C., Giansiracusa C. et al. Imaging in gynecological disease. 10: Clinical and ultrasound characteristics of decidualized endometriomas surgically removed during pregnancy. Ultrasound Obstet. Gynecol. 2014; 44 (3): 354–360. https://doi.org/10.1002/uog.13323

21. Bulanov M.N., Gorta R.N. Ultrasound examination of endometrioid ovarian cysts during pregnancy. Ultrasound and Functional Diagnostics. 2015; 1: 55–71. (In Russian)

22. Van Holsbeke C., Van Calster B., Guerriero S. et al. Imaging in gynaecology: How good are we in identifying endometriomas? Facts. Views Vis. Obgyn. 2009; 1 (1): 7–17. PMID: 25478066. PMCID: PMC4251283.

23. Van Holsbeke C., Van Calster B., Guerriero S. et al. Endometriomas: their ultrasound characteristics. Ultrasound Obstet. Gynecol. 2010; 35 (6): 730–740. https://doi.org/10.1002/uog.7668

24. Guerriero S., Van Calster B., Somigliana E. et al. Age-related differences in the sonographic characteristics of endometriomas. Hum. Reprod. 2016; 31 (8): 1723–1731. https://doi.org/10.1093/humrep/dew113

25. Strachowski L.M., Jha P., Phillips C.H. et al. O-RADS US v2022: An Update from the American College of Radiology's Ovarian-Adnexal Reporting and Data System US Committee. Radiology. 2023; 308 (3): e230685. http://doi.org/10.1148/radiol.230685

26. Kanti F.S., Gorak Savard R., Bergeron F. et al. Transvaginal ultrasound and magnetic resonance imaging in the diagnosis of endometrioma: a systematic review and meta-analysis of diagnostic test accuracy studies. J. Obstet. Gynaecol. 2024; 44 (1): 2311664. https://doi.org/10.1080/01443615.2024.2311664

27. Borisova E.A., Bulanov M.N., Makarenko T.A. Ultrasound image of ovarian endometrioma as an indicator of external genital endometriosis. Ultrasound and Functional Diagnostics. 2023; 3: 37–49. https://doi.org/10.24835/1607-0771-2023-3-37-49 (In Russian)

28. Borisova E.A., Bulanov M.N., Makarenko T.A. The #Enzian classification for ultrasound diagnosis of endometriosis: description and explanation of the classification using our own clinical cases. Ultrasound and Functional Diagnostics. 2024; 1: 88–112. https://doi.org/10.24835/1607-0771-091 (In Russian)

29. Bulanov M.N., Chekalova M.A., Mazurkevich M.V., Vetsheva N.N. Differential ultrasound diagnosis of benign and malignant ovarian tumors: diagnostic models, algorithms, stratification systems, consensuses (1990–2023). Ultrasound and Functional Diagnostics. 2023; 2: 34–61. https://doi.org/10.24835/1607-0771-2023-2-34-61 (In Russian)