Endometriosis is a chronic condition that affects reproductive-age females, where tissue similar to the lining of the uterus grows outside the uterus. It affects approximately one in ten women in their childbearing years and is a prevalent condition both globally and in Singapore [1]. 

Symptoms of endometriosis commonly include painful periods, heavy menstrual bleeding, pelvic pain, and in some cases, infertility. This condition can significantly reduce quality of life, causing not only pain but also fatigue, anxiety, and depression. For some women, the pain can interfere with daily activities, making it difficult to attend work or school. Pain during sex can also disrupt intimacy, affecting both individuals and their partners. 

Endometriosis is a systemic condition that can affect not only the uterus but also the ovaries, vagina, rectum, and other pelvic organs. Early treatment is essential to improve both overall health and reproductive outcomes for women living with the condition. With appropriate medical care,  including medication, lifestyle adjustments, or surgical treatments, many women experience significant relief from symptoms and enjoy an improved quality of life.

Keep reading to find out more about endometriosis and treatment options in Asia.

Understanding Endometriosis

What is Endometriosis?

Endometriosis is an inflammatory condition where tissue similar to the lining of the uterus (endometrium) grows outside the uterus. These growths are often found on the ovaries, fallopian tubes, bladder, intestines, and other pelvic organs. When they respond to hormonal changes during the menstrual cycle, they often cause inflammation, pain, and scarring over time. 

Endometriosis can also damage the fallopian tubes, interfere with embryo implantation, reduce egg quality, and diminish ovarian reserve, ultimately affecting fertility. 

What Causes Endometriosis?

The exact cause of endometriosis remains unknown, but some theories [2] include:

• Retrograde menstruation: Occurs when menstrual blood flows backward through the fallopian tubes into the pelvic cavity, carrying endometrial cells. These cells can attach to the pelvic walls and organs, where they grow and thicken with each menstrual cycle.
• Transformed peritoneal cells: Research suggests that hormones or immune factors may cause peritoneal cells, which line the inner abdomen, to transform into cells resembling those that line the uterus.
• Embryonic cell changes: Hormones such as estrogen may trigger embryonic cells to transform into endometrial-like tissue, contributing to growths during puberty.
• Complications from surgery: Endometrial cells can attach to scar tissue formed after abdominal surgeries, such as a cesarean, leading to endometriosis.
• Endometrial cell transport: Blood vessels or the tissue fluid system may transport endometrial cells to other areas of the body, causing them to implant and grow in locations outside the uterus.
• Immune system dysfunction: Immune system issues may cause endometrial-like tissue to implant and grow.

Several risk factors of endometriosis make some women more prone to developing the condition. These include:

• Never giving birth
• Starting menstruation at an early age
• Entering menopause at a later age
• Short menstrual cycles (less than 27 days)
• Heavy periods lasting more than seven days
• Higher estrogen levels or prolonged estrogen exposure
• Low body mass index (BMI)
• A family history of endometriosis 

Common Symptoms of Endometriosis 

Endometriosis symptoms vary among individuals, and the severity of symptoms does not always correlate [3] with the extent of the disease. Some women with severe endometriosis may have mild symptoms, and vice versa. Some people with endometriosis do not experience symptoms. For those that they do, they often include:

• Chronic pelvic pain, especially before and during menstruation.
• Dysmenorrhea (painful, often debilitating periods).
• Dyspareunia (experiencing pain during or after intercourse).
• Infertility
• Pain and discomfort during bowel movements, bloating, or urinary issues when menstruating. 
• Fatigue, diarrhea, constipation, bloating, or nausea before or during menstruation. 
• Heavy or abnormal bleeding between periods. 

Diagnosis Methods in Asia

Diagnosing endometriosis can be challenging and often delayed due to normalisation of menstrual pain and lack of awareness. In Asia, common diagnostic methods include:

• Clinical history: Taking notes of the patient’s symptoms and medical history. 
• Pelvic examination: To detect cysts or tenderness.
• Imaging techniques:

• Ultrasound (transvaginal or abdominal): Used for identifying ovarian endometriomas.
• MRI Scans: Used for visualising deep infiltrating endometriosis.
• Laparoscopy (minimally invasive surgery): A common diagnostic method that allows direct visualisation and biopsy of growths and lesions.
  

Non-Surgical Treatment Options for Endometriosis in Asia

Many women with endometriosis seek non-surgical treatments to alleviate symptoms, improve quality of life, and preserve fertility. In Asia, a range of non-surgical treatment options are available, including medication, alternative therapies, and lifestyle adjustments. These treatments offer personalised approaches to managing the condition, depending on the severity of symptoms and individual preferences. Here are some common non-surgical treatment options: 

• Oral contraceptives

Oral contraceptives, including birth control pills and hormonal treatments, are commonly used to regulate menstrual cycles, reduce pain, and suppress the growth of endometrial tissue. These treatments help control symptoms, especially in mild cases.

• Pain relief

Non-prescription pain relievers such as NSAIDs are often used to manage pelvic pain and menstrual cramps, offering short-term relief from symptoms. 

• Diet and lifestyle changes 

Anti-inflammatory diets [4], which are rich in omega-3 fatty acids, fruits, and vegetables, may help reduce inflammation and pain. Exercise and stress management techniques, such as yoga or meditation, can also aid in symptom management.

These approaches primarily manage symptoms rather than cure the condition, as there are limitations to non-surgical treatments. For example, hormonal treatments may not be suitable for women trying to conceive or those who experience side effects. 

If symptoms persist despite non-surgical treatments, or if there are concerns about fertility, surgical options such as laparoscopy and robotic gynaecological surgery may be necessary to remove severe endometrial growths.

Surgical Treatment Options for Endometriosis in Asia

For women with severe endometriosis or those unresponsive to non-surgical treatments, surgery is often required to remove endometrial tissue, alleviate pain, and preserve fertility. In Asia, surgical options like laparoscopy and robotic gynaecological surgery offer solutions with varying benefits depending on the severity of the condition and the patient’s goals. 

Types of Surgery for Endometriosis: 

• Laparoscopy (Minimally Invasive Surgery): Laparoscopy involves small incisions through which a camera and surgical tools are inserted to remove or destroy endometrial tissue. This procedure is less invasive, allows for faster recovery, and is often used for both diagnosis and treatment.
  
• Hysterectomy: This involves the removal of the uterus, and in some cases, the ovaries. It is typically considered for women who no longer wish to have children and have not found relief through other treatments. While effective in reducing symptoms, a hysterectomy may not cure endometriosis completely.
  
• Robotic gynaecological surgery: Robotic gynaecological surgery is a minimally invasive surgery [5] that involves using robotic arms controlled by the surgeon for precision. This method allows surgeons to remove endometrial tissue while minimising damage to surrounding organs. One of the primary goals of this surgery is to preserve fertility. The precision of the robotic system allows surgeons to carefully remove endometrial growths while sparing healthy tissue, improving the chances of natural conception or assisted reproductive techniques.

How to Choose the Right Gynaecologic Surgeon for Endometriosis Treatment in Asia

Choosing the right gynaecologic surgeon for endometriosis treatment is essential for achieving the best outcomes. When selecting a surgeon, it's important to consider the severity of your symptoms, fertility goals, and access to high-quality care. If robotic gynaecological surgery is the recommended treatment, it’s ideal to choose a surgeon with experience and expertise in the field. 

A skilled surgeon usually takes a holistic approach, tailoring treatment plans to meet your individual needs and goals. Key factors to consider before surgery include whether preserving fertility is a priority and ensuring the surgeon is accessible for ongoing support and follow-up. It's also important to ask your doctor about their success rates, potential risks, recovery times, and long-term outcomes for patients with similar cases. 

Dr. Ma Li is an internationally recognised endometriosis specialist and minimally invasive gynaecological surgeon based in Singapore, specialising in robotic gynaecological surgery for endometriosis. With a focus on fertility-preserving treatments, Dr. Ma Li offers comprehensive care to help manage the condition. Learn more about Dr. Ma Li’s approach and book a consultation at Dr. Ma Li Clinic.

How much does Endometriosis Treatment Cost?

In Singapore, the cost of endometriosis treatment depends on factors such as the severity of the condition, the type of treatment, and the chosen clinic. For example, laparoscopic surgery typically costs between SGD 25,000 and SGD 35,000, with variations depending on the complexity and fees. Robotic gynaecological surgery tends to be more expensive due to the specialised technology and expertise involved.

Patients in Singapore may use MediSave to help cover some surgical costs. There may also be private insurance coverage, depending on your insurer and plan. When evaluating the cost of treatment, it’s also important to consider the long-term benefits, such as improved quality of life and the potential for fertility preservation.

What to Expect After Endometriosis Treatment

After treatment, particularly surgery, many women experience significant relief from pain, reduced menstrual cramps, and less discomfort during intercourse. This leads to less dependence on pain medications and an improved quality of life. Minimally invasive surgeries such as robotic gynaecological surgery offer faster recovery and quick healing, allowing patients to return to their normal activities as soon as possible. 

As endometriosis is a long-term condition, follow-up appointments are essential to monitor progress, manage symptoms, and ensure long-term health and fertility goals are met. Regular check-ups are important to detect recurrence of endometrial tissue and adjust treatment plans as required. 

Conclusion

For those with severe symptoms or who wish to conceive, endometriosis treatment is essential for pain relief, preserving fertility, and improving overall quality of life. Those who suffer from this condition should be aware that there are various treatment options available, such as robotic gynaecological surgery. By effectively removing endometrial tissue, these treatment options provide significant pain relief and can help preserve fertility.

If you're experiencing symptoms of endometriosis, seeking treatment as soon as possible is crucial. Early intervention can help manage the condition while significantly reducing debilitating symptoms and improving quality of life. 

Frequently Asked Questions 

Can endometriosis be permanently treated?

While there's no cure for endometriosis, the symptoms can be significantly reduced through various treatments, including medication and surgery. 

Is endometriosis a serious problem?

Endometriosis is a chronic condition that causes tissue similar to the uterine lining to grow outside the uterus. This tissue can form adhesions and cysts, and can also damage organs. Left untreated, it can cause serious complications. 

Can endometriosis be cancerous?

Although they may sound similar, endometriosis and endometrial cancer are very different conditions. Endometriosis is not cancer, and having endometriosis does not necessarily lead to endometrial cancer. 

Can endometriosis cause weight gain?

Yes, people with endometriosis may gain weight from fluid retention. Hormonal fluctuations and medication side effects may also contribute to weight gain. Speak to your doctor if you are experiencing symptoms such as weight gain. 

References

1. Chong, C. (2022, March 2). Menstrual pain could be endometriosis; affects 1 in 10 females in child-bearing years in S'pore. The Straits Times. Retrieved from: https://www.straitstimes.com/singapore/menstrual-pain-could-be-endometriosis-affects-1-in-10-women-in-child-bearing-years-here
2. Mayo Clinic. (n.d.). Endometriosis - Symptoms and causes. Mayo Clinic. Retrieved from: https://www.mayoclinic.org/diseases-conditions/endometriosis/symptoms-causes/syc-20354656
3. BMC Medicine (2023). Shining a light on endometriosis: time to listen and take action. BMC medicine, 21(1), 107. Retrieved from: https://doi.org/10.1186/s12916-023-02820-y
4. Harvard Health Publishing. (2024, March 26). Foods that fight inflammation. Harvard Health. Retrieved from: https://www.health.harvard.edu/staying-healthy/foods-that-fight-inflammation
5. Ferreira, H., Ferreira, J. C., & Fernandes, R. C. (2023). Impact of surgical experience on outcomes of robotic gynecologic surgery: A retrospective study. Revista da Associação Médica Brasileira, 69(10), 1443–1448. Retrieved from: https://www.scielo.br/j/ramb/a/XYdLnbxPMG8nNPR5XRV3hMs/

Introduction

Ovarian cysts are fluid-filled sacs that form on or within the ovaries. There are several types of ovarian cysts, and while they are usually harmless, they can sometimes lead to complications that affect a woman’s health and fertility. 

Reproductive health plays a vital role in Singapore, particularly in light of the country’s declining birth rate [1]. Early detection and management of ovarian cysts can help women who are planning to conceive prevent complications and protect their fertility. It is also important to understand the symptoms of ovarian cysts in case of a rupture or other side effects that may affect health and well-being.  

Keep reading to learn more about ovarian cysts, including their causes, symptoms, diagnosis, treatment options, and how they relate to fertility. 

What are Ovarian Cysts?

Ovarian cysts are fluid-filled sacs that form on or inside the ovaries. They are common among women of all ages and are often harmless, typically resolving on their own without the need for medical intervention. However, some cysts may cause symptoms or complications, particularly if they grow larger or rupture.

The size of an ovarian cyst [2] is an important factor in determining its impact. Smaller cysts are typically asymptomatic and less likely to cause problems, while larger cysts may increase the risk of pain or complications such as torsion or rupture.

Understanding the type and size of a cyst is important for effective management and ensuring it does not affect fertility and reproductive health.

Types of Ovarian Cysts

Functional Cysts: These are the most common type and are linked to the menstrual cycle. They include:

• Follicular cysts: Often forming when the follicle fails to release an egg.
• Corpus luteum cysts: These develop after the egg is released.

Pathological Cysts: These are less common and may require medical attention. They include:

• Dermoid cysts: Made up of various tissues such as hair or skin and are also known as teratomas.
• Cystadenomas: Usually grow on the ovarian surface and contain a watery substance.
• Endometriomas: Cysts are associated with endometriosis when tissues similar to the uterine lining grow outside the uterus and attach to the ovary​.

Why do Ovarian Cysts develop?  

Ovarian cysts can develop due to various reasons, including:

• Hormonal imbalances: Disruptions in hormone levels can lead to the formation of functional cysts.
• Menopause: Postmenopausal women can be at risk of cysts that are more likely to be malignant. 
• Underlying conditions:
  • Polycystic Ovary Syndrome (PCOS): A hormonal condition that affects women of reproductive age, often causing multiple small cysts in the ovaries and infertility.
  • Endometriosis:  A condition where tissue and cells similar to the uterus lining grow outside the uterus, sometimes leading to the development of endometriomas.
• Other factors:
  • Genetic predisposition: Having a family history of hormonal imbalances or ovarian cysts. 
  • Pregnancy: Corpus luteum cysts [3] can form in early pregnancy.
  • Pelvic infections that spread to the ovaries.
  • Fertility treatments: Those that stimulate ovulation, such as clomiphene (Clomid) [4], may increase the risk of ovarian cysts.
  • History of ovarian cysts: Those who have had ovarian cysts in the past are more likely to develop them again. 

How do you know if you have Ovarian Cysts?

Ovarian cysts are usually asymptomatic and go unnoticed. However, when symptoms occur, they may include:

• Sharp or sudden pelvic pain
• Abdominal bloating or a sense of fullness in the stomach
• Irregular or missed periods
• Heavy bleeding and pain during periods
• Pain during sexual intercourse
• Frequent urination or discomfort with bowel movements 

If symptoms suggest the presence of an ovarian cyst, your doctor may use the following methods to confirm the diagnosis: 

Pelvic Exam

During a routine pelvic exam, your doctor or gynaecologist may suspect the presence of an ovarian cyst. The doctor will check for any lumps or changes in the ovaries that may indicate a cyst.

Imaging Tests

To confirm the presence and characteristics of an ovarian cyst, imaging techniques are usually used, including:

• Pelvic Ultrasound: The most common and effective method for diagnosing ovarian cysts, a transvaginal ultrasound provides clear images of the ovaries. A small probe is inserted into the vagina, allowing the doctor to assess the cyst’s size, location, and whether it’s fluid-filled or solid.
• CT Scan or MRI: These imaging tests may be recommended when more detailed images are needed, particularly for complex cysts.

Blood Tests

If an ovarian cyst is confirmed through ultrasound, blood tests may be ordered for further evaluation:

• Pregnancy Test: Since ovarian cysts are common during pregnancy, a pregnancy test can help rule it out as the cause of symptoms.
• CA 125 Test: This blood test measures the level of cancer antigen 125, a protein that can be elevated in ovarian cancer. However, elevated CA 125 levels can also occur in non-cancerous conditions like endometriosis or pelvic infections. This test is usually recommended for postmenopausal women or if the cyst seems suspicious.

Do Ovarian Cysts need to be removed? 

Whether an ovarian cyst requires surgical removal depends on its size, type, symptoms, and potential risks. Many ovarian cysts, particularly functional ones, are harmless and often resolve within a few menstrual cycles. Small functional cysts usually disappear without intervention and are frequently monitored through regular ultrasound scans. If a cyst does not cause pain, discomfort, or interfere with daily life, your gynaecologist may opt for a monitoring approach.

However, some cysts may need surgical removal under specific circumstances. These include: 

• Persistent or growing cysts: If a cyst does not resolve or continues to enlarge, your gynaecologist may advise removal to eliminate complications.
• Painful or symptomatic cysts: Cysts causing pelvic pain, bloating, or irregular periods may require intervention.
• Complex or pathological cysts: Dermoid cysts, cystadenomas, or endometriomas may need to be removed to prevent complications or assess for malignancy.
• Cysts with suspected malignancy: Large cysts, especially in postmenopausal women, may be surgically removed for further evaluation to rule out ovarian cancer.
• Complications: If a cyst ruptures, causes ovarian torsion, or results in severe pain, immediate medical attention and surgical intervention may be necessary.

Surgical approaches for ovarian cysts include:

• Laparoscopy: A minimally invasive procedure ideal for smaller or uncomplicated cysts.
• Laparotomy: Open surgery for larger or more complex cysts.

How are Ovarian Cysts treated without surgery?

Ovarian cysts can be managed and treated in several ways without surgery. These include: 

• Hormonal therapy, such as birth control pills, may be prescribed to prevent the formation of new cysts.
• Pain management, lifestyle adjustments, and monitoring through regular check-ups.

Consulting a gynaecologist is essential to determine the best course of action based on your circumstances. Early detection and management can prevent complications and protect reproductive health.

What does a ruptured Ovarian Cyst feel like?

A ruptured cyst is a medical emergency. If you experience these symptoms, seek immediate medical assistance. A ruptured ovarian cyst usually causes:

• Sudden and severe abdominal or pelvic pain.
• Nausea or vomiting.
• Light-headedness or fainting.
• Heavy vaginal bleeding.

Do Ovarian Cysts cause infertility?

While many ovarian cysts do not impact or directly cause infertility, certain types [5] can make it more difficult for women to get pregnant. However, for most women, timely treatment and fertility-focused care can help preserve or restore fertility. Here are some ways that ovarian cysts can lead to fertility issues: 

• PCOS: Causes hormonal imbalances and irregular ovulation, which can lead to infertility.
• Endometriomas: Linked to reduced ovarian reserve and implantation issues.
• Surgical considerations: Repeated surgeries to remove cysts may damage ovarian tissue and reduce egg supply.

Can you prevent Ovarian Cysts from developing?

While not all ovarian cysts are preventable, you can take steps to reduce your risk, especially if you already have risk factors such as hormonal imbalances or a family history of ovarian cysts. These include:

• Maintaining a healthy lifestyle: Following a healthy and balanced diet, exercising regularly, and managing stress effectively can boost your health and prevent ovarian cysts from developing.
• Regular gynaecological check-ups: Early detection through routine screenings is essential, so make it a point to schedule regular appointments with your gynaecologist. 
• Taking hormonal birth control: Your gynaecologist may prescribe birth control medication to regulate ovulation and prevent cysts.
• Paying attention to your menstrual cycle: Keep aware of menstrual irregularities or unusual recurring symptoms to stay aware of your current reproductive health.  

Conclusion

Ovarian cysts are a common aspect of women's reproductive health that are usually harmless but can occasionally lead to serious complications. It is important to take note of any unusual symptoms and seek gynaecological care regularly. Early detection and timely treatment can help manage cysts, alleviate symptoms, and reduce their impact on fertility.

If you have concerns about ovarian cysts or fertility, consult Dr Ma Li in Singapore for guidance and personalised treatment. Specialising in advanced gynaecological surgery, early intervention, and the long-term management of gynaecological conditions, she is dedicated to healing and empowering women through comprehensive care and support. Contact us today to book a consultation. 

Frequently Asked Questions

What does ovarian cyst pain feel like?

If an ovarian cyst causes symptoms, you may experience pressure, bloating, swelling, or pain in the lower abdomen on the side where the cyst is located. The pain can vary in intensity, from sharp to dull, and may come and go. If a cyst ruptures, it can cause sudden and intense pain that requires immediate medical attention.

Do ovarian cysts go away?

Many functional ovarian cysts don’t require treatment and typically resolve on their own within 8 to 12 weeks. If you have recurrent cysts, your doctor may recommend birth control pills (oral contraceptives) to reduce the risk of developing new cysts in the future.

Can a cyst come out during your period?

A cyst can rupture or burst during your period, which can result in sudden, sharp pain and vaginal bleeding. If you experience severe pain and abnormal bleeding during your period, it’s important to seek medical attention right away.

Do ovarian cysts become cancerous? 

Many ovarian cysts typically disappear without causing symptoms, requiring little to no treatment. While it’s uncommon, some ovarian cysts can become cancerous. Regular check-ups and monitoring are essential for early detection and proper management.

References

1. Kearney. (2023, December 1). Solving Southeast Asia’s looming fertility crisis: IVF as a path toward hope. Retrieved from: https://www.kearney.com/industry/health/article/solving-southeast-asia-s-looming-fertility-crisis-ivf-as-a-path-toward-hope
2. Healthline. (2023, November 27). What Size Is Normal for an Ovarian Cyst? Retrieved from: https://www.healthline.com/health/ovarian-cyst-size
3. Cleveland Clinic. (2023, December 5). Corpus luteum cyst. Retrieved from: https://my.clevelandclinic.org/health/diseases/22340-corpus-luteum-cyst
4. WebMD. (n.d.). Clomid oral details. Retrieved from https://www.webmd.com/drugs/2/drug-11204/clomid-oral/details
5. Mayo Clinic. (2023, August 3). Ovarian cysts and infertility.  Retrieved from: https://www.mayoclinic.org/diseases-conditions/ovarian-cysts/expert-answers/ovarian-cysts-and-infertility/faq-20057806