To the Editor:
Matalliotakis and colleagues, in the April 2009 issue of Fertility and Sterility, present an argument for the left lateral predisposition of ovarian endometriomas based on a retrospective series of 251 women who underwent surgical intervention for the disease (1). They also suggest a new ‘female varicocele theory’ for the development of ovarian endometriomas based on the left lateral predilection of ovarian vein dilation (2). The findings of the study, that endometriomas are more common in the left pelvis, are in agreement with previously published studies including our own (3,4); however, our data in 130 women with ovarian endometriomas show that this left predisposition is lost after the age of 35 years (4). It is not clear whether the authors examined such a possibility, and how the age distribution of those women who had ovarian vein dilation compared with those who did not.
Furthermore, ovarian vein dilation was assessed in a small subset of women (32/251) included in the study (1). The finding that left ovarian vein dilation was evident in 20 out of 20 women with left endometriomas, while right ovarian vein dilation in only 2 out of 12 women with right endometriomas, actually argues against an ovarian varicocele theory. If the presence of ovarian varicocele plays a major role in the development of ovarian endometriosis, as the authors suggest, then endometriomas in the left or right pelvis are expected to be associated with a similar proportion of ipsilateral ovarian vein dilation. And since a contralateral endometrioma represents the optimal internal control, did the authors try to examine the ovarian veins in cases with bilateral endometriomas? In addition, pelvic varicoceles are present in 17% of healthy normal women (5) and usually occur in multiparous women and later in the reproductive years (2) when the left lateral predisposition of ovarian endometriomas is suspected to be absent (4).
Still, this theory is interesting and may be playing some role in tilting the balance towards a left predilection of endometriomas in a subset of patients. However, it would also be helpful to include patients with simple or functional ovarian cysts as a control group for a better evaluation of ovarian vein dilation. Nonetheless, if the left predilection of endometriomas is lost with age, as we previously reported, then perhaps an alternative theory to the ‘female varicocele theory’ should be sought for those endometriomas occurring later in reproductive life.
Khalil N. Abi-Nader, M.D.a,b
Antoine Hannoun, M.D.c
Tony Bazi, M.D.c
Muhieddine A. Seoud, M.D.c
Tony G. Zreik, M.D, M.B.A.a,d
aLebanese American University School of Medicine and University Medical Center Rizk Hospital
bUniversity College London
London, United Kingdom
cAmerican University of Beirut Medical Center
dYale University School of Medicine
New Haven, Connecticut
1. Matalliotakis IM, Cakmak H, Koumantakis EE, Margariti A, Neonaki M, Goumenou AG. Arguments for a left lateral predisposition of endometrioma. Fertil Steril 2009;91:975-8.
2. Giacchetto C, Cotroneo GB, Marincolo F, Cammisuli F, Caruso G, Catizone F. Ovarian varicocele: ultrasonic and phlebographic evaluation. J Clin Ultrasound 1990;18:551-5.
3. Al-Fozan H, Tulandi T. Left lateral predisposition of endometriosis and endometrioma. Obstet Gynecol 2003;101:164-6.
4. Bazi T, Abi Nader K, Seoud MA, Charafeddine M, Rechdan JB, Zreik TG. Lateral distribution of endometriomas as a function of age. Fertil Steril 2007;87:419-21.
5. Park SJ, Lim JW, Ko YT, Lee DH, Yoon Y, Oh JH, et al. Diagnosis of pelvic congestion syndrome using transabdominal and transvaginal sonography. AJR Am J Roentgenol 2004;182:683-8.
Published online in Fertility and Sterility doi:10.1016/j.fertnstert.2009.12.034
Authors Declined to Respond