A 46-year-old woman presents with severe dysmenorrhoea and dyspareunia. Examination reveals bilateral tender adnexal masses, CA-125 is mildly raised at 65 U/ml, and ultrasound shows bilateral 5 cm cysts with the typical 'ground-glass' appearance suggestive of endometriomas. She wishes to retain her uterus and ovaries if possible. What is the most appropriate treatment?

Answer: A. Laparoscopic ovarian cystectomy (removal of the endometrioma cyst wall)

Endometrioma management

Bilateral tender adnexal cysts with a ground-glass appearance, dysmenorrhoea and dyspareunia, and a mildly raised CA-125, point to ovarian endometriomas (a metaplastic, not neoplastic, cause of ovarian cysts). A mild CA-125 rise is common in endometriosis and does not by itself indicate malignancy.

Why laparoscopic cystectomy

• Laparoscopic ovarian cystectomy - excising the endometrioma cyst wall (rather than simple drainage/ablation) - gives better symptom control and lower recurrence, while preserving the ovaries and fertility.
• It also provides histology to confirm the diagnosis.

Why not the others

• Hysterectomy with BSO is over-treatment for a woman wishing to retain her ovaries/uterus and is reserved for definitive treatment after failed conservative measures or completed family.
• Long-term opioids are inappropriate for chronic benign pain and risk dependence.
• Reassurance/discharge ignores symptomatic disease; chemotherapy has no role in benign endometriosis.