Endometrioma or Chocolate Cyst: Causes, Symptoms, Treatment, Diagnosis

Ever heard of Endometriomas or Chocolate Cyst? One of the estrogen-dependent gynecological diseases affecting about 5% to 10% of women of reproductive age in the United States of America is Endometriosis. It is estimated that about 17% of sub-fertile women have endometriomas. We will know about endometrioma in this article where we will know about the symptoms, causes, diagnosis along with treatment procedures for Endometrioma or Chocolate Cyst.

Endometrioma is also known by the name endometriotic cyst or Chocolate cyst and are localized form of endometriosis or the benign estrogen-dependent gynecological disease; and are mainly caused within the ovary.

• Endometrioma or Chocolate Cyst contains dark and degenerated blood products following repeated cyclical haemorrhage.
• Endometrioma or Chocolate Cyst or endeometriotic cyst may range up to 20 cm in size, though they are mostly smaller in size, i.e. about 2-5 cm.
• Endometrioma or Chocolate Cysts affect women of reproductive age.
• Though most common location of Endometrioma or Chocolate Cyst is ovary, they may also occur in uterus, colon, posterior broad ligament, ultrosacral ligaments etc.
• Most common symptoms include chronic pelvic pain, dyspareunia, dysmenorrhea etc.
• Ultrasounds can be used as the diagnostic methods to diagnose Endometrioma or Chocolate Cyst.
• Medications are available to treat Endometrioma or Chocolate Cyst along with surgical methods (in severe cases).

We will know more in detail about Endometrioma or Chocolate Cyst in the following arrays of our article.

Here we will take a look on some of the symptoms of an Endometrioma or Chocolate Cyst. Before we proceed on further here, we must add that such cysts are mostly similar to that of an ovarian cyst; however most common symptoms of Endometrioma or Chocolate Cyst or endometriotic cyst are included below.

• Painful periods that may go worse over time in the woman suffering from Endometrioma or Chocolate Cyst
• Cramping or pain in pelvis and abdomen is also one of the symptoms of Endometrioma or Chocolate Cyst.
• Pain in pelvis while having bowel movement or while urinating.
• Pain in the pelvis while exercising or bending over or while stretching in the affected women.
• Symptom may also include severe pain with the rupture of the entometriotic cyst.
• Fever and vomiting may be the symptoms with the cyst rupture.
• One may also experience symptoms of very intense pain if the ovary affected by Endometrioma or Chocolate Cyst twists, losing its blood supply.
• Bleeding or spotting may be experienced between periods in the women affected by Endometrioma or Chocolate Cyst.
• Discharge may be dark in color in women with Endometrioma or Chocolate Cyst.

It must be noted that in case of severe and sudden pain in pelvis, one must seek immediate medical help as a ruptures ovarian cysts or ovarian twisting are actually medical emergencies which must be treated on immediate basis.

Endomtrioma is caused due to a condition known as endometriosis where the tissue that usually lines the inside of uterus grows outside of the uterus. It can be painful and also cause infertility in some affected women.

Now let us talk if Endometrioma or Chocolate Cyst in women’s ovary can affect their fertility.

• It is known that endometriosis or Endometrioma or Chocolate Cysts growing on the ovary can prevent the ovary from forming eggs which are to be fertilized.
• It may be noted that though eggs may be released from the ovary of a woman with endomtrioma; sperm cannot penetrate the walls of these released eggs.
• Due to the presence of Endometrioma or Chocolate Cyst, the fallopian tubes may develop scarring and this in turn may interfere with the transport of the egg and the sperm.
• Apart from this, Endometrioma or Chocolate Cyst may also cause a greater risk of ectopic or tubal pregnancy in the affected women.
• Moreover there may also some other substances present in case of Endometriomas or Chocolate Cysts that may prevent fertilization of the egg.
• Endometriomas or Chocolate Cysts are affected by the reproductive hormones and thus there may be disruption in the balance of these reproductive hormones. This in turn can prevent a fertilized egg from implanting in to the uterine wall and may cause miscarriage.

It must be mentioned that most common incidents of infertility in women with Endometrioma or Chocolate Cyst occurs in women in the age group of 25 to 40 years. The earlier treatment begins, the greater are the chances of having childbirth.

Below are some of the tests done to diagnose Endometrioma or Chocolate Cyst:

1. Ultrasound: Ultrasound is used to diagnose Endometriomas or Chocolate Cysts in ovary, especially in the adults.
2. Doppler Sonography: One more diagnostic procedure to know about Endometrioma or Chocolate Cyst is transvaginal color Doppler sonography. This is mostly used to know about the Endometriomas or Chocolate Cysts that are smaller in size. With this technique the stages of ovarian interstitial blood flow in the endometrioma bed can be seen and this would help in predicting any associated damage in the endometrioma bed like the endometriotic cyst-induced arteriosclerosis and devascularization. Early diagnosis would help in better treatment.
3. Pelvic Endoscopy: Pelvic endoscopy is proposed to diagnose the Endometrioma or Chocolate Cysts in sexually active adolescent. Here there is a direct access to the ovaries.

We have mentioned earlier that Endometrioma or Chocolate Cyst can be usually treated by medications or by surgery. Here in this section, we will take a closer look on the treatment ways for Endometrioma or Chocolate Cyst.

1. Medication as a Means of Treatment for Endometrioma or Chocolate Cyst:

   Usually with the appearance of symptoms of Endometrioma or Chocolate Cyst in a patient; doctor would prescribe some of the medications which may include the following.

   • NSAIDs or the Non-Steroidal Anti-inflammatory drugs are used so as to reduce
     inflammation.
   • GnRH Analogs or Gonadotropin Releasing Hormone Analogs are used to suppress estrogen.
   • In order to suppress the hormone levels that increase endometrial growth; sometime birth control pills may also be used.
   • Aromatase Inhibitors (Femara) may be prescribed which help in disrupting the production of estrogen
   • Androgens (Danazol) may be prescribed for lowering estrogen level and also for shrinking excess of endometrial tissue.

2. Aspiration/Non-Invasive Treatment for Endometrioma or Chocolate Cyst:

   One of the most known non-invasive treatments for Endometrioma or Chocolate Cyst is known as Aspiration. Here a transvaginal ultrasound first identifies the exact location of the Endometrioma or Chocolate Cyst and then needle aspiration is used to remove the fluid by transvaginal access.

   However there are some common risks involved with such a method of treatment which include recurrence, infections, adhesions etc.

3. Surgery as Means of Treatment for Endometrioma or Chocolate Cyst:

   There are certain surgical approaches for treating Endometrioma or Chocolate Cyst. Here we will take a look on some surgical treatments for Endometrioma or Chocolate Cyst.

1. Laproscopy Surgical Procedure:

   Laproscopic surgical procedures are considered very effective in treating Endometrioma or Chocolate Cyst. They make use of a thin lighted tube that is put in to the belly via a small cut or incision to see the internal abdominal organs or the female pelvic organs. Such techniques include excision of ovarian adhesions and of Endometrioma or Chocolate Cysts. Operative laproscopic surgery can be effective in providing pain relief and improve fertility in women with Endometrioma or Chocolate Cysts.
   Below we will take a look on some laproscopic surgical procedures.

   Laproscopic Cystectomy:

   The laproscopic cystectomy procedure strips the cyst wall in the portion of the cyst which contains the endometrial tissue. One of the best advantages of laproscopic cystectomy is there is an increased rate of spontaneous pregnancy followed by the surgery. Moreover, the recurrence chances here is also very less.

   Laproscopic Endometrial Ablation:

   One of the invasive surgical procedures for treating Endometrioma or Chocolate Cyst is Laproscopic endometrial ablation where the cyst is drained and the cyst wall is destroyed by electrosurgical current or with the laser energy.

   There is CO2 laser, plasma laser (that uses argon gas), KTP or Potassium-Titanyl-Phosphate laser ablation which can be used as options in the laproscopic endometrial ablation treatment procedure.

2. Cystectomy Surgical Procedure:

   It is a surgical procedure, mostly used to remove all or some parts of the urinary bladder. It can also be referred to the technique used to remove the cyst surgically or the surgical excision of the cysts.

   Cystectomy with Vasopressin:

   Here vasopressin is injected in to the cyst for reducing the amount of bipolar coagulation required for hemostasis and the amount of healthy tissue that is accidentally reduced. This technique is proved beneficial in treating Endometrioma or Chocolate Cysts.

   Cystectomy with Gelatine- Thrombine-Matrix Gel:

   One more technique for treating Endometrioma or Chocolate Cyst suggests the use of a gelatin-thrombin matrix seal for hemostasis that is to be followed after cystectomy. However more research on this is essential.

3. Sclerotherapy:

   Sclerotherapy is a process of endometrioma drainage. Below we will know about Aspiration with sclerotherapy procedure for treating ovarian endometriomas or chocolate cysts in women.

   Aspiration with Sclerotherapy:

   Ovarian sclerotherapy used to treat endometriomas or chocolate cysts of ovaries make use of ultrasound guided aspiration with the help of a sclerosing agent like methotrexate or 95% ethanol(EST) which prevents the cyst re-growth by destroying the cyst wall chemically. It is less invasive compared to the laparoscopic procedure of surgery and takes approximately about 20 to 30 minutes.

   One more advantage of sclerotherpy is that it is less likely to damage the healthy ovarian tissue and thus is less likely to reduce the ovarian reserve. However there can be risk involved with the treatment technique which may include internal bleeding, infection and irritation due to the sclerosing agent used.

4. Three-stage Treatment Technique:

   This is a technique developed by Donnez et al which consists of three stage treatments including laparoscopic cyst drainage followed by GnRH or Gonadotropin-releasing hormone agonist treatment(for about 3 months for reducing cyst diameter) and finally a second laparoscopic treatment for vaporization of the cyst wall by carbon dioxide.

   This is in fact a potential way to treat Endometrioma or Chocolate Cyst, more potential than cystectomy and also in this case it causes less thermal damage.

5. Combined Ablation and Cystectomy:

   This is a combined technique where the Endometrioma or Chocolate Cyst is treated with cystectomy and CO2 ablation. It is a surgical technique where the surgeon removes about 90% of the cysts by using cystectomy procedure and then uses the laser to ablate the remaining cyst wall. Finally for 3 months following the surgery, a GnRH agonist is used. This is beneficial as it reduces the chances of recurrence and also other risks associated with cystectomy. However the risk involved with this is it can remove a healthy cortex causing thermal damage.

So, in this article we mentioned in brief about Endometrioma or Chocolate Cyst, symptoms and various treatment techniques for the condition. It must be noted that in case you are experiencing any symptom of Endometrioma or Chocolate Cyst; kindly make an immediate doctor’s visit to be properly diagnosed and undergo the relevant treatments as prescribed by your doctor.