Introduction:
Endometriomas are called chocolate cysts because they appear brown, tar-like, and resemble melted chocolate. These cysts acquire such color due to the presence of old menstrual blood and tissues that occupy the cyst cavity. Endometrioma can affect either one or both ovaries and can be present as single or multiple cysts. The presence of an endometrioma is an indicator of endometriosis (a condition in which the tissue that resembles the tissue lining the uterus develops outside the uterus in areas where it does not belong).
How Does Endometrioma Differ From Endometriosis?
The formation of functional endometrial tissue on the external surface of the uterine cavity is called endometriosis, while endometriomas are the most common type of endometriosis. These are formed as a result of recurrent hemorrhage from an ectopic endometrium situated in the ovaries.
What Are the Stages of Endometriosis?
The four stages of endometriosis include:
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Stage 1: A small amount of tissue may be present on the organ's surface where it forms.
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Stage 2: The amount of tissue may be more when compared to the tissue deposition in stage 1. Some of the tissues in this stage may be embedded.
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Stage 3: A lot of tissue may be lodged deeply and can include small endometriomas.
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Stage 4: A lot of tissue may be lodged deeply and can include large endometriomas.
Are Ovarian Endometriomas Common?
About 10 % of menstruating women suffer from endometriosis, and about 17 to 44 % of women with endometriosis are known to have ovarian endometriomas. Ovarian endometriomas can cause discomfort and pain in the pelvis, inflate the risk of acquiring ovarian cancer, and interfere with getting pregnant. Though the risk of ovarian cancer is rare in women with ovarian endometriomas, these cysts can potentially become cancerous.
What Are the Causes of Ovarian Endometriomas?
There are a lot of theories that have been put forth regarding the occurrence of ovarian endometriomas. One theory attributes this to the fact that endometriomas could be a result of endometriosis. The lining of endometriomas is similar to the lining of the uterus in which it grows and sheds in response to the monthly increase and decrease in the level of female hormones. Instead of exiting the body, the tissue gets locked within the cyst cavity. This can initiate inflammation and can disrupt the ovaries.
What Are the Symptoms of Endometriomas?
Chocolate cysts can trigger certain symptoms in a few women, while some may be asymptomatic. The size of the cysts can vary between 2 to 20 centimeters (cm), and the severity and the occurrence of the symptoms are independent of the size of the cyst. A few symptoms of endometriomas include:
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Occurrence of painful periods with cramps.
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Pain in the pelvis that is not linked to the menstrual cycle.
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Pain during sex (dyspareunia).
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Irregular menstrual cycle.
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Pain while pooping or urinating.
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An urge to urinate more.
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Nausea, vomiting, bloating, and back pain.
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Infertility in a few women.
The rupture of an endometrioma or a chocolate cyst can produce sudden, severe abdominal pain on the side where the cyst is situated. A ruptured cyst is an emergency medical condition, and one must immediately consult a physician.
What Are the Diagnostic Procedures to Diagnose Ovarian Endometriomas?
Ovarian endometriomas can be diagnosed in the following ways:
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Pelvic Ultrasound: Pelvic ultrasound may be suggested by the physician if they feel the presence of a cyst during a pelvic examination, endometriosis is suspected based on the patient’s symptoms, or if one is experiencing unexplained infertility.
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Ultrasound: An ultrasound can detect the presence of a cyst but cannot determine the type of the cyst.
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Biopsy: A procedure called laparoscopy is done to extract a sample of the cyst (biopsy). In this procedure, tiny incisions are made in the abdomen, and a thin tube called a laparoscope is inserted. With the help of this tube, the physician can view the cyst, extract a sample of it for analysis (biopsy), or can even remove it completely. Endometrioma can be confirmed by the presence of endometrial glands and stromal cells in the sample. Laparoscopy can aid in diagnosis as well as treatment.
Transvaginal ultrasounds, magnetic resonance imaging (MRI), and computed tomography (CT) are the other diagnostic procedures to detect the presence of a mass. Physical examination or imaging techniques cannot offer a confirmatory diagnosis because two different conditions may appear similar in these diagnostic procedures. For example, a hemorrhagic cyst and ovarian endometrioma can mimic each other on imaging tests since both of these cysts contain blood. Confirmatory diagnosis of endometrioma can only be done by testing the tissue.
How Can Endometriomas Be Treated?
The treatment of endometriomas depends on the age, symptoms, whether or not one desires to have children, and whether the endometrioma is present in one or both ovaries. If the endometrioma is small and the individual is asymptomatic, the physician may suggest waiting and watching. Medications that inhibit ovulation, like birth control pills, may be prescribed to control pain and retard the growth of cysts, but this is not a permanent cure.
Surgery is indicated if the symptoms are painful and cause infertility if cysts are larger than 1.5 inches, or if the cysts are cancerous. Some of the surgical procedures include:
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Laparoscopy: Laparoscopy is indicated if:
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The cysts are larger than 1.5 inches and are painful.
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The potential of the cyst to turn cancerous if it attains the above size.
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When removal of the endometrioma not only relieves the symptoms but also prevents the rupture of the cyst in the future.
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Increase the chances of pregnancy if ovarian endometriomas are the cause of infertility.
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Hysterectomy or Oophorectomy: In cases where other methods have failed to provide relief from the symptoms or if one does not have any plans to become pregnant, then the physician may recommend the removal of the uterus (hysterectomy) or removal of ovaries (oophorectomy).
Are There Any Medications for Endometrioma?
Since endometriosis cannot be cured, even endometrioma cannot be prevented. But, certain medications can interfere with the growth and recurrence of endometrioma. Medications can also help relieve pain. These medications include:
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Progestins.
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Vaginal ring.
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Birth control patch.
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Birth control pills.
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Gonadotropin-releasing hormone (GnRH agonist).
The physician can guide the individual with suitable options based on whether one is trying to become pregnant or not.
How Can Endometriomas Affect Fertility?
Endometriomas or chocolate cysts can conquer, damage, and attack healthy ovarian tissue. This can have an impact on fertility as these cysts are difficult to be treated. Pelvic surgeries that are done to control and remove these cysts can result in ovarian scarring and decreased fertility. Women with endometriomas have fewer eggs, higher levels of follicle-stimulating hormone (FSH), which could signify ovarian issues, and the presence of eggs that are less probable to mature.
Despite such damage done to the ovaries by endometriomas, many women can conceive naturally. One can opt for in-vitro fertilization (IVF) if one is diagnosed with a chocolate cyst and has difficulty becoming pregnant.
What Are the Complications Associated With the Treatment of Ovarian Endometriomas?
More research needs to be initiated to better understand how laparoscopy would influence fertility in couples opting to conceive through IVF. Few researchers state that laparoscopy can lower the number of eggs made by the ovary that has the potential to get fertilized (ovarian reserve). This can complicate the chances of getting pregnant. If the ovarian endometriomas interfere with gaining access and collecting the eggs, then one must consider eliminating the ovarian endometriomas.
Conclusion:
Chocolate cysts or ovarian endometriomas are common in women with endometriosis. The symptoms can be treated with medications, while some cases might require surgery to remove the endometrioma. One must consult a physician, discuss the treatment options, and let the physician know whether one is planning to have children in the future so that the physician can tailor the appropriate treatment plan based on the decision. The positive outlook is that the symptoms start to fade around menopause when the body no longer responds to the hormonal changes that occur during menstruation.
