Endometriosis Cyst – the Chocolate Cyst

Various types of cysts can develop on the female reproductive organs. Endometriosis can also lead to the formation of cysts on the ovaries, known as endometriosis cysts or endometriomas. These cysts earned the colorful nickname “chocolate cysts” because they have a distinct appearance that sets them apart from ovarian cysts formed without endometriosis.

What is a Chocolate Cyst?

A chocolate cyst, also known as an endometrioma or endometriosis cyst, is a specific type of cyst that forms within the context of endometriosis. Like tissue bladders, cysts can be filled with various substances, such as urine in kidney cysts or air in lung cysts. In the case of endometriosis cysts, these cavities become filled with old and thickened blood, which accumulates due to bleeding or during menstruation. The presence of brown-red, thickened blood is what led to their evocative name “chocolate cysts”. Despite ongoing scientific research, the exact process of how these chocolate cysts develop remains yet to be definitively clarified.

What are the Effects of Endometriosis Cysts?

The effects of endometriosis cysts can be significant, with the size of the cyst playing a crucial role in the level of discomfort, particularly pain, experienced during menstruation. However, discomfort may also arise independently of the menstrual period due to the increased pressure and stretching of the cyst wall and ovarian tissue, leading to reduced blood circulation. Inflammatory processes are also suspected to contribute to the occurrence of pain. Overall, the symptoms are similar to general endometriosis symptoms.

Furthermore, endometriosis cysts exert a more pronounced negative effect on ovarian function and hormone production compared to other ovarian cysts. This adverse effect is particularly noticeable in the case of endometriomas. As the cyst grows larger, the detrimental effects on the ovary and consequently on fertility become more pronounced. Hence, endometriosis cysts can be a contributing factor in causing infertility or an unfulfilled desire to have children.

Diagnosis of Endometriosis Cysts

The diagnosis of endometriosis cysts is often facilitated through vaginal ultrasound. In some cases, very large cysts can even be palpated during a physical examination by the physician. Endometriosis cysts may exhibit characteristic shading on the ultrasound, allowing for their recognition. However, there are instances where certainty cannot be established through imaging alone, necessitating surgical intervention to distinguish between various types of cysts. To confirm the nature of the cyst (endometriosis cyst, benign ovarian cyst, or otherwise), the doctor may perform an abdominal endoscopy, during which a tissue sample or the entire cyst can be removed. This procedure is typically part of the surgical therapy for accurate diagnosis and effective management.

The guideline also highlights the importance of considering the potential coexistence of deep infiltrating endometriosis when diagnosing endometriomas.

Treatment Options for Endometriomas

The approach to treating endometriomas depends on various factors, such as the patient’s desire to have children, the size of the cysts, and the severity of the symptoms. The doctor will present several treatment options, enabling the patient to make an informed decision:

Endometriomas can be treated with either medication or surgery. Medications are effective in reducing the size of the cysts and alleviating pain. However, they cannot completely dissolve and heal the endometriosis cyst. For a comprehensive resolution, surgery is necessary, although surgical intervention does not guarantee that the cysts will not recur.

In certain cases, the doctor might recommend the removal of the ovaries. However, this decision is influenced by various factors, including the size of the cyst and the feasibility of preserving the ovaries. It is essential to note that removing the ovaries is typically not the first option and is only considered in a small number of cases.

Gentle Surgery via Laparoscopy

Typically, chocolate cysts are removed using abdominal endoscopy, a minimally invasive procedure involving small incisions made in the belly button and two other sites. This approach ensures minimal scarring. However, in cases of particularly large cysts, the option of an abdominal incision may be considered, although this decision is made based on individual considerations.

Another treatment possibility is sclerosing cysts, which involves injecting an agent into the cyst to transform it into tissue that can be gradually absorbed by the body. However, this method tends to have limited long-term success, as chocolate cysts re-form in 28.9 – 91.5% of women treated this way [1].

Fenestration, a technique involving the simple opening of the cyst, aspiration of its contents, and sclerosing part of the cyst with electricity, is not considered the preferred method. This approach often leads to cyst recurrence, and extensive removal of ovarian tissue can further damage the ovary.

What is the Optimal Method for Treating Cysts Caused by Endometriosis?

Cysts resulting from endometriosis typically require surgical removal. The choice of method depends on several factors, including fertility aspirations and the severity of endometriosis. In general, excision, involving the complete removal of the cyst, proves to be more advantageous compared to ablation/coagulation for endometriomas. This approach not only achieves superior pain reduction but also significantly lowers the recurrence rate when compared to alternative methods. Moreover, excision is associated with a higher rate of successful pregnancies.

One study revealed that after excision, only about 6.2% of cysts recurred, whereas sclerotherapy led to three times as many recurrences.

Ovarian Damage from Manipulation and Sclerotherapy

The impact of surgical procedures primarily affects the ovarian reserve, which refers to the pool of follicles within the ovary that mature into eggs during the normal menstrual cycle. This reserve’s condition can be assessed using certain hormones, such as anti-Müllerian hormone (AMH). The recommended practice is to measure AMH levels in cases of ovarian endometriosis to gauge its condition before determining the appropriate treatment strategy.

Both manipulation and coagulation with electricity can negatively affect the ovarian reserve. The extent of damage depends on the degree of coagulation and manipulation involved.

Specifically, when electricity is used for ablating the cyst, it causes more significant damage to the ovarian reserve compared to cyst excision.

While electricity is often employed to control bleeding, its usage should be minimized.

It is crucial to avoid extensive coagulation of the ovary during surgery whenever possible. To ensure a gentle operation on the ovary, it is advised to seek the expertise of an endometriosis specialist. An experienced surgeon with specific knowledge of endometriosis is more likely to perform the procedure with care and precision.

Caution is warranted when evaluating a surgeon’s experience. Simply knowing the frequency of laparoscopic surgeries may not be sufficient. The key lies in identifying a skilled endometriosis surgeon, rather than someone who has merely conducted numerous laparoscopies in general.

Determining the Appropriateness of Surgery for an Endometriosis Cyst

The decision to undergo surgery for an endometriosis cyst should be carefully considered on a case-by-case basis. This is particularly true for endometriomas, as the potential negative effects of surgery must be weighed against the impact of the endometrioma, especially when a woman desires to conceive. The final decision takes into account the most prominent symptom, the size of the endometriosis cyst, and the patient’s specific preferences and goals.

However, when it comes to new cysts, removal for histological examination is often recommended.

Pain Management

When it comes to managing pain caused by endometriosis, laparoscopic surgery is considered the gold standard. Crucially, excision yields better pain reduction and lower recurrence rates compared to other approaches. During surgery, other endometriosis lesions can also be addressed effectively. In addition to surgical options, hormonal therapies can offer symptom relief. Combination pills or progestin-only pills are among the medications commonly prescribed to alleviate symptoms associated with endometriosis.

Furthermore, it is highly recommended to adopt a multimodal approach to pain management for endometriosis.

Therapy for Infertility in Endometriosis

When infertility due to an endometriosis cyst becomes the primary concern, the size of the endometrioma becomes a relevant factor to consider. In numerous instances, addressing endometriosis through appropriate treatment can improve the chances of conception.

The impact of endometriomas on fertility is an ongoing subject and merits detailed examination. However, one compelling reason to consider surgery is the negative influence of endometriomas on egg quality.

It’s important to note that surgical interventions can also affect the ovaries.

Therefore, the decision-making process, especially concerning endometriomas and fertility treatments IVF and ICSI, must carefully consider the critical size of endometriomas, which appear to be around 3 cm.

Studies have shown that endometriomas larger than 3 cm negatively affect the retrieval of eggs during puncture procedures. Additionally, the pregnancy rate in IVF is significantly reduced in patients with endometriomas over 3 cm.

Hence, the size of the endometrioma should be a significant consideration in the collaborative decision-making process between the patient and the doctor.

Would you like to learn more about possible and typical symptoms of endometriosis? Just download the Endo-App and access valuable insights from our experts.


[1] https://www.ncbi.nlm.nih.gov/pubmed/27039054

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