by Tamer Seckin, MD Endometriosis Excision Surgeon / Seckin Endometriosis Center (SEC)

Ovarian Endometrioma (Chocolate cysts)

Our endometriosis specialists work with patients to understand symptoms, diagnosis, and treatment options for endometriosis.

What are ovarian endometriomas (Chocolate cysts)?

Ovarian endometriomas are highly common and may be present in up to 30-40% of women with the disease. Endometriomas are large, fluid-filled cysts that form on, and may even encapsulate, the ovaries.

How do Endometriomas form?

Retrograde menstruation is one of the believed causes of ovarian endometrioma formation. According to this theory, in cases of endometriosis women will have a higher rate of menstrual backflow, causing an accumulation of blood to flow into the ovaries, and can ultimately form an endometrioma.

As the mature egg is released from the ovaries into the fallopian tubes during ovulation, menstruation occurs. However, some of this blood enters back into the uterus, through the fallopian tubes and into the ovaries. As more and more of this blood flows in, an endometrioma begins to form and develops until it is large enough to leak out of the ovary.

Why are Endometriomas called "chocolate cysts?"

These sizable cystic masses are comprised of menstrual debris, including fragments of endometrial tissue, thickened blood, and inflammatory enzymes. These so-called "chocolate cysts", aptly named for the appearance of the "old" blood they contain, may acutely rupture, causing spillage and adherence of their contents to the walls and nearby organs within the abdominal cavity.

Symptoms

They can cause excruciating abdominopelvic pain. All forms of endometriosis can be associated with significant pain, infertility and interruption of a woman or young girl’s ability to go about her normal routine.

Why is it so important to identify ovarian endometriomas?

Early intervention is the key to effectively resolving this disease. Usually, in patients with an ovarian endometrioma, the patient's symptoms and sonographic findings are dismissed by general practitioners, in that their symptoms are simply from a cyst. Ovarian endometriomas are probably the most clinically important stage of endometriosis since it is usually confused with hemorrhagic ovarian cysts and due to the presence of prolonged asymptomatic stage (showing no symptoms), the disease is often diagnosed late.

Treatment

Treatment for ovarian endometrioma is laparoscopic cystectomy (surgical removal of an ovarian cyst), involving the process of removing the lining of the endometrioma cyst and performing ovarian reconstruction and temporary ovarian suspension. The ovary is suspended temporarily in the peritoneum so that it does not adhere to the pelvic sidewalls for 4-8 hrs postoperatively. The removal of the ovarian cyst must be done with precision without compromising the ovarian vascular supply. However, It is widely known that after ovarian cystectomy for endometriosis, patients are prone to have diminished ovarian function due to loss of ovarian follicles.

Is it possible to preserve ovarian function after having surgery?

With proper adherence to meticulous techniques using microsurgical principles, we follow the strict guidelines of not using any electricity during ovarian surgery (we don't want to cook the eggs) and separate the cyst meticulously from the ovarian blood vessels. Using sutures rather than bipolar (electric) coagulation, we can reduce the occurrence of loss of ovarian function by not damaging the remaining follicles with electric coagulation.

Is it necessary to have my ovaries removed?

Rarely, is the removal of the ovaries (oophorectomy) ever needed in the removal of ovarian endometrioma, or any form of endometriomas for that matter. An oophorectomy should be considered only if there is a suspicion of cancer, persistence of disease despite multiple previous cystectomies, and severe adhesions with deeply infiltrating pelvic sidewall disease-causing neuropathy.