Ovarian Endometrioma (Chocolate cysts)

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.

Endomtrioma forms, chocolate cyst
This image depicts a typical ovarian endometrioma, with old blood and debris giving the cyst its “chocolate” appearance. As you can see in the bottom left corner, this endometrioma has gotten large enough to the point that it is leaking, which often goes on to spill and adhere to the wall and organs of the abdominal and pelvic cavities.

What kind of symptoms can ovarian endometrioma lead to?

They can cause excruciating abdomino pelvic 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.

How is ovarian endometrioma treated?

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 post-operatively. 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 removal of the ovaries (oopherectomy) ever needed in removal of ovarian endometrioma, or any form of endometriomas for that matter. An oopherectomy 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.

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Patient Reviews

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  • Grace Larsen

    After years of excessively painful periods, a serious loss of quality of life, and a series of uninformed and uninterested doctors, Dr. Seckin and Dr. Goldstein turned my life around. I was told I woke up from my surgery almost a year ago with a smile on my face, and I haven't stopped since. Before I heard of Dr. Seckin,…

  • Nicole Novakowski

  • Jacqueline Galindo

    Dr Seckin and his team gave me back my life! Tomorrow will be 1 month since my surgery and I feel great. Dr. Seckin, Dr Liu, and Dr Goldstein are not only beyond words talented and amazing Doctors, but they are also genuinely wonderful and caring people. I cannot say enough great things about Holly, Asiye and Kim as well.…

  • Anna Lu

    Dr. Seckin and his staff spared me from years and years of heavy periods and unbearable endometriosis pain. After having surgery with him (my first) I can now function like a regular human. No more eating NSAIDs like candy and calling out sick from work. Thank you, Dr. Seckin!

  • Sheena Wright

    I underwent surgery with Dr. Seckin in 2017 and have felt like a new woman ever since. If you have, or suspect you have endometriosis, Dr. Seckin and his compassionate team of surgeons and staff are a must-see.

  • Angela Aro

    I have struggled with endometriosis and adenomyosis since first starting my period at 13. I was diagnosed at 21 and what followed was a series of unsuccessful surgeries and treatments. My case was very aggressive and involved my urinary tract system and my intestines. After exhausting all of my local doctors I was lucky enough to find Dr. Seckin. We…

  • Emi O

    Seckin and Dr. Goldstein changed my life!

  • Kristin Sands

    Like so many women who have tirelessly sought a correct diagnosis and proper, thorough medical treatment for endometriosis, I found myself 26 years into this unwanted journey without clear answers or help from four previous gynecological doctors and two emergency laparoscopic surgeries. I desperately wanted to avoid the ER again; a CT scan for appendicitis also revealed a likely endometrioma…