Chocolate cyst is the name given to the presence of cells that normally line the uterus, called endometrial cells, in cysts that form in the ovaries. It is not fully understood why cells that should normally be found inside the uterus appear in cysts that form in the ovaries. We only have theories about the development of endometriomas, or chocolate cysts. There is a theory that suggests that endometrial cells and the cells seen inside chocolate cysts originate from the same ancestor. Another theory is that menstrual blood that occurs during menstruation flows out through the cervix and vagina on one side, while on the other side it pours into the abdominal cavity through the fallopian tubes and settles and grows there. Additionally, it is thought that cells that make up the immune system are also effective in the development of endometrioma.
Endometriosis, similar to endometrioma, is the name given to the presence of endometrial cells that should normally be inside the uterus, outside the uterus on the ligaments that hold the uterus in place, on the top of the uterus, on the tubes, or in the peritoneal region we call pelvic peritoneum. Although it is not known exactly what causes endometriosis, theories similar to those mentioned above for endometrioma development are also put forward for endometriosis development.
Whether it's endometrioma, that is, chocolate cysts, or endometriosis, that is, widespread endometrial foci, in both cases, bleeding similar to menstrual bleeding occurs, just like the shedding of menstrual blood during menstruation. Since there is bleeding similar to menstrual bleeding inside endometriomas, that is, chocolate cysts, and this blood waits inside these cysts for a long time, its consistency becomes chocolate-like, and therefore these cysts are called chocolate cysts.
Chocolate cysts seen in the ovaries can reach large sizes over time, damage the surrounding ovarian tissue, and cause a decrease in ovarian reserve. In endometriosis cases, bleeding from endometriosis foci outside the uterus, similar to menstrual bleeding, and the long-term presence of materials that emerge here in this area can cause adhesions. Due to these adhesions, patients may face problems such as pain during menstruation, pain during intercourse, chronic pelvic pain, and infertility due to the tubes being affected by adhesions, causing blockage of the tubes, preventing natural pregnancy. In more serious cases and when the lower parts of the intestine are affected, patients may also experience constipation and pain complaints while having a bowel movement.
Although endometriosis is mostly seen in the pelvic region, which we call the area where the uterus, ovaries, tubes, intestines, and bladder are located, it has also been reported rarely in the brain, inside the eye, in the lungs, and on the incision areas made during these procedures, whether cesarean or normal delivery.
First of all, the point to keep in mind is this: chocolate cysts or endometriosis are diseases of reproductive age. That is, these diseases are not seen in young children who have not started menstruating. Additionally, in people who have entered menopause, if there are cysts, they tend to shrink. If there are endometriosis foci, they also tend to regress.
In cases of chocolate cysts or endometriosis, the most common problem we encounter is pain. The cause of pain is that during menstruation, bleeding occurs from the endometrial tissue inside these cysts in the form of menstrual blood, and during this time, the capsule of the cyst stretches and pain occurs. Therefore, the most common problem in patients with chocolate cysts or endometrioma is pain that occurs during menstruation.
Since endometrioma or endometriosis will appear some time after reaching puberty, pain does not classically start at the time of first menstruation. It appears years after the first menstruation. That's why we call this type of pain secondary dysmenorrhea. This pain that occurs during menstruation, that is, dysmenorrhea, can sometimes be mild and relieved by taking mild painkillers, while sometimes it can be very severe, affecting daily life negatively, and can be severe enough to take the patient to the emergency room. While pain initially appears only as pain during menstruation, as the disease progresses and time passes, it can also turn into continuous groin pain due to adhesions that develop. We call this condition chronic pelvic pain. In more advanced stages of the disease, especially in cases we call deep pelvic endometriosis, patients complain of pain both during sexual intercourse and during defecation, that is, while having a bowel movement.
Infertility, that is, the inability to conceive naturally despite regular intercourse, is one of the common problems we encounter in endometriosis cases. Patients typically describe groin pain that appears years after starting menstruation, especially pain during menstruation, and the inability to conceive naturally despite regular intercourse. Chocolate cysts or endometriosis should definitely come to mind in patients who have pain complaints during menstruation and cannot conceive despite regular intercourse.
Since endometriosis is a chronic disease and can cause many problems, classifications have also been made regarding this disease. One of the most commonly used classifications for this purpose is the classification made by the American Fertility Society. In this classification, endometriosis was previously evaluated as stage 1, stage 2, stage 3, stage 4, but this was later revised. According to this categorization, Endometriosis;
One of the most helpful aspects in the topic of endometriosis and endometrioma is the patient's history. In the patient's history, secondary dysmenorrhea that appears years after starting menstruation, chronic pelvic pain in more advanced cases, which we call continuous pain in the groin area, and in married couples, the inability to conceive naturally despite regular intercourse are known as the most common symptoms. Pain during sexual activity, that is, during sexual intercourse, is also one of the common symptoms encountered, especially in advanced stage endometriosis cases. More rarely, pain that occurs during defecation, that is, while having a bowel movement, and pain that occurs while urinating can also be seen.
One of the situations that gives us the most valuable information in the diagnosis of endometriosis is the gynecological examination. In a carefully performed gynecological examination by an experienced person, many findings in favor of endometriosis can be detected. During gynecological examinations, pain felt during the examination of the back of the uterus, nodular structures felt during this examination, the uterus being constantly turned backward, pain that occurs in the uterine area when the uterus is compressed between two hands during bimanual examination, pain felt in this area when the ovaries are felt during examination, the uterus not being free and the patient experiencing pain when it is moved, give us very strong ideas about the presence of endometriosis.
When looked at with ultrasonography, which we frequently use as a complementary method to gynecological examination, if there are endometriomas, that is, chocolate cysts in the ovaries, these cysts can be seen with regular borders and inside with what we call hyperechoic hourglass appearance. In cases of endometrioma, that is, chocolate cysts, the sizes of the cysts can range from a few centimeters to 10-20 cm. In the diagnosis of endometrioma or endometriosis, the additional contribution of magnetic resonance and computed tomography is quite limited in addition to ultrasonography.
We know that tumor markers such as CA 125 have also been extensively studied in the diagnosis of chocolate cysts. However, the contribution of tumor markers to the diagnosis of chocolate cysts is almost negligible. Therefore, checking CA 125 in cases suspected of chocolate cysts or endometriosis is not included in routine practice.
The gold standard in the diagnosis of endometriosis or endometrioma, that is, chocolate cysts, is laparoscopy, that is, entering the abdominal cavity with the help of a camera, seeing suspicious foci, taking biopsies from the seen foci, and pathological examination of these biopsy materials. Laparoscopy helps us both in making the diagnosis of endometriosis and in classifying endometriosis. In the pathological examination of biopsies taken during laparoscopy or the removed chocolate cyst, the presence of endometrial cells in these areas and immune system cells (macrophages) that have engulfed these cells confirms the diagnosis of endometriosis.
We have many options in the treatment of endometriosis and endometrioma, that is, chocolate cysts. Among these treatment options are nonsteroidal anti-inflammatory drugs, progestins which are drugs similar to the progesterone hormone our body produces, birth control pills containing estrogen and progesterone hormones together, GnRH analogue drugs that put women into menopause with medication, which are agents that can be used for endometriosis treatment. The last option in the treatment of endometriosis and endometrioma (chocolate cysts) is surgical intervention, that is, surgery.
Determining which patients are suitable for surgery and what type of surgery to choose is the most critical stage at this point. It is expected that ovarian tissue will be damaged to a greater or lesser extent during the removal of chocolate cysts. This situation should be considered especially in women who want to have children and in older women. On the other hand, when deciding on surgery, the potential of these cysts to damage the surrounding ovarian tissue by applying pressure should also be considered when chocolate cysts in the ovaries are followed without surgical removal.
Another point to consider in the treatment of endometriosis is that removing or destroying endometriosis foci during surgery may not provide permanent treatment for life. Because it is likely that there are younger and not yet obvious foci other than the foci we see and treat during surgery. In this case, these foci will not be visible during surgery and will become visible in later periods, causing patients' complaints to start again. After surgery, suppressive treatments are recommended and used to reduce these risks. As a result, since endometriosis is a chronic disease and has the potential to potentially exist, progress, or recur until menopause, which approach is most appropriate for the patient should be carefully evaluated and decided after evaluation together with the patient.
