Endometriosis and Chocolate Cysts

Endometriosis and Chocolate Cysts

We have to mention about endometrium tissue and frequency changes shortly in order to understand endometriosis (chocolate cyst):

Epithelial layer covering the uterus cavity is called endometrium tissue. Endometrium tissue covers intra-uterine walls as a thin layer. This tissue composed of endometrium cells and connective tissues (stroma) experiences cyclic changes every month to prepare for pregnancy. During menstruation, endometrium tissue breaks to pieces and menstrual blood is discharged through cervix and vagina. On the other hand, menstrual blood passes through tubes and reaches abdominal cavity in small quantity in many women. The broken endometrium tissue reaching abdominal cavity with retrograding of menstrual blood is eliminated by “macrophage” cells of immune system.

Endometrium tissue goes through regeneration and spillage phases in a cyclic way. These cyclic changes are affected from brain and hormones excreted by ovaries. While endometrium layer is thin in post-menstrual period (3-5mm), it thickens gradually on the following days with the effect of hormones and reaches up to 9-15 mm. At the end of menstruation, endometrium tissue gets regenerated and thickens gradually. The embryo which develops on nearly 5.-6. days following oocyte breaking reaches uterine cavity. On these days, endometrium should be ready for pregnancy; otherwise, embryo cannot settle in endometrium and conception doesn’t occur.

Endometriosis (chocolate cyst) is settlement of endometrium cells in the places out of this region. The places where endometrium cells settle out of uterus are called ‘focus of endometriosis’. Endometriosis focuses can be in small numbers as well as they can be common in severe cases.

It is not exactly known how endometrium tissue which is normally found at intrauterine layer settles in other places. As mentioned above, it is known that retrograding of menstrual blood and its reaching abdominal cavity plays an important role. However, it is not known why endometriosis disease is seen in only a part of women while retrograding is found in many women. The blame is put on insufficiency of immune system which is required to break and eliminate endometrium tissues reaching abdominal cavity. As a conclusion, the un-eliminated endometrium tissue adheres to and settles in outer surface of uterus, ovaries, lower abdominal cavity membrane (peritoneum) and intestinal surfaces. Although retrograde flow is the strongest theory in formation of endometriosis focuses, it is considered that other mechanisms do also play role (metaplasia theory, hematogen expansion, etc.)


As endometriosis can be seen in the women who have no complaint and become pregnant without any treatment, prevalence of this disease in women is not known exactly. As it is diagnosed with laparoscopic or operative methods, the notified rates vary. However, the prevalence during fertility period is estimated as 10%. While this rate is low in the women without any problem of conception (1-5%), it reaches 20-40% in the woman with infertility problem.

Where and how endometriosis focuses are found?

Endometriosis leads to various types of lesions within abdomen and upon genital organs. These lesions are classified as Stage I-II-III-IV according to their prevalence.

This classification is made personally during laparoscopy according to settlement and prevalence of lesions. It isn’t possible to diagnose and estimate stage of endometriosis without laparoscopy. While the disease is limited and at initial term in Minimal-Mild (Stage I-II) endometriosis, endometriosis is more common in Moderate-Severe (Stage III-IV) forms. At the Stage III-IV, severe adhesions and chocolate cysts are generally found within abdomen. Although this is not always the case, complaints of the patient (pubic pain, severe menstrual pain, pain during sexual act, infertility, etc) do generally increase in proportion to the stage of endometriosis. On the other hand, while there may be no severe signs in advanced endometriosis, the complaints may be severe and intolerable in mild forms.

Endometriosis focuses are small, dark red-blue-black formations like gun powder burns. These focuses may remain unchanged or advance, lead to reaction in their places and draw surrounding normal tissues to themselves and then adhere to them (for example, uterus and intestine may adhere to each other tightly), or lead to thin-thick fibrous band shaped adhesions between organs. While these adhesions don’t lead to any complaint or infertility, extensive adhesions especially between tubes and ovaries may make it difficult or completely prevent to become pregnant. These adhesions may prevent entry and progress of oocytes into tubes, and it also may increase the risk of ectopic pregnancy. Furthermore, deformation of normal anatomic integrity, contractions in organs, adhesions and translocations may lead to severe pains. These pains may disturb women during certain periods (menstruation, sexual act) or they may be continuous.

Endometriosis focuses starting on the surface of ovaries sometimes bleed into ovary tissue every menstrual period and may lead to formation of chocolate cysts (endometrioma). The intrauterine endometrium tissue bleeds and spills due to hormonal changes, and similarly, the endometriosis focuses in the ovary do also bleed and lead to growth of cyst in time. Sometimes, there are chocolate cysts diameter of which can grow up to 10 cm in both ovaries. Typical appearances of chocolate cysts can be seen during ultrasound examination.

For which complaints the patients with endometriosis (chocolate cyst) apply to doctor?

The most common reason is severe pain and infertility. Pain of the patient may be periodical or continuous. The patient may have typical complaints such as severe pubic and/or backache (chronic pelvic pain), severe menstrual pains (dismenore), pain during sexual act (disparonia) or backside pain as well as atypical complaints. The complaints such as irregular menstruation, constipation and ileus are also observed. Furthermore, chocolate cysts can also be detected during routine gynecologic and ultrasound examination although the patient has no complaint.

Relationship between endometriosis and infertility

Infertility is an important problem affecting endometriosis patients. Although it isn’t possible for these patients to become pregnant without treatment, they are helped generally with surgical or infertility treatments especially at advanced stages of the disease. For the purpose of infertility treatment, ovulation induction and fertilization should be applied at the first stage. The patients who haven’t been treated with these methods are applied IVF treatment at the next stage. The patients having undergone laparoscopy or operation due to chocolate cyst or endometriosis are recommended to become pregnant naturally within 1 year after the operation. IVF method is applied to the patients who haven’t become pregnant naturally during this period or who have been diagnosed with advanced problems which may prevent conception during operation.

The main reasons why endometriosis (chocolate cyst) disease leads to infertility

  • Adhesions between organs (especially between uterus, tubes, ovaries and intestines)
  • Obstructions in tubes
  • Chocolate cysts decrease healthy issues in ovaries or affect ovarian reserve.
  • Deterioration of follicle development in ovaries, hormonal anomalies (luteal phase deficiency)
  • Distorts healthy development and implantation of embryo. Leads to changes in immune system.

Endometriosis Treatment

Endometriosis (chocolate cyst) treatment is generally applied for 3 reasons:

  • Pain
  • Infertility
  • Chocolate cyst

  • Most of the patients are suffered from several reasons. Whether a woman is single or married, whether she has any child or she wants to have baby in the future, age and severity of complaints are important factors in terms of selection and method of treatment. Furthermore, if the woman wants to have baby, sperm analysis of her husband should also be evaluated.

    What are the methods of treatment?

    There are treatment options that can vary from person to person:

    • Medical treatment
    • Surgical treatment
    • Medical + Surgery treatment
    • IVF implementations

    1. Medical (drug) treatment:

    It is especially used to eliminate pain. Hormonal effective drugs such as contraceptives, GnRH analogues, danazol, and progestines are used. It is aimed to inhibit endometriosis focuses and cure the pain with these drugs. However, it isn’t possible to eliminate endometriosis focuses completely with these drugs as well as the patients benefit from medical treatment to a certain extent.

    Among these drugs, the most effective one is the injection called GnRH analogue. With the effect of GnRH analogues, pituitary gland and therefore the ovaries are inhibited and this situation results in “artificial menopause”. As endometriosis focuses develop under hormonal effects, these focuses draw back and pain decreases. These drugs are generally used in 3-6-month periods before or after the operation. They are injected monthly or quarterly. It is not recommended to use these drugs for more than 6 months due to their adverse effects. Contraceptives or progestines can be used for longer periods. Generally, the complaints restart after the drugs are given up.

    Today, it is known that medical treatment is not beneficial in terms of infertility. These drugs don’t have any impact on pregnancy of a woman as well as they cause loss of time.

    2. Surgical treatment:

    The prior method of treatment is surgical approach in case of pain, chocolate cyst and infertility due to endometriosis. When surgical treatment is decided, laparoscopic surgery should be preferred in all patients as much as possible. If there is no opportunity for laparoscopy or the surgeon isn’t well experienced, endometriosis can be treated with open operation. Laparoscopic surgery has many advantages over conventional open operations. Especially for the patients who want to have baby in the future, laparoscopic operation should be performed by well-experienced teams.

    The aim of surgical treatment of endometriosis (chocolate cyst) disease is to burn or destroy endometriosis focuses as much as possible, to eliminate the adhesions, to extract chocolate cysts in the ovaries and normalize the deformed anatomy. Electrical energy or laser is used to destroy endometriosis focuses. Especially in case of extensive endometriosis, the laser has a distinctive priority over other methods. Necessary measures should be taken in order to eliminate the adhesions between intra-abdominal and genital organs and prevent repeating of these adhesions.

    Various surgical techniques are being applied for treatment of chocolate cyst in laparoscopic surgery. However, cystectomy technique is the most effective treatment method.

    In case of applications such as aspiration of cyst (emptying the liquid within cyst) and only burning the wall without extracting the cyst wall, or in case of incomplete extraction of cyst, risk of re-development of the cyst within 6 month-1 year increases distinctively. Probability of repeating chocolate cyst after a successful surgical treatment is very low. If the patient doesn’t have any complaint, it is recommended to follow chocolate cysts under 3cm and to extract it surgically if it grows. Medical treatment of chocolate cysts is unsuccessful. The drugs are only used to make the cyst smaller before operation and facilitate the operation or to cure pains during postoperative period.

    While extracting chocolate cyst, it is very crucial to protect and not to give harm to the healthy ovary tissue. It should be avoided to extract healthy ovary tissue together with the cyst unnecessarily and wrongly or to take out the ovary with cyst completely especially in women who are young and want to have baby in the future. In such cases, ovarian reserve and fertility potential of a woman decrease and early menopause may occur. Today, in addition to surgical treatment in some selected patients, medical treatment is applied in order to make chocolate cysts smaller before the operation or for 3-6 months after the operation.

    Chronic pelvic pain means those continuing longer than 6 months. In the women with severe pubic and backache, severe menstrual pain or painful sexual act, additional operations are performed to cure the pain during laparoscopy. The nerve ends causing the pain are destroyed with laparoscopic LUNA (laparoscopic uterine nerve ablation) or presacral nerve ablation. A distinctive recovery is observed in the pain of woman after these operations.

    The period in which chance of pregnancy is the highest after operation on infertility patients is the first 1 year. The patients who don’t become pregnant within 1 year after the operation should be offered the other treatment options. During laparoscopy, all reasons leading to infertility should be eliminated. Using laser, endometriosis focuses should be destroyed, the adhesions should be eliminated if any and the tubes should be made permeable, chocolate cyst in the ovaries (endometrioma) should be extracted if any and the deformed anatomy should be normalized. If the women who want to become pregnant cannot achieve this within 1 year after the operation, other infertility treatments should be applied. If the woman’s husband has sperm problems, the treatment may be selected differently.

    Factors affecting success after treatment:

    • Endometriosis phase
    • Success in operation (preoperative and postoperative state)
    • Age of woman
    • Other problems in the woman (uterine myoma, etc.)
    • Sperm problem in man
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