Chocolate cyst is a pathological cavity formation on the surface of the ovary, consisting of accumulated menstrual blood surrounded by a shell of endometrial cells. Disease in some cases may not manifest for a long time, in others it may be accompanied by abnormal menstruation, infertility, pain, up to the clinic of “acute abdomen”. Diagnosis is based on ultrasound and laparoscopy data. Treatment includes surgical removal of a pathological formation and long-term hormone therapy.
Chocolate ovarian cysts, unlike functional cysts, have a different mechanism of development and in the vast majority of cases are bilateral. In gynecology, pathology refers to the most common manifestations of the genital form of endometriosis, in which cells of the mucous membrane lining the inner surface of the uterus are found in the fallopian tubes, ovaries, vagina and abdominal cavity.
This disease develops in women of reproductive age (30-50 years), usually against the background of internal endometriosis, can be combined with uterine fibroids and endometrial hyperplasia. The size of the ovarian endometrioid cyst can reach 10-12 cm.
Despite the large number of theories of the origin of endometriosis, the exact causes of the disease are still unknown. According to the implantation hypothesis, endometriosis and chocolate cysts can occur during retrograde menstruation, when endometrial cells migrate together with blood and take root in the tissues of the fallopian tubes, ovaries, and abdominal cavity.
The insertion of endometrial fragments is also possible during surgical manipulations that injure the uterine mucosa: gynecological and obstetric operations, diagnostic curettage, medical intake, diathermocoagulation of the cervix. It is also assumed that endometrioid foci may be the result of metaplasia of remnants of embryonic tissue, genetic defects (familial forms of endometriosis) or weakening of immune responses.
There is a connection between the development of this pathology and endocrine disorders in the body: a decrease in progesterone levels, an increase in estrogen (hyperestrogenism) and prolactin, thyroid dysfunction, adrenal cortex. Provoking moments in the development of endometriosis can be:
- any emotional stress;
- long-term use of the IUD;
- endometritis, oophoritis;
- impaired liver function;
- unfavorable ecology.
The resulting endometrioid foci are functionally active and hormone-dependent, so they are cyclically subjected to a menstrual-like reaction. The proliferation of monthly bleeding endometrial tissue in the cortical layer of the ovary leads to the formation (“chocolate” cysts) filled with thick, dark brown contents that have not found an outlet. A histological sign is the absence of glands in its wall.
The severity of clinical manifestations depends on a number of factors: the extent of endometriosis, the presence of concomitant diseases, the psychological state of the patient, etc. In some cases, the formation of an chocolate cyst is asymptomatic or manifested by a violation of reproductive function (infertility).
Chocolate cyst can be accompanied by pain in the lower abdomen and in the lower back, which increases during menstruation, during sexual intercourse. Sometimes the pain can be very severe, and with a large size and rupture of the cyst capsule, the clinic of “acute abdomen” develops.
Chocolate cyst is characterized by abundant menstruation, lengthening of the menstrual cycle with spotting secretions before and after menstruation. Symptoms of intoxication may appear: weakness, nausea, fever.
The proliferation of an chocolate cyst can lead to local changes in ovarian tissue: egg degeneration, follicular cysts, the appearance of scars that violate the normal functions of the ovary. With the long-term existence of an chocolate cyst, an adhesive process in the pelvis with impaired bowel and bladder functions (constipation, flatulence, urination disorders) may be detected. Chocolate cyst is a serious gynecological pathology that can be complicated by suppuration, rupture of the walls of the cyst with the outpouring of its contents into the abdominal cavity and the development of peritonitis.
Gynecological examination does not always reveal signs of endometriosis. With an chocolate cyst, it is possible to detect the presence of a sedentary painful formation in the ovary and its increase before menstruation. The diagnosis of an chocolate cyst is established by the results of ultrasound of the pelvic organs with dopplerometry of uteroplacental blood flow, MRI and laparoscopy:
- Ultrasound with dopplerometry. Determines the absence of blood flow in the walls of the ovarian chocolate cysts.
- The study of cancer markers. When determining the level of the cancer marker CA-125 in the blood, its concentration may be normal or slightly increased.
- Diagnostic operations. In the presence of infertility, hysterosalpingography and hysteroscopy are performed. Diagnostic laparoscopy is the most accurate method of diagnosing an chocolate cyst. A biopsy and subsequent histological examination of the focus of endometriosis in ovarian tissue is necessary to identify the likelihood of its malignancy.
Treatment of chocolate cyst
Treatment can be conservative (hormonal, nonspecific anti-inflammatory and analgesic therapy, taking immunomodulators, vitamins, enzymes), surgical (organ-preserving removal of endometrioid foci by laparoscopic or laparotomic access) or combined. Comprehensive treatment of endometriosis is aimed at eliminating symptoms, preventing the progression of the disease and treating infertility. The tactics of treatment of chocolate cyst depends on the stage, symptoms and duration of endometriosis, the age of the patient and the presence of problems with conception, concomitant genital and extragenital pathology.
With an insignificant size of the chocolate cyst, it is possible to conduct long-term hormonal therapy using low-dose monophasic COCs, norsteroid derivatives (levonorgestrel), prolonged MPA, androgen derivatives, synthetic GnRH agonists. The pain syndrome associated with the proliferation of chocolate cyst is stopped by taking NSAIDs, antispasmodic and sedative drugs.
With the ineffectiveness of conservative therapy for chocolate cysts larger than 5 cm, a combination of endometriosis and infertility, the risk of complications and oncological alertness, only surgical treatment is indicated.
In women of reproductive age who want to have children, they try to avoid radical operations (oophorectomy, adnexectomy). The preferred methods of surgery for endometrioid cysts are enucleation of heterotopic formations or ovarian resection. Removal of foci of endometriosis and chocolate cysts is advisable to be carried out with preliminary and postoperative hormone therapy.
Management of the postoperative period
Preoperative hormone therapy can reduce the foci of endometriosis, their blood supply and functional activity, and the inflammatory response of surrounding tissues. After surgical removal of the ovarian endometrioid cyst, appropriate hormonal treatment promotes regression of the remaining endometrioid foci and prevents recurrence of pathology.
In the postoperative period, it is advisable to prescribe physiotherapy to correct endocrine imbalance, prevent infiltrative and adhesive processes, relapses of chocolate cysts (electrophoresis, ultrasound, phonophoresis, endonasal galvanization, SMT therapy, magnetotherapy, laser therapy, acupuncture, radon baths, etc.).
After removal of the chocolate cyst, in most cases, pain is significantly reduced, normal menstrual and reproductive functions are restored. After treatment of an chocolate cyst, dynamic observation of a gynecologist with ultrasound control and examination of the CA-125 level is recommended.