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What Is A Chocolate Cyst?

Chocolate cysts are cystic structures that arise in the ovaries and contain cells that usually belong to the uterus (the endometrial layer lining the inside of the uterus). Cells lining the uterus around the perimeter and called endometrial cells can also be located outside the uterus on the abdominal membrane, on the ligaments of the uterus, or on tubes. In this case, the disease is called endometriosis. Similarly, the presence of endometrial cells that make up the inner wall of the uterus inside the uterine wall is also called ‘adenomyosis'. Histopathological studies of foci of endometriosis and chocolate cysts show all structures belonging to endometrial cells (iron and stroma).

Image-1: Chocolate cysts.


The question of why the cells that normally line the uterus can be found outside the uterus, in the ovary, the lining of the abdomen, in the tubes or even in distant organs such as the eyes, lungs, intestines and even the brain, is still not clear. There are several theories regarding the development of endometriosis or endometrioma (chocolate cyst). One of them is the reverse flow of bleeding particles through the tubes during menstruation. This theory can explain only part of the facts. He cannot explain cases of endometriosis in distant organs. Other theories are also partially supported and partially unsupported. Thus, information about endometriosis or the development of chocolate cysts does not yet allow us to come to a conclusion, and research is currently underway to clarify its etiopathogenesis.

What Are the Symptoms of Chocolate Cysts?

Chocolate cysts or, in other words, endometriomas are cystic structures that grow in the ovary. Some of these cysts grow imperceptibly in the ovary, do not cause any complaints, and are recognized by tests such as ultrasound or MRI, which, by the way, are looked at for other reasons. On the other hand, some chocolate cysts cause pain during menstruation, that is, during menstruation, especially in cases of endometriosis in other places. It would be appropriate to suspect endometriosis or chocolate cysts, especially in those who have their first periods painlessly, but later menstrual pain (dysmenorrhea) occurs. Another complaint that occurs in cases of chocolate cysts and concomitant endometriosis is pain that occurs during sexual intercourse. According to the place of residence, endometriosis can also cause pain during defecation, that is, defecation. The complaint that occurs in a significant part of women with a chocolate cyst is infertility, that is, infertility. Although it is not fully understood how endometriosis causes infertility by any mechanism, the fact that the passage through the tubes negatively affects due to adhesions that exist in these cases, changes in the mechanisms of the immune system in the abdominal mucosa in cases of endometriosis are the reasons that have been proposed as the cause of infertility.

How Are Chocolate Cysts Diagnosed?

The diagnosis of chocolate cysts can be made using ultrasound, which is performed in patients with or without the complaints described above. Ultrasound shows cysts on one, and sometimes on both ovaries, the echogenicity of the fluid which is almost specific to him. Although this condition is very useful in the diagnosis of chocolate cysts, the main and final diagnosis can be made after these cysts are removed and subjected to a pathological examination. In particular, women who have their first menstruation painlessly, and then have menstrual pains, those who complain of pain during sexual activity or defecation, those who complain of constant pain in the groin, accompanied by swelling and fullness in the abdomen, and women who cannot get pregnant, even if they want to get pregnant (infertile) - these are people who need further examination for the presence of a chocolate cyst or endometriosis. In these patients, pain in the groin during a gynecological examination, nodular structures in the back of the uterus, fullness in the groin, and echogenicity in the ovaries during ultrasound examination, almost specific cysts are useful data in the diagnosis of a chocolate cyst. The reliability of ultrasound is not one hundred percent, but simple cysts or other cystic structures that bleed into them and chocolate cysts cannot be completely distinguished. The final diagnosis is made only with laparoscopy (closed surgery) or laparotomy (opening of the abdominal cavity), removal of the cyst and sending it for pathology, examination of the endometrial glands (glands), and stroma structures lining the inside of the uterus in the materials sent for pathology. Laparoscopy or laparotomy in combination with a chocolate cyst also allows you to determine if you have endometriosis. During laparoscopy, it is also possible to determine whether the fluid flowing through the cervix passes through the tubes (i.e., whether the tubes are open). This process is called chromopertubation. This process is also very useful in the treatment of cases when the child has a desire, and at the same session, it is possible to determine whether the tubes are open. In addition, if there are adhesions in the tubes due to adhesions, the opening of the tubes can also be achieved during the same operation.

How Are Chocolate Cysts Treated?

The treatment of cases of chocolate cysts or endometriosis is usually carried out by individualizing patients. If pain is the main cause that leads the patient to the doctor in case of endometriosis, it would be advisable to prescribe pain treatment. If the main problem is the craving for a child, but the inability to conceive a child, treatment will be prescribed for her. Drugs called nonsteroidal anti-inflammatory (NSAIDs) drugs to combat pain in cases of endometriosis are the first group of drugs of choice for pain management, and most patients turn to a doctor who has already used these drugs. Birth control pills that are used without decommunization, and special medications that are manufactured and produced for the treatment of endometriosis, are also widely used to treat pain. Pain management surgical interventions are one of the highly effective methods of treatment and are often used. In surgical procedures, more aggressive operations, such as opening adhesions due to endometriosis, removal or destruction of foci of endometriosis, cutting of nerves transmitting pain in the pelvis (groin), in even more severe and common cases, and even removal of the affected part of the intestine (segmental resection) in cases with foci of endometriosis and nodules in the wall bowel movements are performed depending on the patient's condition and disease.

It is also useful to know that the foci of endometriosis will regress during pregnancy and during menopause. Since endometriosis is a disease that occurs in the presence of estrogen since estrogen also decreases during menopause, usually the foci regress and patients feel relieved. A large amount of the hormone progesterone secreted by the placenta during pregnancy also contributes to the regression of endometriosis foci. Among those who suffer from menstrual pains, the decommunization ‘when you get pregnant, you relax’ is really true for cases of endometriosis, and during pregnancy, the foci of endometriosis regress, and the progression of foci stops.

How Are the Chocolate Cyst Removal Surgeries Performed?

If a decision has been made to have an operation to treat chocolate cysts or endometriosis, these operations can be performed open (laparoscopy) or closed (laparoscopy: insertion into the abdominal cavity using a camera). In operations on chocolate cysts, the goal is to remove all cysts (which will recur if they are not completely removed along with the cyst capsule), which can be summarized as the destruction of foci if there are foci of endometriosis, and the opening of adhesions if there are adhesions. Operations on an open chocolate cyst used to be very frequent operations. The disadvantages of these operations include performing an open operation, performing relatively large surgical incisions, large blood loss, and a relatively longer return to everyday life. Closed operations for chocolate cysts or endometriosis (laparoscopic operations to remove chocolate cysts) are currently the first-choice operations. Closed surgeries for these patients are easily possible, except in very exceptional cases.

Regardless of whether they have had abdominal surgery before, this is not a problem that prevents patients from undergoing closed surgery. During laparoscopic surgery, an incision is usually made 1 cm from the navel for the camera, and through this incision, the camera is inserted into the abdominal cavity. The operation is performed by opening 2 or 3 incisions with a diameter of 0.5 cm, depending on the need. The advantage of laparoscopic operations over open operations is that the procedure is performed with relatively less blood loss, and the duration of hospitalization and the time to return to everyday life are small.

Can Chocolate Cysts Become Malignant?

Chocolate cysts are known as cysts that lack bad cells, meaning they are not cancerous. However, recently obtained information indicates the presence of certain genetic changes in endometrial cells found inside chocolate cysts that predispose to cancer and, therefore, can form cancer from these cysts. Indeed, it has been found that ovarian cancer of endometrioid and transparent cell types is more common in people with a chocolate cyst than in ordinary society. Consequently, cases of the chocolate cysts without surgery require very careful treatment.

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