Ovarian Endometriomas are the cysts filled with fluid (menstrual blood) that are usually formed deep within the ovaries of a woman. These cysts are also known as “chocolate cysts” as they are brown and tar-like in their appearance and hence, they resemble melted chocolate in terms of appearance. This brown chocolate-like color comes from old menstrual blood and tissue that got filled inside the cavity of these cysts. These cysts can be either singular or even in multiples in one or both the ovaries. These endometriomas or chocolate cysts are found in women who have endometriosis which are generally over 25% of the female population in India between the age group 25 and 40. The occurrence of endometriomas is not something rare as endometriosis, which is the root cause of such cysts, is a common condition itself in women. In endometriosis, uterus-like cells start growing at places other than the uterus like on the fallopian tubes, ovaries, and other reproductive tract areas. Such uterus-like outgrowths cause a lot of pain and even infertility in some individuals.
Who gets affected by Endometriomas?
Endometriomas can affect any woman who menstruates as any woman who is in her menstruating age, usually 25 to 40, can get endometriosis as hence, endometriomas. There are four stages that are usually used to classify endometriosis on the basis of the endometrial tissue that is present outside the uterus and the depth to which this tissue is embedded in the organ where it is present. Generally, individuals who have endometrioma are in the 3rd or the 4th stage of endometriosis.
Causes of Endometriomas:
As we all know that endometriomas are majorly caused due to endometriosis and hence, we should get to the causes of endometriosis in order to know the causes that can lead to the development of endometriomas or chocolate cysts. The following are the possible causes that can be leading to the occurrence of endometriosis in an individual other than idiopathic reasons. These are the following causes:
A) Retrograde Menstruation: This refers to the condition where there is an abnormal flow of the menstrual flow i.e., in the wrong direction. This may be experienced by a normal individual sometimes but it can also lead to endometriosis if it gets severe. In normal menstruation, the body of the woman sheds the uterus lining once every month. This lining composes of menstrual blood and also, uterine tissue along with that. Normally, this lining gets removed out of the body after passing through the cervix. In the case of retrograde menstruation, the opposite of the above takes place as the blood and tissue flow up and reach the fallopian tubes instead of going down and taking an exit out of the usual cervical route. This causes a lot of pain as the tissue gets stuck to the surfaces of pelvic organs where they can continue to grow and hence, can cause endometriosis as a result.
B) Transformation of Embryonic Cells: This refers to the theory that states your hormones transform the cells present on the outside of your uterus, like the abdominal region, into endometrial cells that line the inside of your uterus, and hence, endometriosis is caused as a result.
C) Scar Implantation: During a surgical procedure, there are chances that the endometrial cells may get attached to the incisions made during the surgery and such cells later become endometriomas. This is usually seen in surgeries involving the pelvic area like a C-section.
D) Disorders related to the Immune System: You may get shocked to know that a faulty immune system can also cause endometriosis in a woman, but it has been found to be another one of the possible culprits for endometriosis. In case the body is unable to get rid of the cells during the usual menstrual process, it becomes the duty of our immune system to destroy such cells and hence, when the immune system is not functioning properly then such cells can attach themselves to the other organs and hence, lead to endometriosis.
E) Lymphatic System: Your lymphatic system can also play the part of a culprit as it can sometimes transport the endometrial cells into other body parts and can hence, lead to endometriosis and ultimately, ovarian cysts.
The most major symptom of all is the pelvic pain that is experienced by most people who suffer from endometriomas which are often found to be associated with menstrual periods. The menstrual pain experienced due to such endometriomas is mostly worse than the one seen in usual menstrual periods and hence, can cause a lot of suffering for such women. This pain may also get increased with time. Other than the above symptoms, the following can also be seen:
a) Painful intercourse: This can be caused because of the pull and stretch that is experienced by the uterus during intercourse especially, in cases of endometriomas in the lower region of the uterus.
b) Excessive/ frequent urination: This is mostly caused because of the excessive pressure that is put by the large ovarian cyst on the urinary bladder of the individual.
c) Painful urination or bowel movements: These symptoms are mostly witnessed when one is having her menstrual periods.
d) Infertility: If the endometriomas are caused by serious endometriosis like stage 4 then, there are chances of the individual having to face infertility problems.
e) Other symptoms like back pain, bloating, fatigue, etc. can also be witnessed.
One should remember the fact that the severity of the pain experienced by the individual cannot be taken as a reliable indicator as one can also experience severe pain even if she is mildly endometriotic and there can also be a case where even a woman with advanced endometriosis with slight or no pain whatsoever.
Diagnosis of Endometrioma:
The diagnosis is usually done by your healthcare provider who performs by removing the cyst and then examining the cells in that region. Most of the time it all takes place when laparoscopy is being performed. During laparoscopy, your physician makes little incisions in your abdomen, and then she/he inserts a slender tube known as a laparoscopy. A small camera is fitted on this tube which makes it easier for the physician to observe the internal organs and to perform different functions like removing a sample for testing purposes or even for completely removing the cyst. In case it's an ovarian cyst, she/he will observe the endometrial glands along with the stromal cells in the particular sample. Laparoscopy is a medical advancement that allows us to do the diagnosis and the treatment at the same time. These advanced diagnostic tests are done after the physical examination and the imaging procedures have been done by the physician and there isn't a confirmed diagnosis for such chocolate cysts. In case there is a really large cyst it can be found in the physical examination also. Other than this, Transvaginal ultrasounds, MRIs and CT Scans are some other tests that can be used for the diagnosis of such masses.
Let's take an example to understand a very important point here, you may get shocked to know that an ovarian endometrium and a hemorrhagic cyst both look like the same in imaging tests as they both contain blood in them and hence, to be sure about the diagnosis, the healthcare provider should test the tissue properly. Although test results can't help the healthcare provider to reach a confirmed diagnosis so soon in such cases and hence, the provider starts ruling out other conditions that can usually cause symptoms similar to an ovarian endometrium. There are a few tests that can help your provider in getting close to a confirmed diagnosis. These tests are:
(A) Complete Blood Count Test: In this test, your healthcare provider looks at your blood cells to check if you have any kind of infections or abnormal count (like in the case of anemia when the red blood cells reduce in number). People who have ovarian endometriosis often have low red blood cells that cause heavy bleeding (often seen with endometriosis) as a result.
(B) Urine Analysis: This test helps your healthcare provider to know if these symptoms are caused because of an infection in your urinary tract or not. Because in the case of urinary tract infections also, the symptoms are often the same as the ones caused due to an ovarian endometrioma.
(C) Test for STDs (Sexually Transmitted Diseases): These tests are done to see if you have an STD or not as such diseases like chlamydia also cause similar symptoms.
There is no such cure we have discovered for endometrioma or chocolate cysts and hence, it can only be managed by removing the cysts and hence, aiming to get rid of the associated symptoms.
Your healthcare provider can do the following things with an aim to manage your condition:
• Monitor: The most important thing that needs both your as well as your doctor’s attention is the monitoring part that helps to keep a check on the size of these cysts to be sure that their size is small and hence, not worrisome for you.
•Laparoscopy: You can get a recommendation for getting laparoscopy done especially if the endometriosis is causing you a lot of pain, growing bigger in size i.e., greater than 4 cms. The size should not be large because if such cysts turn cancerous, there can be a lot of risks coming your way. Hence, getting rid of such cysts helps you with your symptoms and reduces the continued harm to your ovarian tissue. Getting rid of such ovarian cysts makes you less prone to infertility issues as well.
Hysterectomy: It refers to the surgical removal of your uterus that is done if the costs are present in your uterus.
Oophorectomy: If the cysts are in the ovaries then you can go for another procedure known as oophorectomy which refers to the surgical removal of your ovaries.
There are different factors that decide the best course of treatment for you. These factors can be your age, risk for cancer development, your future plans related to parenthood, etc. Based on these factors only, the best treatment can be decided for an individual.
Medications: As we know there is no specific treatment identified for endometrioma hence, we can not just stop it from developing or occurring in an individual. We can, however, take the help of medicines in order to prevent such cysts from developing bigger in size and therefore, save ourselves from a lot of problems that are caused due to such cysts. Medicines that have been found helpful in such cases are:
Birth Control Pills
GnRH hormone therapy
Based on your condition and your future preferences in mind, your doctor can prescribe you the best medicine.
Endometrioma is not something to be taken lightly even though it is rarely seen (as already mentioned, less than 3 percent of endometrial women). The symptoms that it cause are not the ones a person can easily deal with. You should also keep in mind that if you don't take it seriously, you may have to face a lot of serious problems like infertility also (as endometrioma and IVF mostly have a different relationship). Hence, it is highly recommended that you keep in mind not just the rarity of occurrence but also the agonizing suffering that comes with endometrioma. Hence, if you are having the symptoms and noticing any physical changes/ outgrowths around your uterus, you get it checked out by a competent doctor. Even if you have endometrioma, she/ he should be someone that sits and discusses all the slightest bit of details and advancements of your case and follow a management protocol that serves not just your bodily health but also your future preferences. It's always best to find out a small cyst than a large endometrioma.