Endometriosis (Chocolate cyst)

Chocolate cyst is formed by the focus of endometrium cells, which are the inner tissue of the uterus, in areas outside of the uterus. This happens 75% of the time in the ovaries. Cysts that develop without any symptoms in some women can cause different negative effects, such as severe pain during menstrual periods and sexual intercourse, inability to conceive, and menstrual irregularity. In this case, it becomes a necessity to treat patients with appropriate treatments. However, there is no definitive treatment for chocolate cyst. Surgical treatment is considered to be the most effective method in this respect. In today's treatment approaches, it is generally tried not to intervene in cysts up to 4-5 cm. Surgical interventions to be applied are more cautious as they will damage the ovarian reserve. Laparoscopic procedure is generally recommended in surgery. In addition, the experience of the surgeon in this field should be taken into consideration. It can be applied to patients in approaches such as drug therapies and external hormone administration other than surgery.
It is not necessary to remove the ovary in the surgical removal of the chocolate cyst. In any case, it is possible to remove the cyst without harming the patient's ovary. In surgery performed with laparoscopy, the pain is less, there is less scar due to the surgery, the duration of hospitalization is shortened, the intraabdominal adhesions are less, the risk of infection is reduced, recovery and return to normal life is faster.

Medical treatments for chocolate cyst
The goal of medical treatments for chocolate cysts is to reduce the effects of the cysts, as they are dependent on the estrogen hormone. In this way, suppression of ovulation in the patient, relief of the patient by stopping menstrual bleeding for a certain period of time and regression of cysts are provided. During drug treatments, drugs such as birth control pills, GnRH analogues and danazol are used. In order to reduce the pain occurring in the patient, it is recommended to use drug therapy for a long time. Cysts do not disappear completely with the treatment applied. However, the negativities caused by the chocolate cyst are suppressed. With the termination of the treatment, the complaints of the patients begin to be effective again. However, with the use of medications, approximately 90% of the patients with pain complaints alleviate the pain. After these drugs are stopped, the negative effects begin to reappear. But they help the woman relax in this process.
Use of birth control pills: The use of these pills in patients can make the menstrual cycle regular, reduce the amount of bleeding, and can be used effectively in the treatment of cysts. With the effect of the pills, the endometriotic foci are suppressed, the pain in the groin is relieved, and the cramps in menstrual bleeding lose their effect. However, due to the side effects of the drugs containing high doses of estrogen and their limited effects as a result of the treatment, they are not used in the treatment of cysts today. However, those that contain less estrogen both stop the progression of the disease and allow the effects of the disease to improve, albeit temporarily. However, if patients with chocolate cysts want to have children, the use of these pills is not an appropriate approach in treatment. If the pills are used for at least nine months or more, the pain caused by the cyst effect decreases by 80-90%.
Application of Danazol treatment: The use of this drug stops the secretion of LH and FSH hormones that manage the monthly menstrual cycle, are secreted from the pituitary gland in the brain, and keep the ovaries under control. In this way, a reduction of 85-95% of the effects that occur on patients is achieved. This method, which has been used in the treatment of cysts for many years, is not preferred today due to its side effects. Side effects of the drug Danazol include weight gain, mental collapse, voice thickening, muscle cramps that occur without cause, fluid retention in the body, fatigue, headache, nausea, increased sexual desire. Because of these effects, the vast majority of women who receive treatment discontinue the treatment. With the discontinuation of the drug, menstrual bleeding starts again in 4-6 weeks.
Treatment with GnRH agonists: Drugs that are GnRH analogues are effective in the treatment of chocolate cysts, as they create a temporary artificial menopausal state in patients. In women, the LH and FSH hormones, which are secreted from the pituitary gland in the brain and control the functioning of the ovaries and manage the menstrual cycle every month, are suppressed with GnRH agonists and their effects are reduced to the woman's menopause level. Since egg development does not occur in the ovaries during this period, a naturally decrease in the estrogen level occurs. There is a decrease in the number and size of the lesions that occur during the disease. These drugs show their effect when used for 6 months. During this process, patients get better. It reduces the pain that occurs in patients. Among the side effects of this drug, there are problems such as flushing, vaginal dryness, sleep disturbances and headache, just like in menopause. Apart from these effects in patients, it may have effects such as memory loss, joint pain and decreased calcium in the bones. Therefore, while the cyst treatment with medication continues, low dose estrogen and progesterone treatment should be applied to the patient in order to prevent the loss of estrogen in the body.

Surgical treatment for chocolate cyst
Depending on the condition of the cyst in the patients, the surgical treatment of the chocolate cyst can be decided in accordance with the severity of the infertility problem, the desire to have children in the future and the age. Deciding on surgical intervention would be the best treatment option, especially in case of severe symptoms. In surgery performed with laparoscopy, endometriosis foci and adhesions in the abdomen are burned and the problems are tried to be eliminated.
In the operation performed with laparoscopy, pain complaints of the patients are greatly reduced. Chocolate cysts in the ovaries are removed. With the removal of these cysts, it reduces the pain in patients by 85%. In case of severe pain in patients, the nerves coming to the area are cut by a procedure called presacral neurectomy. Chocolate cysts in the ovaries should be peeled off with the membrane. But this is not usually possible. If the woman has passed her fertile age, it may be possible to remove the ovary when the chocolate cyst is removed. This will reduce the likelihood of recurrence of the disease up to 1-3%.

Combined treatment for chocolate cyst patients
During the treatment of chocolate cyst, it may be appropriate for patients to apply drug therapy before or after surgical intervention. This treatment is planned according to the severity of the pain in the patient. If the patient does not respond to medical treatment, a large improvement can be achieved by opening the adhesions with a surgical intervention and by burning or removing the cysts in the early stages. At the same time, treatment can be provided by cutting the nerves to the uterus or the nerves in front of the sacrum. When these applications are insufficient in some patient groups, the uterus and ovaries can be removed and treated. In these treatments, factors such as the age of the patient, the condition of the cyst and infertility are taken into consideration.

Precautions and home measures to support chocolate cyst treatment
In the continuation of or after the treatment for chocolate cyst, patients can apply some precautions to be taken at home in order to reduce the discomfort, since the effects of these treatments are effective for a long time.
Taking a hot bath and a heated pad can be helpful to reduce cramps and pain during menstrual periods and to relax their pelvic muscles.
Taking non-steroidal anti-inflammatory pain medications can be used to relieve both pain and cramps during the menstrual period.
Exercising regularly can also be effective in eleminating the complaints.

  • Op.Dr. Zeynep Taşargöl
    Obstetrics and Gynecology Specialist

    You can send me your questions and comments about Endometriosis via this field. The answers provided are advisory. You need to be examined by your doctor for diagnosis and treatment.