Endometriosis and chocolate cysts

What is it?

Endometriosis is development of endometrial glands outside the normal endometrial cavity. It may occur in the ovaries, behind the uterus and other places in pelvis. Normally in every menstrual cycle there is proliferation of endometrial glands and blood vessels. If pregnancy does not occur these glands and blood vessels broken down and shed as menstrual blood. In case of endometriosis the ectopic endometrial glands which developed anywhere other than its normal place also undergo proliferation. In absence of pregnancy these glands along with their blood vessels broken down but can’t expel out as there is no exit. In every month this event takes place and causes accumulation of blood within a closed space. Gradually it forms a cyst containing collection of old and fresh blood. Due to long standing collection of blood it becomes thick turry colored gives the appearance of chocolate. That is why cysts are called chocolate cysts. Main place of occurrence is within the ovaries.

This causes exudation of blood and adhesion of organs with each other. Uterus, fallopian tubes, ovaries and loops of gut become adherent either loosly or firmly in long standing cases with each other and with pelvic walls. It causes severe pain during menstruation called dysmenorrhoea and excessive menstrual blood loss called menorrhagia. Due to adhesion uterus becomes fixed posteriorly and causes severe dyspareunia (pain during intercourse). Tubes become oedematous and compressed by growing cysts or buried within the adhesions. As a result there is tremendous functional disturbances and causes infertility. Due to development of chocolate cysts in the ovaries , ovarian tissue damaged and function reduced. After removal of cysts there is massive destruction of ovarian tissue and reduce ovarian reserve tremendously. As a result reproductive potentiality loss much earlier in comparison to their counterparts.

Diagnosis:
Diagnosis can be made by clinical symptoms and by ultrasonography. Chocolate cysts can be diagnosed and differentiated from other cysts of the ovary clearly by ultrasonography. In early stages laparoscopic evaluation can identify development of endometriosis at different sites of the pelvis as match burned ( black spot due to old blood) appearance. Detaild pelvic condition can be assessed by laparoscopy.

Laparoscopic findings
Ultrasonogrphic findings (Chocolate cyst)

Treatment:

As accumulation of menstrual cyclical blood causes development of cyst and other consequences , stoppage of menstruation can reduce the size of the cysts and symptoms of diseases. Different hormones are used for this purpose. Oral contraceptive pills (OCP), Injection progesterone, Danazole and GnRHa are used to stop menstruation. Among all OCP is the cheapest and convenient drug. GnRHa is the most effective and expensive drug and long continued use causes menopausal symptoms like hot flush. In case of big cyst and severe symptom surgery in the form of adhesiolysis and cystectomy is the treatment of choice. Surgery can be done by laparoscopy or laparotomy. laparoscopy is the gold standard treatment for endometriosis and it needs expertise. In severe endometriosis even conservative surgery like adhesiolysis and cystectomy may not cure the desaese. So if family complete and patient’s age is more than 35 removal of ovaries and uterus can cure the disease completely. As source of development of cyst (ovaries) are removed all symptoms are also revert.

Treatment of infertility:

In case of infertility drugs can’t be used for long as they interfere fertility. So surgical treatment like adhesiolysis and cystectomy is the treatment of choice. Drugs like GnRHa can be used to reduce the size of the cysts before operation and to increase the ease of surgery. If pregnancy does not occur after surgery within a reasonable period COH and IUI can be done. In case of failure of this procedure ART is the treatment of choice. But in moderate to severe endometriosis where fertility conserving surgery becomes difficult long down regulation by GnRHa (4-6 months) followed by ART is the treatment of choice. Before ART mobilization of organs by surgery improves the treatment outcome.

Some patients develop cysts repeatedly that recurs after surgery and need re-laparotomy or re-laparoscopy. Repeated surgery causes extensive damage of the ovarian tissue and finally reduces ovarian reserve tremendously. Sometimes there may be ovarian failure due to absence of ovarian tissue. So early intervention and meticulous treatment can save the patient’s reproductive potential.