Can Chocolate cyst be cancerous?

Chocolate cysts are usually non-cancerous, although there is a rare chance (about 1%) that they may become cancerous.

Does Chocolate cyst go away on their own?

Small chocolate cysts, if benign, may resolve on their own with observation and follow-up imaging studies. However, larger cysts may persist and require medical intervention, such as laparoscopy, for removal.

Can Chocolate Cyst affect pregnancy?

Yes, a large chocolate cyst can affect fertility and make it difficult to conceive.

What causes Endometriomas or Chocolate Cyst?

Endometriomas, commonly known as chocolate cysts, are caused by endometriosis. Endometriosis occurs when tissue similar to the lining of the uterus grows outside the uterus, leading to the formation of cysts filled with old blood, which gives them a chocolate-like appearance.

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3.7 Minute

15-07-2024 Team Medicover Fertility

Chocolate Cyst: Signs, Causes and Treatments

Chocolate cysts are also known as Endometriomas. It can affect 5-10% of all reproductive age group women, but all of them might not have fertility problems.

A woman with a chocolate cyst may be asymptomatic, or some women may experience symptoms that are almost similar to those of endometriosis. It is present in approximately 20-40% of women who have endometriosis. This pathology derives its name from the endometrium, the mucosa that lines the inside of the uterus.

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What is Chocolate Cyst or Endometrioma?

Chocolate cysts of the ovary or Endometrioma are non-malignant cysts growing on the ovary, which are either filled with fluid or, at times, filled with semi-solid materials. So, in this case, it can also be referred to as a complex cyst. If the cavity of the cyst is filled with dark, old menstrual blood and tissues, it is called a Chocolate cyst.

A chocolate cyst forms when endometrial tissue attaches to the ovaries. Endometrial cells may start as small cysts. Stimulated by menstrual hormones, these cells multiply into more cysts.

In normal menstruation, the endometrial lining sheds and exits as menses. With endometriosis, blood cannot flow out and accumulates. The accumulated blood irritates adjacent tissues, causing fibrous scars and cysts filled with blood, and remnant tissues may form.

Symptoms of Chocolate Cyst or Endometrioma

Chocolate cysts or Endometriomas are often discovered in women between the ages of 25 and 40 years due to intense pain in the lower abdomen or if a woman faces an infertility problem. However, in some cases, it may remain asymptomatic.

Chocolate Cyst is only discovered during a routine gynaecological examination, chocolate cyst ultrasound or X-ray. In 30%-40% of cases, women with chocolate cysts or endometriomas can have problems getting pregnant. However, the symptoms of chocolate cysts may vary from one woman to another.

The most common symptoms of chocolate cyst are:

Abdominal cramps
Painful periods
Irregular periods
Abnormal spotting or bleeding in between periods
Pain in the pelvis while urinating or defecating
Pain in the pelvis while exercising
Painful sexual intercourse
Dark-coloured vaginal discharge

Chocolate Cyst Rupture Symptoms

If a chocolate cyst ruptures, it can cause severe pain, and its contents can enter the pelvic cavity. This discharge from the chocolate cyst can cause the ovaries to adhere to the fallopian tubes, thus creating fertility blockages and pain.

So, if you have severe and sudden pain in the pelvis, you should seek immediate medical attention. A ruptured ovarian cyst is a medical emergency that needs immediate attention.

Causes of Chocolate Cyst or Endometrioma

The chocolate cyst causes endometrioma, which is still a debatable topic. According to researchers, there are several theories about its cause. One theory is that it forms due to retrograde menstruation.

During menses, endometrial tissue needs to be excreted.
In women with chocolate cysts, menstrual blood flows back to the ovaries.
Remnant tissues and blood adhere to the ovaries, forming cysts.
One theory suggests immune system disorders contribute to endometriosis.
The immune system fails to detect and destroy endometrial tissue outside the uterus.
Another hypothesis suggests abdominal cells from the embryonic state can become endometrial cells.
Genetic and environmental factors influence this transformation.
Endometriosis may run in families, increasing the risk for daughters and sisters.

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Diagnosis of Chocolate Cysts

A Chocolate cyst may be discovered during a routine gynaecological examination, either through a vaginal ultrasound or X-ray.
A Doctor might suggest a pelvic ultrasound if he or she feels a cyst during a routine pelvic examination.

If you are symptomatic for endometriosis or If you face Infertility issues, a Chocolate cyst can be detected on ultrasound (chocolate cyst USG). Still, the type of cyst cannot be identified.

A needle biopsy may be suggested, in which the liquid is extracted from the cyst and viewed under a microscope to ascertain the diagnosis of a chocolate cyst.

Treatment For Chocolate Cysts or Endometrioma

It is necessary to consult a doctor and get a chocolate cyst treatment when a diagnosis has confirmed a Chocolate cyst. Because if not treated timely, it can cause infertility.

The treatment plan is based on a woman’s age, symptoms, whether both ovaries are affected or not, and your reproductive status (if you want to have any children). After diagnosis, treatment is prescribed based on the patient's condition.

Medication

Analgesics and anti-inflammatories can relieve pelvic pain.
Sometimes, it is coupled with hormonal treatment to reduce bleeding.

Large Chocolate Cysts (over 4 cm)

It may cause pain, infertility, or rarely turn cancerous.
Ovarian cystectomy via laparoscopy is suggested to remove the cyst.
Laparoscopy removes endometrial growths, scar tissue, and adhesions.
There's a risk of removing healthy ovarian tissue, affecting ovarian reserve and function.

Severe Endometriosis

If symptoms persist and cystectomy/adhesiolysis fails, a hysterectomy may be recommended.
Consider the woman's reproductive status and age.
Complete removal of ovaries and uterus is suggested for women over 35 with completed families.

Small, Asymptomatic, Benign Cysts

Follow up with imaging tests.

Postmenopausal Women

Ultrasonography and CA 125 values are used to determine action.
Benign cysts with low CA 125 are monitored with scans every 3-6 months.
Surgery is recommended if there's doubt about the cyst's benign nature.

Chocolate Cysts Effect on Fertility

Chocolate cyst and pregnancy - Chances of pregnancy are there if there is only one chocolate cyst, and that is too small in size. If it remains small (just a few millimetres in size), then it is not a cause for concern. However, some cysts grow large (over 10 cm) and become very painful with the menstrual cycle.

Chocolate cysts can reduce the number of eggs in the ovary and cause immature eggs.
High levels of Follicle follicle-stimulating hormones (FSH) may indicate ovarian problems.
Larger cysts are more problematic for fertility.
If an endometrioma ruptures, it can cause the ovaries to adhere to the fallopian tubes, leading to fertility blockages and pain.
Chocolate cysts can cause scarring in the fallopian tubes, affecting sperm and egg movement and increasing the risk of ectopic pregnancy.
An imbalance in reproductive hormones can interfere with implantation, raising the risk of miscarriage.
Chocolate cysts can disrupt the normal tubo-ovarian relationship.
Severe cases can affect ovarian reserve, damage ovaries, or require oophorectomy, leading to infertility.

Chocolate Cyst and In Vitro Fertilisation (IVF)

Before undergoing any treatment, and if you are facing difficulty in conceiving due to a chocolate cyst, it is advisable to visit an Infertility specialist. Looking at your medical history and the graveness of your cyst, she may suggest the best treatment plan for you.

IVF is an option if a woman is facing difficulty in conceiving, though it may possess some risks. However, here, the experience of a doctor counts while doing any surgical intervention. The risks associated are:

It responds slowly to gonadotropins, which might increase the rate of IVF cancellation cycles.
The location of the cyst plays a significant role as it might interfere with egg retrieval.
The risk of the chocolate cyst being punctured during an egg retrieval process remains, which causes the cyst to rupture and thus lead to infection.
The fluid inside the chocolate cyst might contaminate the follicular fluid, decreasing the chances of blastocyst hatching and lowering the pregnancy rate.

Fertility Preservation should be considered for women who plan to undergo surgery for endometriomas because surgery may decline AMH (Anti Mullerian Hormones) levels significantly, cause inflammation and healthy ovarian tissue can be removed.

A woman has the risk of going into Premature Ovarian Failure, which might cause early menopause.

Conclusion

Women who have endometriosis may have a high risk of developing a chocolate cyst or endometrioma. If they are small, they can be managed well medically; in some cases, they might need to be removed. According to research, in 30% of cases, if the chocolate cyst is large, then it can recur. It can affect fertility, so if you are planning a pregnancy, it is best to visit a doctor and get your treatment plan accordingly.

Frequently Asked Questions

Chocolate cysts are usually non-cancerous, though there are rare chances (1%) that it might turn cancerous.

If a cyst is small in size and usually benign, then a doctor says to wait and watch and follow up with imaging studies. If it is a functional cyst, it usually goes on its own. However, chocolate cysts may stay and might need a laparoscopy to get it removed.

Yes, a chocolate cyst which has become large can affect fertility, thus making it difficult to get pregnant.

Women who have endometriosis have a high possibility of developing a Chocolate cyst or Endometrioma. It derives its name as the Chocolate cyst from the fact that it contains thick old blood which has the appearance of melted chocolate.

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