What is a Chocolate Cyst (Endometrioma)? Symptoms, Diagnosis, and Treatment Methods

A chocolate cyst, medically known as endometrioma, is a cystic structure formed in the ovaries by the disease endometriosis, commonly seen especially in women of reproductive age. It gets its name from the dark brown, chocolate-like appearance of the old blood accumulated inside it.

What is Endometrioma?

The endometrium tissue lining the uterus normally thickens every menstrual cycle, sheds, and is expelled as vaginal bleeding. However, if this tissue grows outside the uterus, especially in the ovaries, and continues to bleed in the same way every menstrual cycle, it forms a cystic structure over time. This is called a chocolate cyst.

According to UpToDate data, chocolate cysts develop in approximately 17-44% of women with endometriosis.

Chocolate Cyst Symptoms It may not cause symptoms in every woman, but the most common complaints are:

• Excessive increase in menstrual pain (dysmenorrhea)

• Pain during sexual intercourse (dyspareunia)

• Infertility

• Chronic pelvic pain

• Brown discharge before or after menstruation

These symptoms can be confused with other gynecological problems. Therefore, an expert evaluation is important.

How Is It Diagnosed?

The following methods are generally used for diagnosis:

• Ultrasonography: The appearance of a thick-walled cyst with homogeneous dark content in the ovaries is diagnostic.

• MR Imaging: Used for differential diagnosis, especially in complex cases.

• Laparoscopy: Can be applied for both diagnosis and treatment. With this method, the cyst is directly observed and can be removed.

According to ESHRE guidelines, a definitive diagnosis of a chocolate cyst can only be made by taking a biopsy during laparoscopic surgery.

The Relationship Between Endometrioma and Infertility Endometrioma can cause tissue damage in the ovaries, reducing egg quality. Additionally:

• It can reduce ovarian reserve.

• It can impair ovulation.

• It can limit the mobility of the fallopian tubes.

According to studies, in the presence of endometrioma, the chance of spontaneous pregnancy can fall as low as 25%.

This is why early diagnosis and appropriate treatment are very important for women who want to have children.

Treatment Methods Treatment is planned according to the patient’s age, desire for children, complaints, and the size of the cyst:

1. Medical Treatment

• The growth of the cyst can be stopped with hormone medications such as birth control pills, GnRH analogs, and progestins.

• This method does not shrink the cyst, it only suppresses the symptoms.

• It is not suitable for those with infertility problems.

2. Laparoscopic Surgery

• The cyst is removed with the closed method (laparoscopy).

• Ovarian tissue is carefully preserved to protect fertility.

• When the cyst wall is completely removed, the risk of recurrence decreases.

• However, ovarian reserve may be affected after surgery, so the procedure must be planned carefully, especially for those who desire children.

3. IVF (In Vitro Fertilization)

• IVF treatment may be preferred directly, especially in women with recurrent cysts or at an advanced age.

• It can be applied before or after surgery if necessary.

• According to UpToDate, in the presence of an endometrioma larger than 4 cm, direct IVF instead of surgery is recommended for some patients to preserve reserve.

Is There a Risk of Recurrence? Yes. Even after surgery, the recurrence rate within 5 years is around 20-50%. Therefore, patients should be followed up regularly after surgery and supported with hormone therapy if necessary.

Conclusion A chocolate cyst is not just a cyst, but part of a chronic disease. It can have negative effects on fertility and seriously reduce the quality of life. Therefore, if there are complaints, they should not be neglected, and an appropriate treatment plan should be made with an expert evaluation.