Endometriosis and Chocolate Cyst (Endometriomas)
Endometriosis is a condition where the endometrium, the inner uterine lining, grows outside of the uterus in areas such as the ovary, pelvic area, and intestine. The disorder may cause abdominal pain and infertility. We are still unclear why endometriosis occurs in some women. It has been speculated that the condition is caused by the backward flow of menses, containing the endometrial cells, up the fallopian tubes into the pelvic cavity during the menstrual cycle. The body cannot eliminate these endometrial cells that have entered the pelvic cavity.
During the early stage of the endometriosis, lesions found on the inner surface of the pelvic cavity are small, smooth, and flat. The color of the lesions may vary from white, clear, brown, red, to black. There severity of the condition does not correlate with the symptoms. In some patients, the endometrial cells may grow on the surface of the ovaries causing a cyst or a membranous sac containing blood to be formed. As time passes, the blood inside the cyst begins to thicken and turns brownish in color, hence the name “chocolate cyst”. The size of the cyst can range from the size of a mung bean to the size of an orange or even larger. Endometriosis may injure the surrounding the tissues and induce “adhesions” to be formed inside the pelvic cavity. These adhesions may attach to the fallopian tubes affecting their abilities to collect the egg from the ovary leading to infertility. Endometriosis can also affect the bowel and vagina causing pain and bleeding.
It has been estimated that 10% of women have endometriosis most of which are asymptomatic or display only mild symptoms. Only a small number of cases will present severe symptoms that include pain in the lower abdomen during menstruation phase, chronic lower abdominal pain, and pain during sexual activity. Many endometriosis lesions are found by accident during a surgery in the pelvic area, especially in women who have never been pregnant. The prevalence of endometriosis may be as high as 50% in women with infertility problems and 20% in women who experience chronic lower abdominal pain.
Endometriosis condition can be classified into four stages; minimal, mild, moderate, and severe. The stage of the endometriosis is dependent upon the location, size, and depth of the lesions. For minimal and mild stages, the lesions are superficial and contain small amount of adhesions. Moderate and severe endometriosis often contains chocolate cyst and large amount of adhesions. However, the severity of the condition does not always correlate with the symptoms.
Endometriosis can be diagnosed during pelvic examination where the doctor may palpate for endometriosis lesions on the back of the uterus, lining of the vagina, or chocolate cyst in the ovary. Ultrasound procedure can detect chocolate cyst but cannot identify small lesions on the surface of the pelvic cavity.
Laparoscopy is a surgical procedure where a small camera, called a laparoscope, is inserted into the abdomen through a small incision on the skin of the stomach area. The images from the camera are then shown on a television screen allowing the surgeon to clearly view the uterus, ovaries, and fallopian tubes. In cases where endometriosis lesions are found, the severity of the condition can be assessed. During the procedure, an instrument applying electrical current can be used to destroy the lesions. Adhesions and chocolate cysts can also be removed during laparoscopy. In women with infertility problems, color dye may be injected into the uterine cavity to allow detection fallopian tube obstruction during the procedure. Laparoscopy is gaining more popularity because only a small incision is made, fast recovery period, less pain compared with open abdominal surgery, and the patients can return to work soon after the surgery. Nonetheless, the procedure requires a specialist who has been trained to perform laparoscopy thus general physicians cannot perform the operation.
Using hormones to treat endometriosis can help improve abdominal pain. The doctor will choose an appropriate hormone for treatment based on the efficiency, desire to conceive, cost, and side effects. For patients who have undergone surgical procedures to remove endometriosis, hormone treatment is required to continue management of the symptoms after the surgery since 40-80% of the patients may have relapse of lower abdominal pain within two years after surgery without continuous hormone treatment after the procedure. Removal of uterus and ovaries will be one of the last options that the doctor will consider, despite that fact that it can alleviate lower abdominal pain associated with endometriosis by 90%, because surgical removal of both ovaries will cause immediate onset of menopause. Therefore, supplementary hormone treatment may also be considered for these cases. For women with endometriosis who want to have children, laparoscopy is one of the options that can be considered since it allows for both diagnosis and treatment because the lesions can be removed during the procedure. Whether a hormone treatment is required or not will be up to the discretion of the physician. Other procedures that can treat infertility such as artificial insemination and in vitro fertilization can also be considered as part of the treatment plan.
In summary, endometriosis can affect many aspects of women’s life including work, daily life, and family. Timely treatment of the condition can have positive outcomes on the patient’s health, family, and daily life. Thus, early consultation with the doctor to determine an appropriate treatment plan is recommended.
Reference
1. Endometriosis, A guide for patients 2012, The American Society for Reproductive Medicine
Compiled by Maj. Chakpan Supadech ,MD, Obstetrics and Gynecology, Reproductive Medicine