Ovarian endometriomas are a type of cyst that develops on or near the ovaries. These cysts are a manifestation of endometriosis, a condition where tissue similar to the uterine lining grows outside the uterus. When this tissue appears on the ovaries, it forms cysts often filled with old blood. The presence of an ovarian endometrioma often indicates a more advanced stage of endometriosis.
These cysts are frequently referred to as “chocolate cysts” due to the dark, thick, brownish fluid they contain, which resembles melted chocolate. This characteristic appearance comes from accumulated menstrual debris, including fragments of endometrial-like tissue and thickened blood.
Understanding Ovarian Endometriomas
The tissue within ovarian endometriomas behaves similarly to the uterine lining, thickening and bleeding with each menstrual cycle. Since this blood has no way to exit the body, it collects within the ovary, forming a cyst.
A leading theory for their formation is retrograde menstruation, where menstrual blood flows backward through the fallopian tubes and into the pelvic cavity. These endometrial cells can then attach to the ovaries and other pelvic organs, where they continue to grow and bleed, leading to inflammation and cyst formation. Other theories include changes in embryonic cells transforming into endometrial-like tissue or the transport of endometrial cells through blood vessels or the lymphatic system. Endometriomas are observed in approximately 17% to 44% of individuals with endometriosis.
Recognizing the Signs
The symptoms associated with ovarian endometriomas can vary significantly, with some individuals experiencing no noticeable signs, while others face considerable discomfort. A common symptom is chronic pelvic pain, which may intensify during menstruation or sexual intercourse. This pain arises from the inflammation and irritation caused by the endometrial-like tissue bleeding within the cyst and its potential to adhere to surrounding pelvic organs.
Individuals may also experience heavy menstrual bleeding or irregular periods. Discomfort during bowel movements or urination, particularly during menstruation, can occur if the endometrioma or associated endometriosis affects nearby organs. A feeling of abdominal bloating or fullness in the lower abdomen is another potential symptom. The severity of these symptoms does not always correlate with the size of the endometrioma, but larger cysts may lead to more persistent pain.
Diagnosis and Treatment Approaches
Diagnosis of ovarian endometriomas involves a combination of methods. A physical pelvic exam may reveal an enlarged ovary or tenderness in the pelvic region. Imaging techniques are the next step, with a transvaginal ultrasound being the initial tool to detect cysts and evaluate their size, appearance, and impact on surrounding structures. Magnetic Resonance Imaging (MRI) can offer more detailed images, aiding in further differentiation from other growths. A definitive diagnosis often requires a laparoscopy, a minimally invasive surgical procedure where a small incision allows direct visualization of the pelvic organs and tissue sampling.
Treatment strategies for ovarian endometriomas aim to alleviate symptoms, preserve fertility, and prevent recurrence. Pain management often begins with nonsteroidal anti-inflammatory drugs (NSAIDs). Hormonal therapies, such as oral contraceptive pills, progestins, or GnRH agonists, are frequently used to suppress menstruation and reduce the growth of endometrial-like tissue, thereby managing pain and potentially shrinking the cysts. These medical treatments do not eliminate existing cysts but can help manage symptoms and prevent their enlargement.
Surgical intervention is considered when symptoms are severe, the cyst is large, or fertility is a concern. A laparoscopic ovarian cystectomy, which involves removing the cyst while preserving the ovary, is a common surgical approach. If the ovary is severely damaged or there’s a concern about malignancy, an oophorectomy (removal of the affected ovary) might be performed. The goal of surgery is to remove the endometrioma and any associated endometrial implants to relieve pain and improve chances of conception, although surgery can sometimes impact ovarian reserve.
Impact on Fertility and Pregnancy
Ovarian endometriomas can affect fertility through several mechanisms. The presence of these cysts may reduce ovarian reserve, which is the number and quality of eggs remaining in the ovaries. The chronic inflammation associated with endometriosis and endometriomas can also create an unfavorable environment for conception by affecting egg quality, fallopian tube function, and the uterine lining’s receptivity to an embryo. Endometriomas can also distort the normal anatomy of the pelvis, leading to adhesions that may block fallopian tubes or prevent the ovary from releasing an egg properly.
For individuals seeking to conceive, various approaches can be considered to optimize fertility outcomes. In vitro fertilization (IVF) is often a recommended option, as it bypasses some of the anatomical and functional issues caused by endometriomas. While surgical removal of endometriomas can sometimes improve natural conception rates, it can also potentially reduce ovarian reserve, making the decision to operate complex and individualized. The choice between surgical intervention and fertility treatments like IVF depends on the size of the endometrioma, the severity of symptoms, and the individual’s age and overall fertility profile.
During pregnancy, the presence of an endometrioma does not pose major complications. However, there is a small risk of the cyst rupturing, which could cause sudden, severe abdominal pain and may require emergency medical attention. Regular monitoring of the endometrioma’s size and any new symptoms is recommended throughout pregnancy to ensure the well-being of both the individual and the developing fetus.