Ovarian endometrioma, more commonly known as a chocolate cyst, is a subtype of endometriosis and appears in approximately 17–44% of women suffering from endometriosis. Chocolate cysts are filled with thick, “old” blood that has the appearance of a brown, syrup-like fluid. The exact mechanism behind the formation of chocolate cysts remains a matter of scientific debate.
The main diagnostic method for chocolate cysts is laparoscopy. However, a transvaginal ultrasound can assist with the initial diagnosis and help differentiate chocolate cysts (endometriomas) from other benign ovarian tumors due to their typical sonographic appearance.
Chocolate cysts may occur on one or both ovaries, with approximately 78% of affected women presenting bilateral cysts. Women with chocolate cysts often share the same symptoms observed in endometriosis, including dyspareunia and/or infertility. A therapeutic challenge arises from the presence of additional endometriotic lesions in the abdomen. Studies have shown that chocolate cysts themselves are not a major cause of chronic pelvic pain, but they are strongly associated with deep infiltrating endometriosis, which is known to cause severe chronic pain.
Therefore, when planning treatment for women with chronic pelvic pain and chocolate cysts, it is essential to also evaluate and treat any deep infiltrating endometriosis.
Chocolate cysts may also pose greater therapeutic challenges due to adhesions that restrict the mobility of pelvic organs. Such restrictions may reduce natural fertility by impairing normal pelvic anatomy.
REMOVAL OF A CHOCOLATE CYST
Ovarian cysts, including chocolate cysts (endometriomas), are often incidental findings. When symptomatic, they may cause pain, a feeling of heaviness or pressure in the abdomen, and sometimes abnormal bleeding. Pain frequently occurs during sexual intercourse, strenuous exercise, or menstrual periods. Additional symptoms may include irregular menstrual cycles and changes in menstrual flow.
Laparoscopic removal of chocolate cysts is essential in many cases, especially when the patient experiences menstrual pain or pain during intercourse.
GOAL OF LAPAROSCOPIC REMOVAL OF CHOCOLATE CYSTS
Dysmenorrhea, dyspareunia, pelvic pain, and infertility are strong indicators of the presence of chocolate cysts. Chocolate cysts may be discovered during a transvaginal ultrasound in women with infertility. Endometriosis is the most common fertility-related factor identified during laparoscopy. Red or white fibrotic lesions are the two major morphological types of endometriotic implants. Endometriosis can be difficult to detect laparoscopically, and therefore detailed inspection and surgical expertise are crucial to minimize overlooked lesions, symptom recurrence, and infertility.
Laparoscopic removal of chocolate cysts provides excellent results, with pregnancy rates of 50–70% after surgery. Complete removal should be preferred over simple drainage, as it significantly reduces recurrence. Deep infiltrating endometriosis in the rectovaginal space is thoroughly examined during laparoscopy. Correct surgical dissection in this area can greatly reduce pain, particularly during intercourse.
ADVANTAGES OF LAPAROSCOPY FOR REMOVAL OF A CHOCOLATE CYST
Shorter hospital stay
Faster return to normal activities
No large surgical scars
Less postoperative pain
Highly positive impact on fertility
Full transparency of the surgical process and the option to provide the patient with a video of the procedure
Reduced likelihood of postoperative adhesions, and consequently, reduced long-term pelvic pain
Laparotomy should be avoided, as it leads to more severe adhesions, making any future surgery significantly more difficult.
REMOVAL OF ENDOMETRIOSIS
Laparoscopy is the most common surgical method for diagnosing and removing endometriosis in mild or moderate cases. Instead of a large abdominal incision, the surgeon inserts a high-definition camera through a small opening. If greater access is needed, additional small incisions allow insertion of surgical instruments.
Laparoscopy is recommended for:
Inspection of internal organs to identify endometriotic lesions
Removal of endometriosis and scar tissue causing pain or infertility
Removal of endometriomas (chocolate cysts)
Severe endometriosis involving bladder or bowel
Persistent or recurrent pain despite hormonal therapy
Severe pain in patients who decline hormonal treatments
Detection of an endometrioma during ultrasound
Endometriosis suspected as a cause of infertility
Between 60–80% of women report reduced pain in the first months after the procedure.
More than 50% report recurrence of symptoms within 2 years.
For moderate and severe endometriosis, laparoscopy increases the chances of conception. In very severe cases, in vitro fertilization may be the best option.
THE LAPAROSCOPIC PROCEDURE
Patients must avoid food and liquids for at least 8 hours before surgery. Laparoscopy typically requires general anesthesia. The abdomen is inflated with CO₂ or nitrous oxide to provide space for visualization and instrumentation. A camera is inserted through a small incision, and further incisions may be used to insert instruments. The procedure typically lasts 30–45 minutes. Endometriosis is removed using excision, laser or electrocautery. Incisions are closed with a few stitches, and scarring is minimal.
AFTER THE SURGERY
A one-day hospital stay is usually sufficient. Most patients return to normal activities within one week.
WHY LAPAROSCOPY?
It allows evaluation of pelvic organs, removal of cysts and scar tissue, and treatment of symptoms with minimal tissue trauma and rapid recovery.
EFFECTIVENESS
Pain relief: Most women experience reduced pain post-operatively, though recurrence is common.
Hormonal therapy after surgery may help delay recurrence.
Infertility: If infertility is the main concern, the surgeon removes endometriotic lesions to improve pregnancy rates.
IMPORTANT CONSIDERATIONS
Choosing an experienced surgeon is crucial, as laparoscopic treatment of infertility-related endometriosis requires advanced training.
Laparoscopy offers reduced tissue trauma, shorter hospital stays, faster recovery, and minimal scarring.
