Endometriotic Ovarian Cyst
An endometriotic ovarian cyst is a fluid-filled cyst that develops on the ovary due to the presence of endometrial tissue outside the uterus, causing symptoms such as pain, menstrual irregularities, and potential fertility issues.
Endometriosis is a prevalent gynecologic disease characterized by the presence of endometrial tissue outside the uterus, leading to inflammation. Endometriomas, cystic lesions originating from endometriosis, are commonly found in the ovaries. It affects around 10% of reproductive-aged women and often causes chronic pain, dyspareunia, dysmenorrhea, and infertility.
Endometriotic Ovarian Cyst is the primary manifestation of endometriosis on the ovary, although implants can also be found in the abdomen, including the bowel, surgical incisions, and rare cases in distant body locations like the cerebellum. Approximately 17 to 44% of women with endometriosis experience an Endometriotic Ovarian Cyst, referred to as chocolate cysts due to their thick, dark brown fluid. This type of cyst indicates a more severe disease state and can lead to specific issues such as decreased ovarian reserve.
Endometriotic Ovarian Cyst (Image source: Blausen Medical, 2014)
How Do Endometriotic Cysts Form in the Ovaries?
When endometrial tissue implants on the surface of the ovary, it can continue to respond to hormonal changes during the menstrual cycle. This results in the formation of cysts filled with old blood or thick, dark fluid. Over time, these cysts can enlarge and cause symptoms such as pelvic pain, menstrual irregularities, and infertility.
The exact mechanism of how endometriotic cysts form is not fully understood, but it is believed to be related to the presence of retrograde menstruation. Retrograde menstruation occurs when menstrual blood flows back through the fallopian tubes into the pelvic cavity instead of exiting the body. The presence of endometrial cells in the pelvic cavity can lead to the development of endometriotic implants and cysts on the ovaries.
Other factors, such as hormonal imbalances, immune system dysfunction, and genetic predisposition, may also contribute to the formation of endometriotic cysts in the ovaries. However, the precise cause and development of endometriosis and endometriotic cysts are still the subject of ongoing research.
Right Ovarian Endometriotic Cyst
A right ovarian endometriotic cyst refers to a cystic structure that develops on the right ovary as a result of endometriosis. Endometrial tissue implants on the surface of the right ovary, leading to the formation of a cyst filled with old blood or chocolate-like fluid. These cysts are also known as endometriomas or chocolate cysts.
The management of a right ovarian endometriotic cyst may involve medical treatments to alleviate symptoms, hormonal therapies to suppress the growth of endometrial tissue, or surgical intervention such as laparoscopic excision to remove the cyst and surrounding endometriotic tissue.
Left Ovarian Endometriotic Cyst
A left ovarian endometriotic cyst refers to a cystic structure that develops on the left ovary due to endometriosis.
According to a study conducted by Emerich et al. (2008) from the Department of Gynecology and Gynecological Oncology, Medical University, Gdansk, Poland, the most common type of ovarian endometriosis cyst is typically found on the left ovary. The study involved 284 Polish women with histopathologically proven endometriosis, of which approximately 253 women (89.1%) had ovarian endometrioma or ovarian endometriotic cysts.
In the discussion, the researchers stated, “We found that the left ovary is more commonly affected by endometrioma than the right ovary. Other studies also report a higher prevalence of deep endometriosis and ureteral endometriosis on the left side. Endometriotic implants are also found more frequently on the left hemipelvis.”
Bilateral Ovarian Endometriotic Cyst
It’s important to note that endometriosis and endometriotic cysts can occur on either the left or right ovary, or even on both ovaries simultaneously. The distribution of endometriotic cysts can vary among individuals, and it is possible to have cysts on one side or both sides.
Hemorrhagic Endometriotic Cyst
A hemorrhagic endometriotic cyst, also known as a “chocolate cyst,” is a type of ovarian cyst that is filled with old blood. It occurs as a result of endometriosis, a condition where the tissue that normally lines the uterus grows outside of it.
In the case of a hemorrhagic endometriotic cyst, endometrial tissue implants on the ovary and forms a cystic structure. Over time, the cyst can fill with blood, typically due to bleeding from small blood vessels within the cyst walls. As the blood accumulates, the cyst may enlarge and become filled with thick, dark brown fluid, giving it the appearance of chocolate.
Ruptured Endometriotic Cyst
A ruptured endometriotic cyst occurs when a cyst filled with endometrial tissue and fluid bursts or breaks open. This can happen due to various factors such as increased pressure within the cyst, trauma to the abdomen, or hormonal changes.
When an endometriotic cyst ruptures, it can cause sudden and severe abdominal pain, typically on one side of the lower abdomen. The pain may be accompanied by other symptoms such as nausea, vomiting, dizziness, and in some cases, fainting. The severity of symptoms can vary depending on the amount of fluid and blood released into the abdominal cavity.
In addition to intense pain, a ruptured endometriotic cyst can also lead to inflammation and irritation of the surrounding tissues. This can cause further discomfort and may result in the formation of adhesions (scar tissue) or the development of other complications such as infection or internal bleeding.
Symptoms of Ovarian Endometriotic Cyst
Symptoms of an endometriotic ovarian cyst, also known as an endometrioma or chocolate cyst, can vary among individuals. Some common symptoms associated with endometriotic ovarian cysts may include:
- Pelvic pain: Persistent or cyclical pain in the pelvic region, which may worsen during menstruation.
- Menstrual irregularities: Irregular menstrual cycles, including heavy or prolonged periods.
- Painful intercourse: Discomfort or pain during sexual intercourse, known as dyspareunia.
- Infertility: Difficulty in conceiving or getting pregnant.
- Abdominal bloating or swelling: A feeling of fullness or bloating in the abdomen.
- Urinary symptoms: Frequent urination, urgency, or pain during urination.
- Digestive issues: Gastrointestinal symptoms such as constipation, diarrhea, or abdominal cramping.
- Back or leg pain: Pain radiating to the lower back or legs.
- Fatigue: Generalized fatigue or low energy levels.
- Painful bowel movements: Pain or discomfort during bowel movements, especially during menstruation.
It’s important to note that the severity and presentation of symptoms can vary from person to person. If you suspect you may have an endometriotic ovarian cyst or are experiencing any of these symptoms, it is recommended to request an appointment with New York Gynecology Endometriosis (NYGE) for proper evaluation, diagnosis, and appropriate management.
Diagnosis of Ovarian Endometriotic Cyst
Endometriomas can often be detected using imaging techniques. However, their appearance on imaging is similar to that of other cystic lesions, and the definitive confirmation is only achieved through surgery. If imaging fails to reveal these findings, diagnosing endometriosis becomes even more challenging. It’s important to note that surgical visualization of the lesions is necessary for a conclusive diagnosis of endometriosis. Therefore, there is no specific diagnostic test available. Nevertheless, a few tests can serve as supportive tools in the diagnostic process.
Laboratory assessments that may be considered for these patients include a complete blood count (CBC), cancer antigen (CA)-125, CCR1, urinalysis, and sexually transmitted infection (STI) testing. The CBC helps evaluate for infection and anemia. An increased white blood cell count raises suspicion of an infectious cause of pelvic pain. Hemoglobin levels can indicate the extent of blood loss, as these patients often experience heavy periods and may be anemic as a result. CA-125 levels may be elevated in women with endometriosis; however, this marker is nonspecific and not routinely ordered.
Transvaginal ultrasound is commonly used for imaging to identify the cause of pelvic pain in these patients. Superficial endometriosis implants are not visible on ultrasound or other imaging modalities. However, ultrasound is frequently used to detect endometriomas. Endometriomas typically appear as simple cysts but can also present as multi-loculated cysts or cystic-solid lesions.
On ultrasound, these lesions typically exhibit low-level homogeneous echoes, resembling a ground-glass appearance, which indicates old hemorrhagic debris. These lesions generally show no vascularity when examined with doppler flow.
Surgical Methods for the Treatment of Endometriotic Ovarian Cyst
There are different surgical methods available for the treatment of ovarian endometriotic cysts. The choice of surgical approach depends on factors such as the size and location of the cyst, severity of symptoms, and the patient’s reproductive goals.
Here are the commonly used surgical methods:
Laparoscopic Cystectomy
This minimally invasive procedure involves making small incisions in the abdomen and inserting a laparoscope (a thin, lighted instrument with a camera) and other surgical instruments. The cyst is carefully dissected and removed from the ovary while preserving healthy ovarian tissue. Laparoscopic cystectomy is considered the gold standard for treating endometriotic cysts and offers advantages such as shorter recovery time and reduced postoperative complications.
Laparoscopic cystectomy is commonly regarded as a safe and efficient treatment choice for ovarian endometriomas. It offers several benefits compared to traditional open surgery, such as smaller incisions, reduced pain and scarring, and faster recovery. Nonetheless, like any surgical procedure, there are potential risks and complications, including bleeding, infection, injury to nearby organs, and the possibility of cyst recurrence.
Healthcare Bluebook estimates the fair price range for a laparoscopic cystectomy to be between $5,031 and $12,413.
It is important to note that these estimates are only intended to provide a general idea of the cost of the procedure and may not reflect the actual cost you may incur. It is recommended that you request an appointment with New York Gynecology Endometriosis (NYGE) to get a more accurate estimate of your costs.
Robotic-Assisted Laparoscopy
Robotic-assisted laparoscopy is a surgical approach that can be used for the treatment of endometriotic ovarian cysts. This technique combines the benefits of laparoscopic surgery with the enhanced precision and control provided by robotic technology.
During the procedure, small incisions are made in the abdomen, and a robotic surgical system is utilized. The robotic arms, equipped with specialized instruments, are inserted through the incisions. The surgeon then operates the robotic system from a console, which provides a magnified 3D view of the surgical site.
With the robotic system, the surgeon can perform precise movements and maneuvers to remove the endometriotic ovarian cyst. The robotic instruments offer enhanced dexterity and flexibility, allowing for meticulous dissection and removal of the cyst while minimizing damage to surrounding healthy tissue.
The advantages of robotic-assisted laparoscopy for endometriotic ovarian cysts include smaller incisions, reduced postoperative pain, less scarring, and a shorter recovery period compared to traditional open surgery. The high-definition visualization and improved instrument control provided by the robotic system contribute to a more precise and efficient procedure.
It’s important to note that not all cases of endometriotic ovarian cysts may be suitable for robotic-assisted laparoscopy. Factors such as the size, location, and complexity of the cyst, as well as the surgeon’s expertise and availability of robotic systems, will be considered when determining the appropriate surgical approach.
The expense associated with robotic-assisted laparoscopy can fluctuate based on several factors such as your geographical location, the intricacy of the procedure, and your insurance coverage. As per Healthcare Bluebook, the anticipated cost range for robotic-assisted laparoscopic surgery aimed at removing an endometriotic ovarian cyst falls approximately between $6,207 and $15,365.
Laparotomy
Laparotomy is a surgical procedure performed to remove an endometriomic ovarian cyst. This procedure involves making a larger incision in the abdomen to gain direct access to the cyst and surrounding structures.
During the laparotomy, the surgeon carefully opens the abdomen and identifies the endometriomic ovarian cyst. The cyst is then excised or removed along with any associated endometriotic implants or adhesions. The surgeon may also perform additional procedures, such as ovarian cystectomy or oophorectomy (removal of the ovary), depending on the severity and extent of the disease.
Laparotomy is generally reserved for cases where the endometriomic ovarian cyst is large, complex, or involves extensive adhesions. It allows the surgeon to have a better visual and tactile assessment of the cyst and surrounding tissues. However, compared to minimally invasive laparoscopic techniques, laparotomy involves a larger incision, longer recovery time, and increased risk of complications, such as infection, bleeding, and scarring.
The cost of ovarian endometrioma laparotomy can vary depending on several factors, including your location, the complexity of the surgery, and your insurance coverage. According to Healthcare Bluebook, the fair price range for laparotomy to remove an ovarian endometrioma is estimated to be between $12,753 and $31,511.
Laparoscopic Ovarian Drilling
This procedure is primarily used for the management of ovarian endometriosis-related infertility. Multiple small puncture holes are made in the ovary using a laser or electrocautery, which helps reduce the number of cysts and restore normal ovarian function.
Ovarian Cyst Drainage
In some cases, when the endometriotic cyst is causing severe pain or complications, a temporary measure known as cyst drainage may be performed. Fluid is drained from the cyst using a needle, which can provide relief from symptoms. However, it is important to note that cyst drainage alone does not remove the cyst wall, and the cyst may recur.
Pankaj Singhal, MD, MS, MHCM
Master Surgeon in Robotic Surgery
Dr. Pankaj Singhal, a globally recognized endometriosis surgeon, possesses over 25 years of expertise in laparoscopic excision surgery, enabling him to tackle even the most challenging endometriosis cases with confidence. Dr. Pankaj treats patients with diverse endometriosis-related conditions, ranging from ovarian endometriomas to severe deep infiltrating endometriosis that affects the bowels and other organs.
Dr. Pankaj prioritizes minimally invasive surgery and provides comprehensive personal care. Additionally, he is the owner and founder of New York Gynecology and Endometriosis (NYGE), and has dedicated his life to advocating for, respecting, and treating women suffering from this little-known disease. He is one of the few surgeons in the entire United States who have completed over 5,718 robot-assisted gynecologic surgeries. Learn more >
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