What are Ovarian Cysts and Endometriomas?
An ovarian cyst is a fluid-filled sac that develops on or within the ovary. While many cysts are “functional” (forming as a normal part of the menstrual cycle and resolving on their own), cysts associated with endometriosis are distinct and require specialized attention.
These are known as Endometriomas, or “Chocolate Cysts”. They form when endometrial-like tissue grows on the ovaries. Over time, this tissue bleeds during each menstrual cycle, but unlike a period, the blood has no way to exit the body. It accumulates inside the cyst, turning thick, dark, and brown—resembling melted chocolate.
Endometriomas are a sign of advanced disease (often Stage 3 or 4). They are not merely fluid sacs; they are active, inflammatory lesions that can damage healthy ovarian tissue, compromise egg quality, and cause severe scarring that adheres the ovaries to the pelvic sidewalls or the back of the uterus. Because they are deeply embedded, they rarely resolve on their own and often require surgical intervention.
The most common symptoms
Functional cysts may be asymptomatic, but endometriomas and large complex cysts often cause specific, persistent symptoms that can severely impact quality of life.
Persistent Pelvic Pain and “Heaviness”
Patients often describe a constant, dull ache or a sensation of “heaviness” on one or both sides of the pelvis. As the cyst grows, it adds weight to the ovary, causing a dragging sensation. This pain often intensifies significantly during menstruation (dysmenorrhea) and ovulation, as the cyst becomes inflamed and swells. Unlike a simple cramp, this pain feels deep and localized to the site of the ovary.
Sudden, Sharp Pain (Rupture or Torsion)
If a cyst becomes too large, it can cause the ovary to twist around its own blood supply, a condition known as Ovarian Torsion. This presents as sudden, excruciating, one-sided pain accompanied by nausea and vomiting, requiring emergency surgery to save the ovary. Similarly, if an endometrioma leaks or ruptures, the release of inflammatory “chocolate” fluid into the pelvis causes immediate, widespread burning pain and inflammation.
Pressure on the Bladder or Bowel
Large cysts (often exceeding 5cm) occupy significant space in the pelvis. They can press against the bladder, causing a frequent urge to urinate even when the bladder is empty. If they press against the rectum, they can cause painful bowel movements, constipation, or a feeling of incomplete emptying. This “mass effect” is often misdiagnosed as digestive or urinary issues rather than a gynecological problem.
Our Surgical Philosophy
Ovarian-Sparing Cystectomy
At Endometriosis Surgical Specialists International (ESSI), our approach to treating ovarian cysts is defined by one critical goal: Preserving your fertility.
We understand that the ovary is a precious organ, and our surgical techniques are designed to save every possible healthy egg.
We specialize in Laparoscopic Cystectomy, which involves meticulously peeling the cyst wall away from the healthy ovarian tissue. We do not simply drain the cyst (fenestration), as this leads to a near-100% recurrence rate.
Our expertise allows us to distinguish between Type 1 and Type 2 Endometriomas—a critical distinction that many general surgeons overlook:
- Type 1 (Invaginated): The cyst is formed by the ovary surface folding in on itself. These are “sticky” and incredibly difficult to remove without shredding healthy tissue.
- Type 2 (Invasive): The disease has invaded a pre-existing cyst. These are generally easier to separate.
Recognizing this difference allows us to tailor our dissection technique to the specific pathology, ensuring we remove the disease completely while protecting the ovarian cortex (the outer layer where your eggs reside).
This microsurgical precision is what separates a true specialist from a generalist, minimizing the risk to your ovarian reserve (AMH levels).
Ovarian Cysts
Frequently Asked Questions
1. Will surgery for an endometrioma lower my egg count (AMH)?
This is the most common concern for our patients. Any surgery on the ovary carries a risk to the ovarian reserve (measured by Anti-Mullerian Hormone, or AMH).
However, leaving an endometrioma untreated also damages the ovary through chronic inflammation and physical stretching. At ESSI, we use “cold excision” techniques whenever possible, avoiding heat energy (cautery) near the delicate egg supply to minimize thermal damage.
Our goal is to strike the perfect balance: removing the toxic cyst to improve the environment for your remaining eggs, while physically preserving as much healthy tissue as possible.
2. What is the difference between a “functional cyst” and an “endometrioma”?
A functional cyst is a normal part of ovulation. It contains clear fluid and usually disappears on its own within 1–3 menstrual cycles. An endometrioma is a disease-state cyst filled with old blood (“chocolate”) and lined with active endometriosis tissue. Endometriomas do not go away on their own, do not respond to hormonal suppression (birth control will not shrink them), and typically grow over time, requiring surgical removal.
3. Why do you need to remove the cyst wall? Can’t you just drain the fluid?
Draining the fluid (aspiration) provides only temporary relief. Because the cyst wall is made of living, active endometriosis tissue, it will simply refill with blood again, often within weeks.
The “gold standard” treatment is the complete removal of the cyst capsule (cystectomy). By removing the actual container and the disease lining it, we significantly reduce the chance of the cyst returning.
4. Can an endometrioma turn into cancer?
While the vast majority of endometriomas are benign (non-cancerous), there is a slightly increased risk of certain types of ovarian cancer (such as clear cell or endometrioid carcinoma) in women with long-standing, untreated ovarian endometriosis. However, the overall risk remains low.
Surgery allows us to send the tissue to pathology for a definitive diagnosis, providing peace of mind while removing the source of inflammation.
5. How do I know if I have a Type 1 or Type 2 Endometrioma?
This is a sophisticated diagnosis that is often only confirmed during surgery, but an expert can find clues on a specialized ultrasound or MRI.
Type 1 cysts often look “invaginated” or folded into the ovary and are associated with deeper, more adhesive disease.
Type 2 cysts often appear rounder and more distinct. Asking your surgeon if they understand this distinction is a great way to vet their expertise; a surgeon who treats all cysts the same may inadvertently cause more damage to a Type 1 cyst.