WORLD JOURNAL OF PHARMACY AND PHARMACEUTICAL SCIENCES

Sara et al. World Journal of Pharmacy and Pharmaceutical Sciences

S JIF Impact Factor 6.041

Volume 5, Issue 9, 1042-1048 Review Article ISSN 2278 – 4357

CHOCOLATE CYST – AWARENESS AND LIFESTYLE

MODIFICATION – A REVIEW

K. Sara*, B. Yodha, K. Hari Prasath and L. Siddhartha

Department of Pharmacy Practice, Vishwa Bharathi College of Pharmaceutical Sciences

Guntur-09, Andhrapradesh, India.

ABSTRACT
Article Received on
12 July 2016, Chocolate cyst or endometriomas is a particular type of ovarian cyst,
Revised on 03 Aug. 2016,
Accepted on 24 Aug. 2016
associated with intracavitary haemorrhage and formation of hematoma
DOI: 10.20959/wjpps20169-7662 containing old brown blood. Normally it affects women during their
reproductive period. Currently its treatment involves medications by
using NSAIDs and few surgical methods are available. Women over
*Corresponding Author
K. Sara
40years detected with chocolate cyst are recommended oophorectomy,
Department of Pharmacy which eradicate the chance of cancer. The complete cure of the disease
Practice, Vishwa Bharathi is still challenging and need recent medical technology. In this paper
College of Pharmaceutical
we will review about brief information regarding the disease and its
Sciences Guntur-09,
recent development in the treatment procedure and the lifestyle
Andhrapradesh, India.
Modifications to be taken to avoid its Complications.
KEYWORDS: chocolate cyst, endometriomas, oophorectomy, NSAIDs and laparoscopy,
retrograde menstruation.

INTRODUCTION
Endometriosis is the presence of endometrial glands and tissue outside the uterus. Pelvic
pain is the most common symptom of endometriosis. Medical and surgical options are
available to reduce and manage potential complications. Endometriosis often occurs due to a
process called retrograde menstruation, which cause the flow of blood back through the
fallopian tubes into the pelvic cavity instead of leaving the body.Also when the cells in the
abdomen grow from embryonic cells, which can change shape and act like endometrial cells.
The hormonal changes of the menstrual cycle affect the misplaced endometrial tissue, and the
tissue will grow, thicken, and breakdown. In endometriosis Fertility is the most serious
complication. Women with milder forms of endometriosis may be able to conceive and carry

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a baby to term. Medications don’t improve fertility. Some women have been able to conceive
after having endometrial tissue surgically removed. Otherwise, fertility treatments or in-vitro
fertilization (IVF) help to improve the chances of having a baby.Chocolate cysts are a
particular type of ovarian cyst linked to endometriosis. Actually the chocolate cyst is the cyst
of the ovary with intracavitary haemorrhage and formation of hematoma containing old
brown blood. Chocolate cysts are affecting women during their reproductive period and may
cause chronic pelvic pain associated with menstrual periods. In this paper we will review
about the causes, symptoms, pathophysiology, diagnosis, complication and recent trends in
the treatment of chocolate cyst in brief.[1,2]

Figure.1. Chocolate cyst

CAUSES
Endometriomas may be caused by stress and emotion, During stress and Emotion the adrenal
glands produce cortisol which affects the function of the body to cleanse toxins resulting in
stimulating the growth of Endometriomas.

The other cause is the toxic environment, By exposing the body to toxins found in pesticides
and some harmful waste products may have some hormonal and chemical influence causing
activation of endometriomas at the time of menstruation cycle.[2] Sex during menstruation is
the other cause, sexual intercourse during menstruation causes the endometrial tissue to travel
into the fallopian tubes then into the ovary resulting in developing ovarian endometriomas.[3]

SYMPTOMS
The associated symptoms in endometriomas are, painful periods[4], painful sex[2], pain in the
lower abdomen and pelvic area[5], Infertility (as the passage of the egg from the ovary to the
fallopian tube may be blocked.

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PATHOLOGY
The pathophysiology involved in endometriomas is not clear, and different theories are
elucidated to reveal its pathophysiology.

a. Retrograde menstruation
This theory suggests that during menstruation the blood flows backward instead of outward
causing menstrual blood to go through the fallopian tubes to the pelvic and abdominal cavity,
resulting in blood embedding on the outside of the ovaries, causing endometriomas.[3]

b. Weakening of immune system

The immune system will destroys endometrial cells which are located outside the uterus. If
the immune system is weakened, it allows the endometrial cells that shed to attach and grow
on the surface of the ovaries.[3]

c. Embryonic theory
This theory suggests during the embryonic stage, some endometrial cells which normally
grow in the uterus instead develop in the ovaries.[3]

d. Hormone imbalance Theory

The imbalance of hormones during the menstrual cycle causes conversion of normal
estrogens into bad estrogens and over production of prostaglandins, leading the cervix to
contract resulting in altering of the menstrual period, causing menstrual cramps and
endometriomas. Nutritional deficiency is also one of the causes of hormone imbalance.[3]

e. Hereditary Theory
It may be resulting from genetic errors, causing some women to become more likely than
others to develop the condition. Study shows that women are 5times more likely to develop
endometriomas if her sister has it.[6]

f. Xenoestrogen intervention Theory

Body with certain chemicals causes a disruption of the body’s hormones as resulting of over-
production of estrogens causing the growth of endometriomas.[3]

DIAGNOSIS
X-ray (or) trans-vaginal ultrasounds, Positive results on a blood test called CA125;
inultrasonography diagnosis ofchocolate cysts will be captured in the image, because of their

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darker shapes than other fluid filled cysts. The other method, trans-vagina ultrasound works
by measuring the thickness of the endometrium, endometrial hyperplasia, endometriomas and
cancer. Laparoscopy is used to look inside of uterus and ovaries, visually the presence of the
endometriomas can be confirmed.

Figure.2. Laproscopical image & Ultrasound images for chocolate cyst

COMPLICATIONS
A chocolate cyst rupture may result in its contents spilling into the pelvic cavity, something
which may cause abnormal bleeding. This will be accompanied by the usual symptoms of an
ovarian cyst rupture which include severe pain. The rupturing of the endometrial cyst might
also result in infections and thus putting the women under the risk of developing further
complications. Formation of scar tissues on other parts of a woman’s reproductive system
after the bursting of a chocolate cyst can also occur. This may make it hard for a woman to
get pregnant since these scar tissues may prevent implantation of the embryo or the improper
development of the foetus.[7]

TREATMENT
Medication
NSAIDs (treatment of pelvicpain), Progestational agents (Hormonal contraception) Eg:
Medroxyprogestroneacetate,Hormonal treatment sometimes has a large number of permanent
side effects, such as hot flushes, loss of bone mass, deepening of voice, weight gain, and
facial hair growth. Danazol, Gestrinone, Gonadotropin – releasing hormone agonists (GnRH),
GnRH can be combined with estrogens and progesterone (add-back therapy) without loss of
efficacy but with fewer hypo estrogenicsymptoms.Side effects and risks in general, taking the
above medication may cause the following side effects and risks. Blood clots,stroke and heart
attacks, weight gain, hormonalimbalance, long term loss of period after coming off the pill in

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some women,nausea, bloating, breast tenderness,male pattern hair growth and deepening of
voice,indigestion, etc.[6]

Surgery
Laparoscopic surgical approaches include excision of ovarian adhesions and of
endometriomas. Endometriomas frequently requires surgical removal and excision is
considered to be far superior in terms of permanent removal of the disease and pain relief.
Laser surgery and cauterization are considered to be effective and only burn the top layer of
endometrial tissue, allowing for the endometrioma and endometriosis to grow back quickly.
Conservative surgery can be performed to preserve fertility in younger patients but as earlier
stated can have the effect of raising FSH values and making the ovaries less productive,
Operative laparoscopic surgery can provide pain relief and improved fertility. Radical
surgical options could include singular or bilateral oophorectomy.Bleeding caused by
medical instrument during operation, Injure to adjacent organs also caused by medical
instrument during surgery, infection, anaesthesia risk.[7]

LIFE STYLE MODIFICATIONS

To control the risk of developing chocolate cyst which involves the following lifestyle
modification.

Dietary changes
The first important diet control involves avoiding fatty foods, where fats are the major source
for the production of oestrogen. Also nutrition rich with green vegetables, soya, cold water
fish and fibre where taken in large amount to balance the hormone levels. Omega3 fatty acids
rich foods such as fish oil act as a good source for hormone oestrogen. Apart from nutritional
sources minerals such as calcium, magnesium are to be included in daily food.

Stress management
Stress is one of the most critical, common risk factor in induction of number of illness. Hence
to control stress various ailments are suggested by physicians and health doctors. Exercise
and yoga will play a major role in stress management.[8]

Hormone balance
The excess oestrogen level in the body induces decrease in progesterone level in chocolate
cyst. However by using natural progesterone cream will balance the hormone level. To

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promote the hormonal balance, regular ovulation and proper circulation to the reproductive
organs by using naturally available herbs.Maca root (Lepidiummeyenii), is a great fertility
herb that helps the body to produce progesterone and balance the hormone. Black cohosh root
(Actaearacemosa), this herb promote regulation of entire menstrual cycle. Milk Thistle seed
(Silybummarianum), this herb support hormonal balance through liver support.Tribulus
(Tribulusterrestris), has been used as the tonic to nourish the female reproductive system for
patient with chocolate cyst.[9]

Systemic enzyme therapy: Systemic enzyme help the body to break the excess foreign
tissue and reduce inflammation. Hence using this the size of the cyst can be reduced (eg:
Wobenzym N).

Ancient therapy: There are number of natural remedies were available for treating various
types of ovarian cyst in folklore practice For example castor oil, which was used to clean and
heal the area of the body where the cyst are present. Castor oil stimulate the lymphatic
system, which remove toxins and waste from the area of the cyst.[10]

CONCLUSION
Chocolate cyst is the type of ovarian cyst causing intracavitary bleeding, associated with
severe pelvic pain during menstruation cycle. Recent development in the field of medicine
provides symptamatic treatment rather than not giving asymptamatic relief. Delayed
diagnosis of this disease may leads to a risk of ovarian cancer. Hence awareness about this
disease should be created among both medical and non medical profession. Women must be
educated about the illness for prevention of cyst in the ovary, by changing the lifestyle rather
than by using group of drugs.

ACKNOWLEDGEMENT
The authors are thankful for the management of Vishwa Bharathi College of Pharmaceutical
Sciences, perecherla, guntur,AP for providing necessary facilities to carry out the review
article.

REFERENCES
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endometriomas-in.html.

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