Endometrioid ovarian cyst

The endometrioid ovary cyst is a benign cavity formation of the ovary, which appeared as a result of the destruction of the ovarian tissue by endometriosis. This type of cysts forms an epithelium structurally reminiscent of the endometrium, and from inside they are filled with a viscous dark brown( chocolate-like) liquid. Because of their characteristic appearance, endometrial cysts are also called "chocolate".

The reason for the formation of the endometrioid cyst is the implantation of endometrial cells into the ovarian tissue( the mucosa lining the uterine cavity).

It would seem, where from the ovaries located at a distance from the uterus, there is an epithelium from the uterine cavity? The reason for this is a hormone-dependent disease with an unidentified etiology - endometriosis.

There is no reliable reason for endometriosis at the moment, and its development is explained by several theories. The most popular was the theory of hormonal dysfunction, mainly associated with improper synthesis and utilization of estrogens.

Endometriosis is diagnosed mainly in hormone-active women, usually 20-40 years( 75%), it is often combined with myoma.

The essence of the pathological process in endometriosis is the migration of elements of the functioning mucous layer of the uterus beyond its limits.

The uterine wall is formed by three layers:

- External, serous, the layer( perimetry) is similar in structure to the peritoneum, since it is its continuation. Perimetry is very strong and is designed to protect the uterus from negative external influences.

- The middle layer( myometrium) forms extremely strong and strong muscle fibers. Their layers are located in different directions and reinforced with elastic fibers.

- External, lining the inside of the uterine cavity, the mucous layer( endometrium).It is the endometrium that can be modified according to the monthly cyclic hormonal fluctuations. The mucous membrane of the uterus, in turn, is structurally heterogeneous: it contains two layers that are unequal in structure and purpose. External, functional, the layer is constantly updated, increasing the volume in the first phase of the cycle and tearing away completely( menstruation) into the second. In the functional layer, many receptors are located that sensitively capture quantitative hormonal changes( especially estrogen concentrations).

Under the functional layer is the basal layer of the endometrium, it is not affected by estrogens, has a constant volume and serves as a source of cellular material to restore the functional layer after menstruation.

A healthy uterus always retains a layered structure and does not allow the migration of cells from one layer to another, or even beyond the limits of the organ. In endometriosis, the elements of the functional layer of the endometrium begin to appear in the underlying layers of the uterus( adenomyosis) or in other organs and tissues, including the non-genital sphere. Getting on the "alien" territory, the uterine mucosa forms islets and begins to function according to its purpose - to grow and tear off with the release of blood in a cyclic rhythm. It can be said that endometriotic foci "menstruate" like the uterus.

If the endometrium moves from the uterine cavity over the fallopian tubes to the ovaries, an endometrioid cyst is formed. Clinically, it manifests itself associated with menstruation pain. Endometrioid cyst of the right ovary provokes pain in the right projection of the appendages, and the endometrioid cyst of the left ovary - respectively, in the left.

Diagnosing the endometrioid cyst is more often helped by instrumental techniques. Ultrasound scanning helps to see the cyst, determine its size and precise localization, but, unfortunately, it is not always able to differentiate it from the cysts of another, nonendometrioid, origin. Laparoscopy of the endometrioid cyst of the ovary diagnoses it almost in 100%, and also allows to eliminate the formation.

The removal of the endometrioid cyst of the ovary, contrary to the widespread misconception of patients, does not always imply the removal of the epididymis. Small asymptomatic cysts sometimes disappear after adequate complex therapy, but this does not mean a cure. Unfortunately, endometriosis of the uterus has a chronic recurrent course, and often the cysts "return" or begin to increase. The surgeon visually assesses the cyst and its characteristics, and then either exposes it, or cuts it along with a small amount of surrounding tissue. However, even in the case of the need for surgical eradication of the cyst, the ovary along with it is removed infrequently.

The removal of the endometrioid ovarian cyst does not mean the treatment of endometriosis. To it start after operation. More often the treatment is reduced to the elimination of hormonal dysfunction by hormone therapy.

What is the ovarian endometriosis cyst

The ovarian cyst in endometriosis has some characteristics inherent in cysts and of another origin: it has an oval or rounded shape, a thin capsule and liquid contents. Large sizes of endometrioid cysts are not characteristic, they are often confined to 5-8 cm. Also, they are extremely rarely multiple( that is, several in one ovary).

The "classic" endometrioid cyst is a hollow, round structure with a dense liquid inside, no more than 12 cm in diameter, localized on the surface or deep in the ovary behind the uterus. It is very well visualized by ultrasound scanning, if it is carried out in dynamics, you can see how the size of the detected formation varies in different phases of the menstrual cycle, and assume the presence of endometriosis. Often, cysts in endometriosis appear in both ovaries, and a single endometrioid cyst of the right ovary is diagnosed a little more often on the left.

With laparoscopy, which allows you to "look" into the pelvic cavity, the origin of the cyst is indicated by a dense capsule of a dark blue hue and a content similar in color and density to liquid chocolate.

The uniqueness of the structure of the "chocolate" cyst lies in the fact that its wall( capsule) is formed by cells of the endometrium, which should not be in the ovary in the norm. These cells function symmetrically with the uterine epithelium: during menstrual bleeding, they are rejected and, together with blood, enter the cyst cavity, which explains its specific "chocolate" appearance. The size of the cyst during the period of menstruation increases, and its capsule forms microscopic holes due to cell rejection. Through these holes, blood from the cystic cavity can seep into the surrounding structures and provoke an inflammatory process.

Causes of endometrial ovarian cyst

The only cause of ovarian endometriosis is the implantation of endometrial cells in the ovarian tissue. The most likely causes of such a pathology are:

- Hormonal dysfunction, namely quantitative changes in the hormone concentration: an increase in the fraction of estrogens, follicle stimulating( FSH) and luteinizing( LH) hormones, prolactin and a decrease in the concentration of progesterone. Often, hormonal imbalance occurs with the participation of androgens of the adrenal glands.

- Menstrual bleeding. There is a possibility of a retrograde spread of menstrual flow out of the uterine cavity, that is, when the endometrium elements are thrown together with blood into the cavity of the fallopian tubes, and from there they get to the ovaries. On this assumption, the implant theory of the origin of ovarian endometriosis is based.

- Genetic predisposition. There are cases of the presence of endometriosis of various forms in women bound by family ties, and even a specific marker of such heredity is identified.

- Immune disorders. Endometrium can fall on the ovaries and without further pathological changes, which occurs in the majority of healthy women. And only 10% with this situation in the ovaries appear endometrioid heterotopia. Correctly functioning immune defense helps to destroy the elements of the "foreign" tissue that has fallen on the appendages from the uterine cavity. Immune dysfunction leaves the endometrial cells to exist outside the zone of their normal localization.

- Possibility of metaplasia( transformation).There is a version about the possibility of some tissues transform into others, in this case - in the endometrioid.

- Embryonic disorders. After the detection of cases of endometriosis in 11- to 12-year-old girls, a theory appeared about the possible connection of endometriosis with the developmental disorders of the female fetus.

Endometriosis refers to hormone-dependent pathologies, therefore the leading role in its appearance is attributed to the disturbances in normal interrelation in the system "hypothalamus-pituitary-ovaries" responsible for the normal hormonal function.

All these reasons remain only theories. Most likely, each of them has less independent value for the development of pathology than their combination.

Providing the development of the endometrioid cyst is capable of situations that facilitate penetration of the endometrium into the ovaries. This can happen:

- with instrumental manipulations: caesarean section, hysteroscopy, operations on the uterus and the like;

- if the mucosa is damaged during scraping of the uterine cavity for diagnostic and / or therapeutic purposes or with artificial abortion;

- if there is persistent hormonal dysfunction or immune disorders.

Certain inflammatory diseases of the genital area, which deplete the mechanisms of immune defense and provoke hormonal dysfunction, play a certain negative role in the development of endometriosis, and ovaries.

Symptoms and signs of endometrioid ovarian cyst

The clinically endometrial cyst of the left ovary does not differ from that on the right. Sometimes small cysts with endometriosis of the ovaries are asymptomatic, but the inevitable increase in them always provokes a pain syndrome.

The symptoms provoked by endometrioid cysts are diverse, often masked under the clinic of another pathology, and their severity is determined by localization and degree of dissemination.

Endometriosis in the ovaries can develop asymptomatically until the microperforation process begins in the wall of the enlarged cyst. Through the microscopic holes, the contents of the cyst fall outside its limits, involving the pelvic peritoneum or adjacent organs in the pathological process. Around the ovary begins aseptic inflammation, spikes can form which "solder" the ovary to the surrounding structures, making it immovable. Appear dull aching pain in the projection of the uterus, and if the process is unilateral - on the side of the ovary with an endometrioid cyst. With the onset of menstrual bleeding, pain is exacerbated in almost 80% of patients.

Sometimes manifestations of endometriosis of the ovaries are taken for algodismenorea of ​​another genesis, an inflammatory process in the appendages( salpingo-oophoritis).

Other symptoms of the endometrioid cyst are related to its causes. So, for example, if the source of endometriosis of the ovaries is hormonal dysfunction, the endometrioid cyst will be combined with a menstrual cycle.

Often also, endometriosis is associated with infertility. However, the endometrioid cyst alone provokes it rarely. As you know, endometriosis appears against a background of hormonal imbalance, which also leads to anovulation. In addition to hormonal causes, female infertility against the background of endometriosis of the ovaries can be caused by a soldering process or inflammation.

Features of the pain syndrome in the endometrioid cyst lie in its connection with menstrual bleeding, when the pain increases in intensity during menstruation and subsides after its termination. Menstruation can become longer, lose the usual rhythm.

The most common complications of the endometrioid ovarian cyst are the adhesive process and the rupture of its capsule. The ruptured endometrioid cyst of the ovary provokes the symptoms of acute surgical pathology( "acute abdomen") related to life-threatening conditions.

Adhesive process in endometriosis of the ovaries can lead to the fusion of the uterus and the affected ovary into a single painful conglomerate, reminiscent of palpation myoma. Sometimes spikes grow so much that they "pull" adjacent organs to the uterus, provoking a disruption in their work, and there are problems with defecation and / or urination.

Often, endometriosis exists in different forms, when one patient is diagnosed with endometriotic foci of different localization. So, the endometrioid cyst can simultaneously exist with endometriosis of the uterus, tubes, peritoneum and so on. Combined forms of the disease affect his clinic, diagnosis and treatment.

Endometriosis of the ovaries is formed in stages, so the appearance of a cyst is preceded by a number of structural changes. It is accepted to allocate several degrees of development of ovarian endometriosis:

- 1 degree: small, pointlike, endometriotic foci on the surface of the ovaries, which can also appear on the peritoneum;

- 2 degree: small heterotopia is still present on the peritoneum, and a small( less than 6 cm) cyst appears in the ovary on the background of a moderate adhesive process in the area of ​​the affected epididymis;

- 3 degree: "chocolate" cysts more than 6 cm in diameter are already present on both ovaries, and the foci of endometriosis extend to the tubes, continue to infect the peritoneum, the adhesion process is aggravated;

- 4 degree: large bilateral endometrioid cysts of the ovaries and endometriosis of adjacent organs.

When gynecological examination, it is impossible to identify the endometriosis of the ovaries. The presence of a painful enlarged ovary or conglomerate in the projection of the uterus during palpation is not a typical sign of endometriosis, therefore diagnosis requires additional examinations.

Ultrasound scanning reveals the characteristic signs of the endometrioid ovarian cyst. Typically, the examination visualizes the formation of a cavity in the projection of one or both ovaries with clear outlines, no larger than 12 cm. The finely divided contents of the cyst indicate the presence of coagulated blood in it.

Laparoscopy of the endometrioid ovarian cyst combines elements of diagnosis and treatment. The technique allows you to directly see the ovarian cyst, determine( if possible) its type by characteristic external characteristics, and then eliminate it.

Completes the diagnostic search by the conclusion of histologists made on the basis of studying the tissues of the cyst obtained laparoscopically.

Endometrioid ovarian cyst and pregnancy

Endometriosis is considered the most common cause of ovarian infertility( both primary and secondary) in women over 25 years old. The risk of infertility in endometriosis depends on its location, the degree of spread, the presence of complications, the degree of hormonal dysfunction and other factors.

The topographically endometrioid ovarian cyst does not always prevent pregnancy from occurring, but its behavior is unpredictable.

Often, the presence of an endometrioid cyst in the ovary is detected by accident, when a woman is already pregnant and visits the ultrasound diagnosis room in a planned manner. In other situations, it provokes pain and continues to function, complicated.

If pregnancy occurs in the presence of an endometrioid cyst, nevertheless, the physiological changes in the ratio of hormones, namely, the dominant role of progesterone on the background of a decrease in estrogenic influence, begin to play the role of natural "therapy" when endometriosis stops progressing and its foci decreases. There are cases of complete regression of endometrioid cysts during pregnancy. Unfortunately, after the termination of pregnancy, when the hormonal function restores its initial indices, this "curative" effect is eliminated.

Since pregnancy often hinders the development of ovarian endometriosis, its treatment can be postponed. The decision on the need for urgent treatment( operation) is accepted if:

- cyst continues to increase intensively;

- a pregnant uterus, increasing, pressing on the cyst, which is fraught with the development of the most formidable complication - rupture of the capsule of the cyst, which is an emergency condition.

Currently, specialists have accumulated extensive experience in the therapy of deformation of reproductive function in women with ovarian endometriosis( and not only).In most cases, if the patient is ready for a long and difficult course of therapy, infertility is successfully treated. Even in case of failure, the joy of motherhood guarantees in vitro fertilization.

Treatment of the endometrioid ovarian cyst

The choice of the method for the treatment of ovarian endometriosis depends on several factors that do not always imply only surgical treatment. The operation is indicated if:

- the size of the endometrioid cyst is more than 5 cm, and at the same time it functions in a stable rhythm;

- conservative drug therapy, conducted during half a year, did not have the expected effect;

- adjacent organs were involved in the pathological process;

- purulent infection develops in the area of ​​cyst localization;

- a pronounced adhesion process prevents the onset of pregnancy;

- there are categorical contraindications for hormone therapy.

Sometimes, even a small cyst causes a severe pain syndrome, which does not allow the patient to maintain a habitual way of life.

When the capsule is ruptured, the operation is performed in an emergency mode.

The tactic of the surgeon during the operation depends on the specific situation. Endometriotic cysts are removed laparoscopically. Often after a preliminary examination of the pelvic cavity, small endometrioid heterotopias are found on the peritoneum, tubes and uterine ligaments. They are eliminated by coagulation( cauterization), which can be performed with a laser or a red-hot loop.

Depending on the situation, the detected endometrioid cyst is removed in several ways.

The most sparing is the enucleation of the cyst when its tight capsule is opened and the contents are evacuated. The remaining cyst tissue( capsule) can subsequently become a source of development of a new foci of endometriosis, since it contains endometrial cells. Therefore, it is also completely removed.

Prolonged existing endometrioid ovarian cysts always damage surrounding tissues. Around them, inflammation is often formed, as well as rough adhesions that do not allow the cyst to be isolated from the ovarian tissue. Complicated cysts can be removed only together with the underlying pathologically altered tissue, that is, by resection. The method allows to relieve the ovary from endometriosis and to keep its healthy, unaffected part. The remaining part of the ovary is capable of performing the basic functions.

To situations that do not allow to save the ovary or its part in endometriosis, include:

- Excessively large size of the endometrioid cyst. Large cysts, as a rule, provoke irreversible structural abnormalities in the tissues of the ovary, so this "sick" ovary remains inadvisable.

- Large endometrioid cysts in the ovaries of premenopausal patients, especially if they are prone to recurrence. It is believed that against the background of climacteric hormonal dysfunction, which is not always able to cope with pathological proliferative processes, the endometrioid ovarian cyst is capable of provoking an oncological process.

It should be reminded to patients that the removal of the endometrioid ovarian cyst is not identical to the cure for endometriosis, because the cyst is a consequence of a serious dyshormonal process, without which it is impossible to pacify the disease. Therefore, treatment after removal of the endometrioid cyst ovary( or ovary with the cyst) is not completed. It is necessary to restore the normal ratio of hormones with the help of adequate hormone therapy.

Treatment of the endometrioid cyst without

operation As already mentioned, at the heart of endometriosis is hormonal dysfunction, therefore, in the therapy of any of its forms, hormonal drugs are widely used. Before the start of conservative therapy, a detailed laboratory study of the hormonal status of the patient is conducted to determine the extent of hormonal disorders.

There are no universal regimens in the treatment of the endometrioid ovarian cyst. The list of necessary hormonal means the specialist makes individually in such a way as to artificially restore the physiological hormonal balance. Most often, in the treatment of ovarian endometriosis, gestagens are recommended( Danazol, Danol, Decapeptil and analogs).

Conservative treatment is only able to cope with the disease in the initial stage of pathology development. However, even with a positive effect of therapy, endometriosis is not completely cured and tends to recur. The most favorable situation is observed in women on the eve of menopause, when against the background of a natural decrease in the concentration of estrogens, the foci of endometriosis cease to function actively and decrease. On the background of menopause, endometriosis disappears.

Hormonotherapy is supported by symptomatic treatment, helping to relieve pain, improve immune defenses and restore vitamin deficiency.

Unfortunately, specialists have to deal more often with a common form of endometriosis, when endometrioid heterotopias are found outside the ovaries. In such a situation it is advisable to think about the operation and continue the treatment after the removal of the endometrioid cyst conservatively.

Endometriosis does not belong to completely curable diseases, therefore it requires patients to conscientiously treat both their ailment and the recommendations of specialists.