How Is Chocolate Cyst Disease Diagnosed?

One of the most important points in treating diseases correctly is that the diagnosis is definitely made correctly. For example, pain in the patient’s groin area may arise from a chocolate cyst, but it may also arise from a chronic inflammatory condition, from adenomyosis (a disease that occurs as a result of the endometrium, the inner layer of the uterus, settling into the muscle layer of the uterus) or from adhesions in the bowel due to previous operations.

Endometriosis — to listen to all our Podcast recordings about it, do not forget to follow our Spotify account.

Of course the treatment of each one is also different from the others. The following steps are frequently carried out for the diagnosis of chocolate cyst disease. To diagnose endometriosis, your doctor checks whether there are abnormal changes in your body, asks about your complaints and then performs a gynaecological examination. However, it is very difficult to obtain an accurate result without more advanced tests being carried out. We will discuss these in turn.

Detailed Medical History:

At the outset, a detailed history is always taken. Your symptoms and complaints and your family history are asked about in detail. The symptoms frequently seen in chocolate cyst disease must be asked about by the doctor even if the patient does not report them.

Gynaecological Examination:

It is performed in order to check the patient’s vagina, uterus, cervix (the neck of the womb), bladder and rectum. The doctor checks whether there is any change in the shape, size and colour of the organs or whether there is any mass present (especially in the ovaries). The patient’s vagina and cervix are checked with a “speculum”. In particular, it is investigated whether there are nodules behind the cervix that can be seen in Deep Infiltrating Endometriosis (DIE). These nodules sometimes also involve the vaginal wall and can be seen on examination as a black-blue lesion on the vaginal wall. When DIE is present, it is specifically examined whether there is involvement of the rectum (the section of bowel where stool is stored last). In addition, again during the examination, the presence of painful trigger points on the vagina, behind the cervix – the sacrouterine ligaments – and/or the rectum, which are frequently involved in DIE, is investigated. If the patient has pain, a ‘’pain map’’ is drawn up. According to the pain map, important information is obtained about the areas that are involved. If there is a painful point, the treatment plan is always made in such a way as to include this lesion. Unfortunately, if these lesions are not identified beforehand, they may not be removed during the operation and as a result this may lead to treatment failure. Therefore it is extremely important that the examination is carried out by a doctor experienced in endometriosis.

Ultrasonography (USG):

((Transvaginal USG / Transrectal USG)

In the imaging method known among the public as ‘’ultrasound’’, high-frequency sound waves are used to investigate the gynaecological organs in the pelvic region (the inside of the pelvic bone). In this test the doctor examines the gynaecological organs vaginally, or rectally if the patient has never had sexual intercourse. Although the ovaries, the uterus and the vagina in the pelvis are examined in particular, the rectum, the urinary tract and the bladder (the urine sac) are also included in the examination. The presence of a nodule in the rectovaginal area is always investigated. Sometimes, for these nodules, both transvaginal and transrectal USG can be performed in the same session. In this examination the patient receives no radiation. The procedure is easy and it is a repeatable examination method.

One of its most important features is that it can be performed immediately together with the gynaecological examination. A doctor experienced in chocolate cyst can, without needing many imaging methods, make a full diagnosis and plan the treatment with the ultrasonography performed together with the examination. One of the important problems is that many doctors focus only on the ovaries on USG for the diagnosis of chocolate cyst disease. If there is no chocolate cyst in the ovaries, this disease may not come to mind. The absence of a chocolate cyst in the ovaries does not mean that chocolate cyst disease is not present. Therefore the doctor’s experience is very important for a correct diagnosis and assessment.

Magnetic Resonance Imaging (MRI):

In disease that is not limited to the ovaries alone, in situations where involvement of a neighbouring organ (especially the bowel) is suspected (Deep Infiltrating Endometriosis), and in situations that cannot be clearly distinguished with ultrasonography (cancer?), MRI is used. One of the important points regarding MRI is that the radiologist who will interpret the MRI must certainly be experienced in this field and must be in communication with the gynaecologist. That is, if the gynaecologist plans the treatment on the basis of the MRI report alone, the likelihood of making a mistake increases. With very well performed ultrasonography, the routine use of MRI has today become quite limited.

Rectoscopy (EUS):

In Deep Infiltrating Endometriosis, especially in bowel (rectal) involvement, it can be performed in selected cases in order to understand how much of the bowel wall is involved, in particular whether the bowel mucosa is involved, and whether there is a narrowing in the passage of stool. In this procedure, assessment can be made with special devices – EUS (in which there is also an ultrasound at the tip of the instrument) – during the endoscopic procedure. In patients with bowel involvement, this procedure is extremely important for planning the surgical treatment.

Intravenous Pyelography (IVP), Computerised (CT) Urography, Magnetic Resonance (MR) Urography:

It is an investigation carried out for the purpose of imaging kidney function, the collecting systems and the entire urinary system by taking a series of images at certain intervals after the injection of a drug into a vein. It is performed especially in cases where the tubes carrying urine from the kidney to the bladder are under pressure or narrowed because of a chocolate cyst. While IVP was more widely performed in the past, today CT or MR urography is more widespread; the substance given into the vein stains the urinary tract and is then excreted. In cases where loss of kidney function is suspected, it may be necessary to perform a scintigraphy.

CA125 Test:

This test checks the level in the blood of a protein known as CA125, which is a marker of the tumours in some gynaecological cancers (ovarian, uterine cancer) but which is at the same time also present in the blood of women who have endometriosis. However, CA125 levels can also be high because of pregnancy, menstruation (the menstrual period) and other gynaecological diseases or cancers. Today, both national and international  treatment guidelines on the treatment of chocolate cyst do not recommend that it be checked routinely.

HE-4 Test (Human Epididymis Protein 4: HE4):

This protein is used in particular to distinguish complex masses in the ovaries from simple cystic structures (including chocolate cysts). While it is at a normal (low) level in chocolate cyst, it can be raised in ovarian and uterine cancer. The fact that it can be checked in the blood at any point in the menstrual cycle is also an important advantage.

Ovarian Reserve Tests:

In those who wish to have children, those with bilateral chocolate cysts or those who have undergone repeated endometriosis surgery, it is extremely important to learn the condition of the ovaries before the operation. In patients whose ovarian reserve is very low, it may be recommended to postpone treatment until after infertility treatment or the freezing of eggs or embryos, before surgical treatment.

Laparoscopy:

The definite diagnosis of endometriosis is made by seeing the lesions laparoscopically and by the pathological examination of tissue samples taken from these lesions. In the same session both the presence and the extent (stage) of the disease are assessed, and thanks to the tissue sample a definite diagnosis is made. But today laparoscopy (Diagnostic Laparoscopy) is not performed only to diagnose the disease. Laparoscopy is performed if surgical treatment is also to be carried out.