Ovaries are the most important part of female reproductive organs, which are closely related to women’s health and beauty! In life, ovarian chocolate cysts plague many women. The reason why I want to popularize this disease with you today is that among all benign ovarian tumors/diseases, this disease not only has a high incidence, but more importantly, it has the most serious adverse effects on women’s fertility, ovarian function and quality of life, the greatest surgical difficulty and the highest postoperative recurrence rate! Therefore, how to timely and standardized diagnosis and treatment of ovarian chocolate cysts is especially important. 1. What is ovarian chocolate cyst? Ovarian chocolate cysts (professional name: ovarian endometriosis cysts) are the most common type of endometriosis. Under normal circumstances, the endometrium grows in the uterine cavity, but for various reasons, the endometrium becomes ectopic to the ovary, where periodic bleeding occurs and single or multiple cysts are formed in the ovary, which are commonly referred to as ovarian “chocolate cysts” because the old blood collects in the cysts to form a coffee-colored thick liquid that resembles chocolate. Therefore, ovarian chocolate cysts (abbreviated as: chocolate cysts) are not ovarian tumors in the strict sense. It’s not a good idea to panic about it, because it’s mostly benign, and timely and standardized treatment can get good results. 2.What are the clinical manifestations of ovarian chocolate cysts? The common symptoms of coeliac disease include pain, abnormal menstruation and infertility, while some patients do not have any symptoms. (1) Pain is the main symptom and can be manifested as dysmenorrhea, which is mostly located in the deep part of the lower abdomen and lumbosacral region, and sometimes can radiate to the perineum, anus or thighs. The degree of pain is not necessarily proportional to the size of the coeliac sac. Some patients may have painful intercourse, and rupture of the cyst may cause acute abdominal pain. 2) Menstrual abnormalities may be manifested as increased menstrual flow, prolonged menstrual period or dripping menstruation, which may be related to the destruction of ovarian tissues by the lesion and affect ovarian function. 3) Infertility can be caused by complex reasons, including: pelvic adhesions due to endometriosis lesions, changes in the pelvic environment and abnormal ovarian function. Therefore, women with dysmenorrhea, painful intercourse and abnormal menstruation should go to the local regular obstetrics and gynecology hospital in time. By asking medical history, performing gynecological examination, combined with ultrasound imaging results and tumor markers (serum CA125) and other auxiliary examinations, most patients can be initially diagnosed with ovarian chocolate cysts. 3.How should ovarian chocolate cysts be treated? Ovarian chocolate cysts are mainly treated by surgery, because the recurrence rate is high after surgery, so for patients with severe disease, they need to be treated with medication after surgery. How large is a chocolate cyst in the ovary that requires surgery? Generally speaking, if the diameter of the cyst is less than 4 cm and the symptoms of dysmenorrhea are not obvious, short-term follow-up can be performed to observe the growth of the cyst; if the diameter of the cyst is ≥4 cm, surgery is recommended to achieve a clear diagnosis, remove the lesion, relieve pain and treat infertility. Should I choose laparoscopy or open surgery? It should be said that laparoscopy is the best surgical route for the treatment of coeliac disease. Because laparoscopic surgery has a wide field of view, it can remove the lesions (cysts) and adhesions in the pelvic cavity to the maximum extent and restore the normal anatomy of the pelvis, while fully flushing the pelvic cavity and improving the pelvic environment, so laparoscopy is significantly better than traditional open surgery in promoting the patient’s postoperative recovery and treating infertility! 4.Why is surgery of ovarian chocolate cyst more difficult than other benign ovarian cysts? 1) The main reason is that most patients with coeliac cysts have pelvic adhesions, and if the lesions are densely adherent to the surrounding tissues, the risk of injury to important organs (such as intestines and ureters) increases accordingly, and at the same time, the trauma is prone to bleeding and not easy to stop bleeding, which greatly increases the difficulty of surgery. 2) Most patients with coeliac cysts are young, and a considerable number of patients have fertility requirements, so the surgery needs to take into account the greatest possible removal of all lesions (cysts), while preserving as much normal tissue as possible. At the same time, it is necessary to preserve as much normal ovarian tissue as possible in order to protect the ovarian function of the patient. This means that the laparoscopic release of adhesions, removal of lesions, hemostasis of the wound, and suturing of the ovary are all aspects of the surgery that require a high level of skill. The delicacy of the surgery is closely related to the patient’s postoperative recurrence and ovarian function! Therefore, it is recommended that patients with chocolate cysts should try to choose a local regular obstetrics and gynecology hospital (preferably a tertiary hospital) to perform the surgery. 5. Why is post-operative chocolate cyst easy to recur and how to treat recurrence? According to statistics, the recurrence rate after surgery is as high as 30%, and the reasons for recurrence are multifaceted, one of which is that the recurrence rate after surgery is much higher than that of other benign ovarian cysts due to the disease characteristics of endometriosis. Third, according to the patient’s intraoperative condition, a postoperative continuous drug consolidation treatment plan can prevent and reduce recurrence. In case of postoperative coarctation recurrence, treatment principles basically follow those of primary treatment, but should be individualized and should be based on the patient’s coarctation size, age, whether she has fertility requirements, assessment of benignity and malignancy, and the patient’s wishes. Treatment options include: re-laparoscopic surgery to remove the lesion or ultrasound-guided puncture to extract the cystic fluid, post-operative medication; or control with the Mannakar ring, etc. It is very important to follow medical advice for standardized medication consolidation and outpatient follow-up after surgery. 6. Can ovarian chocolate cysts become malignant? Although ovarian chocolate cysts are benign lesions, they still have a tendency to become malignant. Foreign literature reports that the incidence of malignant change in chocolate cysts is 0.26-2.5%, and the average age of malignancy is 41.5-53.6 years. The cause and mechanism of malignancy is unknown and is mainly associated with abnormal gene expression. The possibility of malignancy should be highly valued in patients with significant abdominal pain, ultrasound suggestive of a blood-rich mass in the pelvic or adnexal region, and increased serum CA125 levels. Women with coeliac disease must follow the doctor’s instructions after surgery and have regular outpatient follow-up, pay attention to the recurrence of coeliac disease and be alert to the malignant transformation of coeliac disease! In conclusion, ovarian chocolate cysts are highly prevalent clinically and seriously affect women’s fertility and quality of life. Laparoscopic surgery is the main treatment, and postoperative medication consolidation and outpatient follow-up are needed to reduce postoperative recurrence and to be alert to malignant transformation of coeliacs.