Q. I am a 23-year-old woman. Recently, I went for a pelvic ultrasound scan as I have been having frequent bad menstrual cramps before my period, on the first day of my period and towards the end of it.
The scan result showed a cyst in my left ovary and the radiographer mentioned that it is a "chocolate cyst".
It looks quite big from the ultrasound picture but it is not cancerous. Other than the cramps, I feel no pain during my period.
What is the cause of this problem and why would it occur in a young woman like me?
Is surgery necessary to remove the cyst? Is there a possibility that the cyst will decrease in size or go away on its own without surgery?
Are there any natural remedies that can remove the cyst?
A. From the account you have given, it sounds like you have an endometriotic cyst.
This is otherwise known as a "chocolate cyst", as it contains mainly old blood which is trapped within an ovary, thus forming a cyst.
A cyst is a collection of fluid within a sac.
The old blood turns brown in colour and is thick, looking like melted chocolate, and hence the name given to such cysts.
Endometriosis is the condition in which cells that make up the inner lining of the womb, called endometrium, are found outside the womb, usually around the pelvis.
Nobody really knows how the endometrium gets there.
One of the more popular theories is that of retrograde menstruation.
During the normal menstrual cycle, new endometrium grows in the womb to prepare for a fertilised egg.
If there is no fertilised egg and a woman does not become pregnant, the womb is prompted by cyclical hormonal changes to start menstruation.
This is when the womb sheds the endometrium, which then flows out of the body in the form of menstrual blood.
Retrograde menstruation implies that there is some back flow of menstrual blood, which then lands on and implants in abnormal places, such as an ovary (endometrium should be found only within the inner part of the womb).
Since the endometrium implants on the ovary, it also responds to the cyclical hormonal changes in the body, just like the womb.
Hence, when menstruation occurs each month from the uterus, the abnormal implants on the ovary also "bleed".
The end result is the formation of old blood which is trapped within the ovary.
In addition, chemicals released from these abnormal implants during menstruation also cause irritation and this results in bad menstrual cramps.
Cysts can spread
Cysts can spread
Endometriosis appears to be progressive in nature and, therefore, can extend and spread, causing scarring and adhesions.
Once a "chocolate cyst" is formed, it does not go away as old blood is enclosed within the ovary.
To date, we do not have any medication, not to mention any natural remedy, that will "dissolve" endometriotic cysts, particularly if it is of a large size, say more than 6 to 7cm.
Therefore, for cysts larger than, say, 4 to 5cm, it is common practice to recommend surgery to remove the cysts, and also to clear up any remaining endometriosis as much as possible.
For cysts that are smaller than 4cm, it is acceptable to wait for a few months before re-evaluation of the cyst to see if surgery is necessary.
This is because although an ultrasound scan is sensitive in detecting cysts, it may not be specific about the type of cyst.
Certain functional or physiological cysts may initially look like endometriotic cysts, but may get resorbed or "dissolve" a few months later.
During the normal menstrual cycle, one of the ovaries prepares for ovulation, which is the process in which it releases a mature egg.
This requires an egg follicle to develop and grow.
This may sometimes measure up to 3 to 4cm and be mistaken for a true cyst and, hence, the term, functional cyst.
This may disappear a few months later, after ovulation and subsequent degeneration of this egg follicle.
In such instances, the doctor may prescribe hormonal pills to suppress the ovary in order for new functional cysts not to appear.
It is best to seek medical advice early.
Occasionally, there is a small risk of rupture or leakage of endometriotic cysts, which results in severe abdominal pain that may require emergency treatment.
DR FONG YOKE FAI
Head and senior consultant at the division of benign gynaecology and department of obstetrics and gynaecology at the NUH Women's Centre at National University Hospital
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