WORLD JOURNAL OF PHARMACY AND PHARMACEUTICAL SCIENCES Sara et al. 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. Article Received on 12 July 2016, Revised on 03 Aug. 2016, Accepted on 24 Aug. 2016 DOI: 10.20959/wjpps20169-7662 *Corresponding Author K. Sara Department of Pharmacy Practice, Vishwa Bharathi College of Pharmaceutical Sciences Guntur-09, Andhrapradesh, India. ABSTRACT Chocolate cyst or endometriomas is a particular type of ovarian cyst, associated with intracavitary haemorrhage and formation of hematoma 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 40years detected with chocolate cyst are recommended oophorectomy, which eradicate the chance of cancer. The complete cure of the disease is still challenging and need recent medical technology. In this paper we will review about brief information regarding the disease and its recent development in the treatment procedure and the lifestyle 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 www.wjpps.com Vol 5, Issue 9, 2016. 1042
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. www.wjpps.com Vol 5, Issue 9, 2016. 1043
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 overproduction 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 www.wjpps.com Vol 5, Issue 9, 2016. 1044
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 www.wjpps.com Vol 5, Issue 9, 2016. 1045
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 www.wjpps.com Vol 5, Issue 9, 2016. 1046
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 1. Kyle J. Norton, (2009). Endometriomas Chocolate cysts In Conventional Medicine Perspective,http://ovariancysts endometriomas.blogspot.in/2009/12/chocolate cysts endometriomas-in.html. www.wjpps.com Vol 5, Issue 9, 2016. 1047
2. Dr Tim Kenny. Endometriosis. Patient.co.uk. 2013; 4: 42-44. 3. Ballard K, Lane H, Hudelist G, Banerjee S, Wright J. Can specific pain symptoms help in the diagnosis of endometriosis? A cohort study of women with chronic pelvic pain.fertile.ateril. 2012; 94(1): 20-7. 4. Surgit, O; InegolGumus, I. "Single-port Laparoscopic Total Hysterectomy and Bilateral Salpingo-oopherectomy Combined with Burch Colposuspension.". ActachirurgicaBelgica. 2014; 114(4): 12-15. 5. Cho, MJ; Kim, DY; Kim, SC "Ovarian Cyst Aspiration in the Neonate: Minimally Invasive Surgery. "Journal of pediatric and adolescent gynecology. October 2015; 28(5): 348 53. 6. Nohuz, E. "[How I do...the aspiration of an adnexal cyst without iterative needle punctures neither irrigation-aspiration device during a laparoscopy]. "Gynecologie, obstetrique & fertilite. 11 December 2015; 44: 63 6. 7. Nisolle M, Paindaveine B, Bourdon A, Berlière M, Casanas-Roux F, Donnez J. "Histologic study of peritoneal endometriosis in infertile women". Fertility and Sterility. June 1990; 53(6): 984 8. 8. Practice Committee of the American Society for Reproductive, Medicine. "Treatment of pelvic pain associated with endometriosis: a committee opinion."fertility and Sterility. April 2014; 101(4): 927 35. 9. American Society For Reproductive M, "Revised American Society for Reproductive Medicine classification of endometriosis: 1996". Fertility and Sterility. May 1997; 67(5): 817 21. 10. May KE, Conduit-Hulbert SA, Villar J, Kirtley S, Kennedy SH, Becker CM. "Peripheral biomarkers of endometriosis: a systematic review". Hum. Reprod. Update. 2010; 16(6): 651 74. www.wjpps.com Vol 5, Issue 9, 2016. 1048