February 28, 2022

Chocolate Ovaries


This article is not intended as medical, legal or coding advice regarding this topic. Please consult with an expert if you are experiencing symptoms of endometriosis or chocolate ovarian syndrome.

Chocolate has been especially appealing over the past 24 months due to stresses related to the COVID pandemic. Did you know dopamine is released into your brain when you eat chocolate and can actually lower your levels of stress? Ok, let’s get serious (I’m always serious about chocolate), but instead about another serious conversation - a painful condition called chocolate ovaries.

Chocolate ovaries, or chocolate cysts, is a condition also known as ovarian endometrioma. While noncancerous, this condition causes fluid-filled cysts that typically form deep within the ovaries. They get their name from their brown, tar-like appearance. The fluid inside an ovarian endometrioma resembles chocolate syrup.

According to the Endometriosis Foundation of America, chocolate cysts occur in 20-40 percent of women who have endometriosis. Endometriosis is a common disorder in which the lining of the uterus, known as the endometrium, grows outside the uterus and onto the ovaries, fallopian tubes, and other areas of the reproductive tract. The overgrowth of this lining causes severe pain and sometimes infertility. Chocolate ovaries/cysts are a subgroup of endometriosis. They’re often associated with more severe forms of the disorder.

The ICD-10-CM code for chocolate ovary syndrome or endometriosis of the ovary is N80.1

N80.1 Endometriosis of ovary

A chocolate cyst can affect one or both ovaries, and may occur in multiples or singularly.

Chocolate ovaries/cysts can be such a “pain”! But realize that the size of the cyst is not directly related to the severity or presence of symptoms. This means a woman with a small cyst may experience symptoms, while someone with a large one may not. Cysts can range from 2 to 20 centimeters (cm) in size.

When symptoms do occur, they’re similar to those of endometriosis and can include:

  • Painful, crampy periods
  • Pelvic pain not related to your menstrual cycle
  • Irregular periods
  • Pain during sex (dyspareunia)
  • Urgency to urinate
  • Bloating
  • Back pain
  • Nausea
  • Infertility for some women
  • Increased risk of getting ovarian cancer

Ovarian cancer is rare among people with ovarian endometriomas, but these cysts can become cancerous.

Anyone who menstruates can get endometriosis. And only people with endometriosis get ovarian endometriomas. According to the Cleveland Clinic, patients between ages 25 and 40 are more likely to have endometriosis.

If a chocolate ovary/cyst ruptures, it can cause severe, sudden abdominal pain on the side of the body where the cyst is located. A ruptured cyst can be a medical emergency. Patients should seek emergency care if an ovarian endometrioma bursts, which may present with these warning signs:

  • Fever
  • Vomiting
  • Feeling weak or dizzy
  • Severe pain in abdomen that happens without warning

The American Society for Reproductive Medicine (ASRM) has identified four different stages of endometriosis. The stage is determined on how much endometrial tissue is outside of the uterus, characteristics, and how deeply it is embedded in the organ where found, like an ovary.

When patients have ovarian endometrioma, they are in Stage 3 or 4.

     Stage 1: Small amount of tissue, mostly surface-level on the organ where it’s found

     Stage 2: More tissue than in Stage 1, and some of it is embedded

     Stage 3: A lot of tissue that’s deeply embedded, including small endometriomas

     Stage 4: A lot of tissue that’s deeply embedded, including large endometriomas

Physical exams and imaging procedures can provide clues of the presence of an ovarian endometrioma. If the cyst is especially large, the provider may notice it during a pelvic exam. Transvaginal ultrasounds, magnetic resonance imaging (MRIs), and computed topography scans (CT scans) can detect a mass.

Test results can’t show for sure whether your cyst is an ovarian endometrioma. However, tests can help the provider rule out other conditions that cause symptoms similar to ovarian endometriomas. Certain tests can also help the provider get closer to a diagnosis, such as:

  • A complete blood count (CBC) to detect infection or potential anemia. People with ovarian endometriomas often have low red blood cell counts because of the heavy bleeding that comes with endometriosis.
  • A urinalysis: to rule/out a urinary tract infection (UTI).
  • Sexually transmitted infection (STI) tests: to rule/out an STI, like gonorrhea or chlamydia, which may be causing the symptoms.

Since there currently is no cure for endometriosis, there’s no way to stop an ovarian endometrioma from forming. However, the provider may suggest medications to help prevent an ovarian endometrioma from growing bigger or growing back once it’s been removed. Medication can help with managing the pain, too. The doctor may prescribe:

  • Progestins
  • A vaginal ring
  • Birth control pills
  • A birth control patch
  • Gonadotropin-releasing hormone (GnRH agonist)

The best treatment depends on various factors, such as age, risk for cancer, plans for becoming pregnant, and whether or not the patient is considering in vitro fertilization (IVF). The provider can recommend the best treatment options based on each patient’s unique situation.


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