Ovarian chocolate cyst rupture

　　(I) Causes of Disease

　　Ovarian endometrioma can rupture under the following conditions:

　　1. Repeated bleeding before or during menstruation increases the intracystic pressure.

　　2. During pregnancy, the level of progesterone increases, or when using exogenous progesterone treatment, progesterone causes the cyst wall blood vessels to proliferate, become congested, swell, and soften, leading to rupture.

　　3. The existence of the ovulatory orifice can also lead to the rupture of the cyst.

　　4. The cyst can also rupture due to external force compression, sexual activity compression, or gynecological examination.

　　(II) Pathogenesis

　　Ovarian chocolate cysts are often bilateral. The surface of the cyst is smooth in the early stage, and the wall is relatively thin. With the menstrual cycle, repeated bleeding causes fibrous thickening and roughness, and adhesion occurs with the broad ligament, uterus, and appendages, making the wall uneven in thickness and brittle. When the blood vessels in the cyst wall become congested, the tissue softens, or bleeding occurs during the menstrual period, the intracystic pressure increases, or it is affected by external forces (such as increased abdominal pressure) at the same time, it is prone to cause the rupture of the cyst.

　　The severity of abdominal pain during the rupture of ovarian chocolate cysts varies depending on the amount of cyst fluid discharged. If the rupture hole is small and the content discharged is not much, it can cause local inflammatory reaction and fibrous tissue proliferation, which is quickly surrounded and adhered by surrounding tissues. If the old blood in the pelvic cavity contains viable endometrial tissue, it can secondary implant in the peritoneal cavity, leading to further progression of the disease. If the rupture of the ovarian endometriotic cyst is large and the content discharged is much, it can cause severe abdominal pain, forming an acute abdomen.

　　In severe cases of ovarian chocolate cyst rupture, there is significant tenderness in the lower abdomen, with rebound pain, and some may manifest as severe abdominal pain. Those with a large amount of bleeding may present with symptoms such as dry mouth, palpitations, dizziness, blurred vision, and fainting, indicating shock. If not treated promptly, it may threaten life. The long-term complications are mainly due to adhesions of surrounding tissues caused by bleeding from the cyst rupture, or secondary infection leading to pelvic inflammation after surgery. Especially, it may affect tubal function and lead to infertility.

　　Common symptoms include nausea, repeated bleeding, abdominal pain, severe pain, shock, blood pressure drop, mobile dullness, vaginal bleeding, and so on.

　　(1) The onset is often before or in the latter half of the menstrual cycle (luteal phase), due to repeated bleeding in the cyst cavity before and after menstruation, causing a sharp increase in intracystic pressure, making it prone to spontaneous rupture or rupture under the influence of gravity or gynecological examination, leading to the rupture of the cyst.

　　(2) There is no amenorrhea or irregular vaginal bleeding.

　　(3) Sudden severe lower abdominal pain, starting on one side, followed by pelvic pain, accompanied by nausea and vomiting.

　　(4) Occasionally, symptoms such as hypotension and shock may occur.

　　The following are the preventive methods for the rupture of ovarian chocolate cysts:

　　The blood that leaks into the pelvic cavity from the rupture of the ovarian chocolate cyst is old accumulated blood, not a large amount of fresh bleeding. Apart from abdominal pain, it usually does not affect vital signs and does not lead to shock. Some people believe that since it does not threaten life, conservative treatment without surgery can be adopted to alleviate the patient's suffering from surgery. However, this is not the case. After conservative treatment, the rupture in the cyst wall heals and the symptoms disappear, but it is possible to have spontaneous rupture again soon. Such repeated attacks and suffering, and the more frequent the attacks, the more severe the pelvic adhesions, leading to symptoms such as abdominal pain caused by pelvic adhesions.

　　Therefore, patients diagnosed with ovarian chocolate cysts with a diameter of 3 centimeters or more should undergo surgery to remove the 'bomb' explosion risk. At this time, surgery often takes the form of chocolate cyst stripping, thus maximizing the preservation of normal ovarian tissue. Traditional laparotomy or laparoscopic surgery can achieve the therapeutic goal. After surgery, medication should be taken to consolidate the efficacy, which is of great significance for preventing the recurrence of ovarian chocolate cyst rupture.

　　1. CA125 (ovarian cancer-associated antigen) determination:CA125 is a high-molecular-weight glycoprotein found in the embryonic coelomic epithelial pararenal duct derivatives and their neoplasms. It can bind specifically to monoclonal antibody OC-125. As a tumor-associated antigen, it has certain diagnostic value for ovarian epithelial cancer. However, in patients with endometriosis, the CA125 level may increase, and the positivity rate also rises with the progression of endometriosis stage. It has high sensitivity and specificity, so it is helpful for the diagnosis of endometriosis and can detect the efficacy of endometriosis treatment.

　　2. Antifetal endometrial antibody (EMAb):Antifetal endometrial antibody is an autoantibody targeting the endometrium and causing a series of immunopathological reactions. It is a marker antibody for endometriosis.

　　3. B-ultrasound examination:There is an irregular cystic cavity closely connected to the uterus in the paraovarian area, filled with disseminated and chaotic fine echoes in the liquid dark area, or uneven patchy echoes, or there is a liquid dark area in the rectouterine pouch.

　　4. Posterior fornix puncture of the vagina:Withdraw coffee-colored or chocolate-colored turbid fluid, or even blood-containing fluid.

　　5. MRI examination:The MRI manifestations are variable, depending on the different pulse sequences used and the different components within the lesions. Completely hemorrhagic lesions appear as uniform high-signal intensity on T1 and T2-weighted images, with signal increase on T2-weighted images.

　　6. Laparoscopic examination:The best method for diagnosing endometriosis is to use laparoscopy to directly inspect the pelvic cavity. Upon seeing ectopic lesions or performing biopsies on visible lesions to confirm the diagnosis, the clinical stage of pelvic endometriosis and the treatment plan can be determined based on the findings of the laparoscopy. Under laparoscopy, attention should be paid to whether there are endometriotic lesions in the uterus, fallopian tubes, ovaries, uterosacral ligaments, pelvic peritoneum, and other parts. The characteristics of ectopic foci under the microscope are: red, blue, black, brown, gray, spotted, vesicular, nodular, or polypoid lesions.

　　Appropriate foods for patients with ovarian chocolate cyst rupture:

　　1. For bleeding ovarian chocolate cysts: It is recommended to eat sheep's blood, snails, conch, squid, mustards, lotus root, mushrooms, malan head, stone ear, hickory nuts, and persimmon cakes.

　　2. For ovarian chocolate cysts: It is recommended to eat more foods with antitumor effects: horseshoe crab, sea horse, turtle, dragon pearl tea, and hawthorn.

　　3. For abdominal pain and distension, it is recommended to eat pork kidneys, bayberries, hawthorn, tangerine cake, walnuts, and chestnuts.

　　4. Infection of ovarian chocolate cyst: It is advisable to eat eels, clam, snake, needlefish, carp, kelp, celery, sesame, buckwheat, rapeseed, toon, red beans, mung beans, etc.

　　5. The postoperative diet of chocolate cysts should be light, and the diet should be rich in nutrition, correcting malnutrition and abnormal eating habits, and avoiding the frequent intake of刺激性 and seafood. Suitable foods: milk, spinach, yam, cabbage, rapeseed, mushrooms, lean meat, eggs, crucian carp, apples, duck pears, jujube, peanuts, black rice, etc.

　　6. The dietary rules after the operation of chocolate cysts should be mastered, poultry, livestock, eggs, milk, fish, and fresh products can generally be eaten, and for those with deficiency of Qi and blood, it is better to use them for invigorating Qi and nourishing blood.

　　Dietary taboos for patients with ovarian chocolate cyst rupture:

　　1. It is necessary to control the intake of tobacco, alcohol, coffee, tea, and the like.

　　2. It is necessary to avoid the intake of greasy foods, including fatty meat, fried foods, etc., and in addition, it is necessary to be cautious about moldy and salted foods to prevent the aggravation of the disease.

　　3. Do not eat spicy seasonings, such as scallions, garlic, peppers, cinnamon, etc.

　　4. It is necessary to avoid the intake of warm and spicy foods, such as dog meat, mutton, chives, pepper, etc.

　　I. Surgical treatment

　　1. After diagnosis, it is advisable to undergo surgery immediately, as the leaked cyst fluid can cause pelvic adhesions, infertility, or the recurrence and spread of ectopic endometrium.

　　2. For young women who have not given birth, after aspirating and thoroughly rinsing the cyst fluid that has overflowed into the pelvic cavity, perform cystectomy to try to preserve normal ovarian tissue, which is helpful for maintaining ovarian and endocrine function, and also helpful for increasing the chance of pregnancy in the future.

　　3. For patients with both ovaries involved, the principle is also to try to perform cystectomy. If the cyst is tightly adhered to the surrounding tissues and it is easy to damage the organs when forcibly removed, then anhydrous alcohol can be applied to the cyst cavity to cause the epithelial layer in the cyst cavity to necrose, in order to prevent recurrence in the future, and drug treatment should still be used after surgery.

　　4. For patients with normal contralateral ovary and no involvement of the uterus who are older and have children, to avoid recurrence in the future, it may also be considered to remove the affected side of the adnexa.

　　5. For patients with ovarian chocolate cyst rupture, it is advisable to thoroughly clean the peritoneal cavity during surgery, remove the lesions as much as possible, relieve adhesions, and place 80,000U of gentamicin, 5mg of dexamethasone, 1000U of hyaluronidase (hyaluronidase), 250ml of normal saline in the peritoneal cavity before closing the abdomen to prevent postoperative adhesions.

　　6. After surgery, it is still advisable to take drugs for the treatment of endometriosis to prevent the occurrence of new dissemination and implantation of lesions caused by the spread of invisible lesions or cyst fluid into the peritoneal cavity.

　　II. Drug treatment

　　1. Highly effective progestin: Treatment with pure and highly effective progestin can inhibit the proliferation of the endometrium, cause the ectopic endometrium to atrophy, and lead to amenorrhea in patients. Generally, medroxyprogesterone acetate (medrogestone), norethindrone (18-methyl norethindrone), and others are used. During treatment, if breakthrough vaginal bleeding occurs, a small amount of estrogen can be added, such as 0.03mg/day of ethinylestradiol or combined estrogen (Premarin) 0.625mg/day. The pregnancy rate after treatment is comparable to that of pseudopregnancy therapy, but the side effects are milder, and most patients can persist with the treatment.

　　2. Danazol: It is a derivative of a synthetic 17α-ethynyltestosterone with mild androgenic activity. It inhibits the synthesis and secretion of pituitary gonadotropins to inhibit the development of follicles, reducing the level of plasma estrogen; at the same time, it may also bind to estrogen receptors, causing the atrophy of the endometrium and ectopic endometrium, leading to amenorrhea in patients, and is therefore also called this treatment 'false menopause therapy'. In vitro experiments have shown that danazol can inhibit the proliferation of lymphocytes and the production of autoantibodies, and has immunosuppressive effects. It is speculated that danazol may also improve fertility by purifying the pelvic environment and reducing the production of autoantibodies. The usual dose is 400-600mg/d, taken in 2-3 divided doses, starting from the first day of the menstrual period, for a continuous period of 6 months. The rate of symptom relief reaches 90%-100%, and ovulation can be restored within 1-2 months after discontinuation. The pregnancy rate after treatment is 30%-50%. If pregnancy does not occur within one year, the recurrence rate is 23%-30%.

　　3. Gestrinone (18-methyl triazole): It is a derivative of 19-norandrostenedione, with a mechanism of action similar to danazol, but with weaker androgenic effects. Due to its long half-life in the body, it is not necessary to take the medicine every day. It is usually taken from the first day of the menstrual period, 2.5mg each time, twice a week. The pregnancy rate after treatment is similar to that of danazol, but the adverse reactions are lighter, and liver damage is less common. The recurrence rate after discontinuation is also high. Some reported that the recurrence rate after 1 year of discontinuation is 25%.
　　4. Gonadotropin-releasing hormone agonist (GnRH-a): It is an artificial 10-peptide compound with the same action as the pituitary gonadotropin-releasing hormone (GnRH), but its activity is 50-100 times stronger than that of GnRH. After continuous administration of GnRH-a, the GnRH receptor of the pituitary gland will be exhausted and show a down-regulating effect, reducing the secretion of gonadotropins and significantly inhibiting ovarian function, leading to amenorrhea. Due to the extremely low level of estrogen in the body, it is generally referred to as 'medicated oophorectomy'.