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Endometrioma/Chocolate Cyst vs Hemmorhagic Ovarian Cyst: Which is it or both?

One of the most common ways endometriosis patients get sent down decade-long (or more!) diagnostic derailments is when their endometriotic ovarian cyst (endometrioma/chocolate cyst) is misdiagnosed as a hemorrhagic ovarian cyst – or other forms of usually (but not always!) harmless, so-called ‘normal functional ovarian cysts.’*

To the untrained eye, there may be seeminlgy indistinguishable symptom overlap between potentially organ-destroying endometriomas and usually innocuous normal functional ovarian cysts. However, with a more careful clinical evaluation, differences usually can be identified, at least enough distinction to help patients secure a referral for a diagnostic laparoscopy with biopsy when it appears more than a functionional cyst is involved.

Considering that endometriosis is not only so common (more prevalent than diabetes), but also a leading cause of severe disability and hospitalization for millions around the world, it’s really beyond time for healthcare systems and providers to take the health concerns of endometriosis patients seriously. It’s not just the right thing to do, but it’s also the lawful thing to do, when you consider that these systemic misdiagnoses actually represent patterns of gender-based discrimination that are prohibited by most modern governments.

*And, for the asterisks you saw above, we’d even like to push back on the normalization and trivialization of ovarian cysts in general.  In fact, it’s really time to interrogate the assumption that chronic pain involving so-called normal ovarian cysts is really normal at all. After all, who even decided that normal ovarian cysts are supposed to be painful? Indeed, if we investigate the data more carefully, often it becomes clear that an underlying pathology was involved all along.

In the case of a sudden onset of chronic ovarian cysts (of any type), it’s also important to know that many common medications, such as certain birth control pills, hormone releasing-IUDs, IVF medications, and medications prescribed to endometriosis patients, can actually cause previously normal functional ovarian cysts to grow rapidly and increase the risk of torsion, degeneration, transformation into more harmful cysts, or other complications. Ruptured ovarian cysts (of any type) can cause excruciating pain and become a medical emergency as well, which is another reason all patients presenting with adnexal masses of any type should never be dismissed due to outdated beliefs. Ovarian cancer is also one of the most commonly misdiagnosed forms of malignancy around the world, with many cases initially mistaken for harmless normal functional ovarian cysts – or are even dismissed as indigestion, anxiety, or an overactive imagination. Taken together, it’s so clear we are facing an epidemic of system-wide massive healthcare failures, which continue to disproportinately impact historically marginalized communities and bodies.

That’s why it’s more important than ever to arm yourself with tips on distinguishing between potentially serious adnexal masses like endometriomas, from the usually less harmful normal functional ovarian cysts.

Before diving in, a good first step toward finding the right diagnosis would be to click here to take this AI-based online endometriosis risk assessment test, which helps assess your risk of having endometriosis and/or adenomyosis. It’s an app-based assessment tool developed by Prof. Dr. Camran Nezhat, the inventor of video laparoscopy, founder of the EndoMarch Movement, and the pioneer who developed many of the gold standard excision surgery standards we recognize today. Although the gold standard for diagnosing endometriosis is still the surgical procedure of video laparoscopy (with biopsy/histopathological confirmation), this online test can help assesss your risk, with an approximately 90% accurate rate to date.

Ovarian involvement of endometriosis occurs in an estimated 50% to 70% of all cases. Endometriotic lesions often appear differently at the ovary compared to other sites. Given that there are more than a dozen different types of ovarian cysts or pathological ovarian growths that can manifest (and even more sub-types), distinguishing between endometriotic ovarian cysts from normal functional ovarian cysts continues to present challenging diagnostic dilemmas for non-specialists. However, here are a few symptom differences:

PAIN: One of the key differences between endometriosis of the ovaries versus putatively normal functional ovarian cysts is the pain level. For symptomatic forms of endometriosis, the pain is indescribably excruciating. Those who have experienced child birth labor say the pain of endometriosis is worse. Or, think of testicular torsion-levels of pain, if that’s more relatable. Whatever you can imagine as absolutely unbearable, that’s about the closest we can come to describing endometriosis. So, if you are experiencing chronic, cyclic pain anywhere in the body, particularly with menstruation, that has you unable to move, unable to function, causes you to pass out, causes you to vomit constantly from the pain, and/or causes excruciating bowel, bladder, back, leg, shoulder, chest, hip, and/or stomach pain, these sorts of symptoms are significanlty more likely to be caused by endometriosis, or some other serious medical condition that deserves to be immediately evaluated and taken seriously. With the exception of child birth labor, normal biologically processes, such as menstruation, ovulation, and other bodily functions, are not supposed to be painful. Pain is not normal. You deserve to be treated without unlawful gender or racial discrimation in healthcare settings. (Important caveat:  Some normal functional ovarian cysts can also cause acute pain, especially in cases of ovarian torsion. This is why it’s important to seek out an endometriosis specialist if at all possible, as many nuances may be at play in trying to determine the underlying pathology or pathologies).

ANATOMICAL ANOMOLIES:During a physical exam, a doctor may palpate your abdomen and notice that a painful adnexal mass (ovarian mass of unknown type) is located on or near your ovaries. Gentle palpation of the ovaries from the abdomen should not be painful, and so this is an important sign that doctors must taken seriously. During an abdominal physical exam, the doctor may also notice that the uterus does not move freely around, as it should, but instead seems to be adhered or glued down and immobile, which could indicate frozen pelvis or other severe adhesion-formation has developed due to endometriosis or other serious medical conditions that, again, deserve to be taken seriously.

CHRONICITY: If you find yourself diagnosed with chronic functional ovarian cysts that are continue to cause pain and other severe symptoms over and over again, this is another common sign that it may be endometriosis and/or another serious medical condition that deserves to be evaluated more thoroughly.

Drs. Nezhat have put together brief overviews here , here, and here, with more details about symptoms and and ways to help clinically assess differences between endometriomas versus normal functional ovarian cysts (prior to surgical diagnostic evaluation, which, again, is the gold standard for diagnosing any form of endometriosis). However, some key imaging signs to look for include the following:

– Ultrasound: In up to 50% of cases, an endometrioma will present at ultrasound with the so-called ‘classical presentation’ findings as an “avascular unilocular cyst containing low-level, homogeneous “ground-glass” like internal echoes”, due to the hemorrhagic debris.


– CT Scan:

Another important detail to keep in mind is that some endometriomas have been known to develop within or closely intertwined with hemorrhagic ovarian cysts in particular. Endometriosis surgeons with extensive experience have seen this enough times that many now believe hemorrhagic ovarian cysts (in particular) should be considered a potential risk factor for developing endometriomas and/or other forms of endometriosis.  Co-occurrence is also another possibility to consider, as it’s entirely possible that one may have both normal functional ovarian cysts, such as hemorrhagic cysts, in addition to endometriotic ovarian cysts, at the same time.

– Ovarian torsion can actually be caused by any adnexal mass on the ovaries, including even a usually harmless functional ovarian cyst, and is considered a medical emergency which usually requires emergency surgery to help save the ovary from being permanently damaged or destroyed completely;
– Ovarian cysts of any type greater than 9 centimeters (>9 cm) are a red flag for potential risk for malignancy and/or other serious complications that usually require surgical intervention;
– A fast-growing ovarian cyst of any type is considered another concerning red flag that may indicate an aggressive form of endometriosis and/or malignancy that should be taken seriously and usually requires surgical evaluation;
– Cysts which also include solid, tumor-like features, are considered red flags that deserve additional evaluation.

For further reading of peer-reviewew articles on endometriosis of the ovaries, check out a few good articles here, here, here, and here. For great social media platforms with accurate, well-curated content, check out a few of our favorite here, here, here, and here. (This page was last updated April 2024).

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