Ruptured Endometrioma - When Chocolate Turns Catastrophic: A Case Series on Clinical Presentation, Management and Outcomes

Background: Cancer antigen 125 (CA-125) is widely used as a tumor marker for epithelial ovarian malignancy. However, significantly elevated CA-125 levels may also occur in benign gynecological conditions such as endometriosis, particularly in cases of ruptured endometrioma. Such marked elevation may mimic ovarian carcinoma and create diagnostic confusion, especially in reproductive-age women. Methods: We report two cases of young unmarried women presenting with acute abdomen and markedly elevated serum CA-125 levels associated with ruptured ovarian endometriomas. Clinical presentation, imaging findings, intraoperative findings, histopathology, management, and postoperative outcomes were analyzed. Results: Case 1 involved a 23-year-old woman with bilateral ovarian endometriomas and hemoperitoneum, with serum CA-125 of 4927 IU/mL and CA 19-9 of 291 IU/mL. Case 2 involved a 26-year-old woman with bilateral endometriomas and hemoperitoneum, with CA-125 of 5704 IU/mL and CA 19-9 of 1401 IU/mL. Both patients underwent laparoscopic surgery, which revealed ruptured endometriotic cysts with chocolate-colored peritoneal contamination. Histopathological examination confirmed endometriosis in both cases. Postoperatively, serum CA-125 levels normalized within three months following surgical management and medical therapy. Conclusion: Extremely elevated CA-125 levels do not always indicate ovarian malignancy. Ruptured endometrioma should be considered in the differential diagnosis of reproductive-age women presenting with acute abdomen, pelvic masses, and markedly elevated CA-125 levels. Careful clinical, radiological, and histopathological correlation is essential to avoid unnecessary radical surgical intervention.