Hemorrhagic ovarian cysts (HOCs) usually result from hemorrhage into a corpus luteum or other functional cyst. Radiographic features are variable depending on the age of the hemorrhage. They typically resolve within eight weeks.
Patients may present with sudden-onset pelvic pain, pelvic mass, or they may be asymptomatic and the hemorrhagic ovarian cyst is an incidental finding 4. A hemorrhagic or a ruptured ovarian cyst is the most common cause of acute pelvic pain in an afebrile, premenopausal woman presenting to the emergency room 5. They can occur during pregnancy.
Hemorrhagic ovarian cysts typically develop as a result of ovulation. Secondary to a hormone response the stromal cells surrounding a maturing Graafian follicle become more vascular, and after the oocyte has been expelled, the Graafian follicle develops into a corpus luteum with a highly vascular and fragile granulosa layer, which ruptures easily, forming a hemorrhagic ovarian cyst 4.
Hemorrhagic ovarian cysts can have a variety of appearances depending on the stage of evolution of the blood products and clot.
- lace-like reticular echoes or an intracystic solid clot
- a fluid-fluid level is possible.
- thin wall
- clot may adhere to the cyst wall mimicking a nodule, but has no blood flow on Doppler imaging
- retracting clot may have sharp or concave borders, mural nodularity does not
posterior acoustic enhancement
- may be less noticeable if harmonics or compounding is used
- there should not be any internal blood flow
- circumferential blood flow in the cyst wall is typical
If there is rupture of a hemorrhagic cyst, other findings may be present.
Relatively well defined cystic lesion in association with the ovary. Signal characteristics can vary depending on the age of the hemorrhage.
- T1: high signal
T2: high signal
- "T2 shading" is suggestive of chronic blood products and is more typical of endometrioma
- hemorrhage evolves from the center of the cyst and then extends peripherally (i.e. the center may show chronic stage of hemorrhage while the periphery is more subacute)
- T1 C+ (Gd): no enhancement
Treatment and prognosis
Most hemorrhagic cysts resolve completely within two menstrual cycles (8 weeks).
Cysts with a typical appearance of a hemorrhagic cyst should lead to follow-up ultrasound or MRI imaging in 6-12 weeks if:
- the cyst is > 5 cm in diameter if the patient is pre-menopausal
- any size of a hemorrhagic cyst if the patient is perimenopausal 2
In the postmenopausal patient, surgical evaluation is warranted.
A cystic structure that does not convincingly satisfy the criteria for a benign cyst cannot be considered a cyst and should be evaluated with a short interval follow-up ultrasound or MRI
Differential considerations on ultrasound include:
cystic ovarian neoplasm: the most helpful feature in distinguishing ovarian neoplasms from hemorrhagic cysts are
- papillary projections
- nodular septae
- color Doppler flow in the cystic structure
- typically contains uniform low-level internal echoes with a hypervascular wall on Doppler ultrasound.
- more often multiple
- on MRI, endometrioma shows high signal in T1 and low signal in T2 (shading sign), although there is overlap in appearance with hemorrhagic cysts
- 1. Jeong YY, Outwater EK, Kang HK. Imaging evaluation of ovarian masses. Radiographics. 20 (5): 1445-70. Radiographics (full text) - Pubmed citation
- 2. Levine D, Brown DL, Andreotti RF et-al. Management of asymptomatic ovarian and other adnexal cysts imaged at US: Society of Radiologists in Ultrasound Consensus Conference Statement. Radiology. 2010;256 (3): 943-54. doi:10.1148/radiol.10100213 - Pubmed citation
- 3. Hricak H. Diagnostic Imaging. AMIRSYS. (2007) ISBN:1416033386. Read it at Google Books - Find it at Amazon
- 4. Jain KA. Sonographic spectrum of hemorrhagic ovarian cysts. J Ultrasound Med. 2003;21 (8): 879-86. Pubmed citation
- 5. Cicchiello LA, Hamper UM, Scoutt LM. Ultrasound evaluation of gynecologic causes of pelvic pain. Obstet. Gynecol. Clin. North Am. 2011;38 (1): 85-114, viii. doi:10.1016/j.ogc.2011.02.005 - Pubmed citation
Related Radiopaedia articles
Ultrasound - gynaecology
- ultrasound (introduction)
- acute pelvic pain
- chronic pelvic pain
- Mullerian duct anomalies
- ovarian follicle
- ovarian torsion
- pelvic inflammatory disease
- ovarian cysts and masses
- ovarian cyst
- corpus luteum
- hemorrhagic ovarian cyst
- ruptured ovarian cyst
- ovarian epithelial tumors
- granulosa cell tumors of the ovary
- paraovarian cyst
- polycystic ovaries
- ovarian hyperstimulation syndrome
- post-hysterectomy ovary
- fallopian tube