Hemorrhagic ovarian cyst

Last revised by Mina Sameh Rizk on 22 Oct 2023

Hemorrhagic ovarian cysts 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 8 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 ref:

  • 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: most of them show low signal and may have intermediate to high signal components 6

  • T1 fat sat: intermediate to 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 a chronic stage of hemorrhage while the periphery is more subacute)

  • T1 C+ (Gd): no enhancement

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 in a pre-menopausal patient

  • the cyst is any size in a peri-menopausal patient 2 

In a post-menopausal 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.

Endovaginal ultrasound may be deployed for specifically diagnosing hemorrhagic ovarian cysts amongst other adnexal masses, as internal architectural details are accurately visualized 4

Differential considerations on ultrasound include:

  • cystic ovarian neoplasm: the most helpful feature in distinguishing ovarian neoplasms from hemorrhagic cysts are

    • papillary projections

    • nodular septa

    • color Doppler flow in the cystic structure

  • endometrioma

    • typically contains uniform low-level internal echoes with a hypervascular wall on Doppler ultrasound

    • more often multiple

    • on MRI, endometriomas show high signal on T1 and low signal on T2 (shading sign), although there is overlap in appearance with hemorrhagic cysts

    • T2 dark spot sign is specific 7

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