Presentation
Acute onset pelvic pain. Irregular last couple of menstrual cycles.
Patient Data
Uterus is anteverted, measures 6.8 x 3.3 x 4.6 cm. (CC x AP x TR). Normal junctional zone. Normal endometrium with thickness of 13 mm. No focal lesions.
Right ovary is enlarged, measures 5.3 x 4.4 x 4.6 cm, 53 cc . It shows a thin smooth walled cyst of size 3.9 x 3.8 x 4.2 cm, 31 cc. It shows a fine internal septation within with dependent haemorrhagic sediment. The ovary is surrounded by moderate fluid in and around in pouch of Douglas with organising clot within.
Left ovary measures 4.4 x 2.0 x 1.7 cm, 7 cc. Normal in morphology with multiple normal sized follicles. No focal lesions.
No pelvic lymphadenopathy. Normal pelvic bones.
Urinary bladder is partially distended. No mural thickening or diverticuli. No calculi.
Visualised pelvic bowel loops are normal.
Case Discussion
This patient initially had an ultrasound done which identified a right para-ovarian complex cyst with features of haemorrhage. MRI was immediately done in view of cyst complexity and pain patient was undergoing. MRI not only helps in clearly identifying the cyst location ( ovarian vs para-ovarian), but also a detailed characterisation even in the absence of i.v. gadolinium contrast.
The dependent T2 hypointense haemorrhagic organising clot within the otherwise clear cyst and the evidence of organising clot in the free fluid in cul-de-sac confirms the diagnosis.
Cysts larger than 3 cm tend to be more symptomatic. Usually nothing more is warranted other than symptomatic management and follow up ultrasound after six to eight weeks to reassess the ovary.
A common differential to keep in mind is an ectopic pregnancy and asking for a pregnancy test in a sexually active woman is recommended.
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