Hemorrhagic ovarian cysts: One entity with many appearances

FOREWARD

Steven R. Goldstein, MD, CCD, NCMP
Professor, Department of Obstetrics and Gynecology, New York University School of Medicine; Director, Gynecologic Ultrasound; and Co-Director, Bone Densitometry, New York University Medical Center, New York

This is the inaugural offering in a new series, titled Images in Gyn Ultrasound. It is interesting and important that Dr. Michelle Stalnaker and Dr. Andrew Kaunitz have chosen hemorrhagic ovarian cysts as their debut topic.

Realize that since the vaginal probe was introduced in the 1980s, our entire specialty has had to undergo a learning curve--just as individuals will have a learning curve. In the early days of transvaginal ultrasound, an imager often provided a differential for such masses, along the lines of “compatible with hemorrhagic cyst, endometrioma, dermoid…cannot rule out neoplasia.” Today, however, with better understanding, and especially with the addition of color flow Doppler, very often a definitive diagnosis can be made.

These “hemorrhagic cysts” are nothing more than bleeding into a corpus luteum at the time of ovulation−the more blood that collects before tamponade or clot stops its accumulation, the larger the “cyst” can become. As the cyst goes through a “maturation” process and undergoes clot retraction and clot lysis, the variable internal echo patterns presented in the following images are possible, but there will ALWAYS only be peripheral blood flow as evidenced by the morphologic appearance of the vascular distribution. See video.

Study these images carefully as they are very representative of the many faces of the hemorrhagic corpus luteum.

Hemorrhagic ovarian cysts: One entity with many appearances

Michelle L. Stalnaker, MD
Assistant Professor and Associate Program Director, Obstetrics and Gynecology Residency, Department of Obstetrics and Gynecology at the University of Florida College of Medicine–Jacksonville

Andrew M. Kaunitz, MD
University of Florida Research Foundation Professor and Associate Chairman, Department of Obstetrics and Gynecology at the University of Florida College of Medicine–Jacksonville. Dr. Kaunitz is a member of the OBG Management Board of Editors.

Hemorrhagic cysts are normal in ovulatory women, usually resolving within 8 weeks. They can be quite variable in appearance, however, and can be confused with ovarian endometriomae. Presenting characteristics can include:

• reticular (lacy, cobweb, fishnet) internal echoes due to fibrin strands
• a solid-appearing area with concave margins
• on Color Doppler: circumferential peripheral vascular flow (“ring of fire”), with no internal flow

Management. With respect to hemorrhagic cysts, the Society of Radiologists in Ultrasound 2010 Consensus Conference Statement indicates:

• For premenopausal women:
  • No follow-up imaging needed unless there’s an uncertain diagnosis or if the cyst is larger than 5 cm
  • Cyst size > 5 cm; short-interval follow-up ultrasound is indicated (6-12 weeks)

• For recently menopausal women:
  • Follow-up ultrasound in 6 to 12 weeks to ensure resolution of the initial findings

• For later postmenopausal women:
  • Cyst possibly neoplastic; consider surgical removal