What is the initial management approach for a patient with a hemorrhagic cyst or endometrioma in the Emergency Department (ED)?

From the Guidelines

The initial management of a hemorrhagic cyst or endometrioma in the Emergency Department (ED) should focus on pain control, hemodynamic stabilization, and appropriate disposition, with referral to a gynecologist for further evaluation and management if the cyst is greater than 5 cm or if the patient is postmenopausal 1. The management approach involves assessing the patient's symptoms, medical history, and performing a physical examination. For pain management, NSAIDs like ibuprofen (400-600mg every 6 hours) or naproxen (500mg initially, then 250mg every 6-8 hours) are first-line, with opioids reserved for severe pain unresponsive to NSAIDs. Key considerations in the ED include:

• Administering intravenous fluids if the patient shows signs of hypovolemia from significant bleeding
• Ordering laboratory tests including CBC, pregnancy test, and type and screen
• Using pelvic ultrasound as the preferred imaging modality to confirm diagnosis and assess for complications
• Considering admission if the patient is hemodynamically unstable, has severe pain uncontrolled by oral medications, shows signs of acute abdomen, or has evidence of cyst rupture with significant hemoperitoneum
• Immediate gynecological consultation is warranted for patients with suspected torsion, ruptured ectopic pregnancy, or those requiring surgical intervention, as well as for postmenopausal patients with a hemorrhagic cyst, as these should not occur in this population 1. Patients should be advised to return to the ED if they experience worsening pain, dizziness, syncope, fever, or heavy vaginal bleeding. For endometriomas, similar management principles apply, with consideration of the patient's age and the size of the cyst, as well as the risk of malignancy in postmenopausal patients 1.

From the Research

Initial Management Approach

The initial management approach for a patient with a hemorrhagic cyst or endometrioma in the Emergency Department (ED) involves assessing the patient's symptoms and medical history.

• The patient's symptoms, such as pain and bleeding, should be evaluated to determine the severity of the condition.
• The patient's medical history, including any previous diagnoses or treatments for endometriosis or ovarian cysts, should be reviewed.

Referral to OBGYN

In most cases, patients with hemorrhagic cysts or endometriomas should be referred to an Obstetrician and Gynecologist (OBGYN) for further evaluation and treatment 2, 3, 4.

• The OBGYN can perform a thorough examination and order diagnostic tests, such as ultrasound or MRI, to confirm the diagnosis and determine the size and location of the cyst or endometrioma.
• The OBGYN can also discuss treatment options with the patient, including surgical or medical management, and develop a plan for ongoing care.

Treatment Options

Treatment options for hemorrhagic cysts or endometriomas may include:

• Surgical removal of the cyst or endometrioma, which can provide symptom relief and reduce the risk of recurrence 3, 4, 5.
• Medical management, such as hormone therapy or pain management, which can help alleviate symptoms and improve quality of life 6, 4.
• Expectant management, which involves monitoring the patient's symptoms and adjusting treatment as needed, may be appropriate for asymptomatic patients with small, stable endometriomas 4.

Emergency Department Care

In the ED, patients with hemorrhagic cysts or endometriomas should receive:

• Pain management, such as nonsteroidal anti-inflammatory drugs (NSAIDs) or other analgesics, to alleviate symptoms 6.
• Stabilization and support, including fluid resuscitation and monitoring, if the patient is experiencing severe symptoms or complications.
• Referral to an OBGYN for further evaluation and treatment, as soon as possible.