What is the treatment for a ruptured ovarian cyst?

Treatment of Ruptured Ovarian Cysts

Conservative management is the standard treatment for most ruptured ovarian cysts, with surgical intervention reserved only for cases with hemodynamic compromise, large hemoperitoneum, or diagnostic uncertainty. 1

Initial Assessment

• Evaluate vital signs with particular attention to:

  • Diastolic blood pressure (dBP ≤70 mmHg indicates higher risk) 2
  • Signs of hemodynamic instability

• Imaging assessment:

  • Ultrasound is the first-line diagnostic tool 3
  • Assess for:
    • Size of the cyst
    • Amount of free fluid in pelvis (≥5.6 cm depth suggests need for surgery) 2
    • Complex features suggesting hemorrhage

Treatment Algorithm

Conservative Management (First-Line)

Conservative management is appropriate for 80-85% of patients with ruptured ovarian cysts 1 and includes:

• Pain management:

  • NSAIDs for pain control
  • Acetaminophen as an alternative

• Monitoring:

  • Serial vital signs
  • Hemoglobin levels if significant bleeding is suspected
  • Follow-up ultrasound in 8-12 weeks for persistent symptoms 4

• Activity modification:

  • Rest until acute pain resolves
  • Gradual return to normal activities

Indications for Surgical Intervention (15-20% of cases)

Surgery is indicated when any of these factors are present 1, 2:

1. Hemodynamic instability (particularly dBP ≤70 mmHg)
2. Large hemoperitoneum (≥5.6 cm depth on imaging)
3. Large ovarian cysts (>5 cm)
4. Diagnostic uncertainty or suspicion of malignancy
5. Failure of conservative management with worsening symptoms

Surgical Approach

When surgery is necessary:

• Laparoscopy is the preferred approach 5

  • Allows for:
    • Evacuation of hemoperitoneum
    • Control of bleeding
    • Cyst excision with ovarian preservation when possible

• Laparotomy may be required in cases of:

  • Severe hemodynamic instability
  • Technical limitations for laparoscopy
  • Suspected malignancy

Prevention of Recurrence

For patients with recurrent ruptured ovarian cysts:

• Hormonal suppression of ovulation (typically combined oral contraceptives) 3
• Regular follow-up imaging for persistent cysts

Special Considerations

• For patients on anticoagulants with cyst hemorrhage:

  • Temporary discontinuation for 7-15 days after hemorrhage onset 4
  • Balance risk of recurrent hemorrhage against thromboembolism risk

• For patients on antiplatelet therapy:

  • Consider interruption of aspirin for 3 days following hemorrhage 4
  • Continue P2Y12 inhibitor if on dual antiplatelet therapy

Follow-up Care

• Follow-up ultrasound in 8-12 weeks for persistent symptoms 4
• No scheduled follow-up imaging necessary for completely resolved simple cysts ≤3 cm 4
• Annual ultrasound surveillance for persistent cysts 4

The combined approach of initial conservative management with careful monitoring and selective surgical intervention based on specific clinical indicators provides optimal outcomes for patients with ruptured ovarian cysts.