What is the best course of action for managing small left adnexal cystic lesions that could be either resolving hemorrhagic cysts or endometriomas?

Management of Small Left Adnexal Cystic Lesions: Understanding Hemorrhagic Cysts vs. Endometriomas

For small left adnexal cystic lesions measuring up to 1.7 cm that show T1 hyperintensity/T2 hypointensity and are decreasing in size, continued imaging surveillance with ultrasound and/or MRI is the most appropriate management approach. 1

Understanding Your MRI Findings

• The MRI shows small left adnexal cystic lesions (up to 1.7 cm) that are:
  • Demonstrating T1 hyperintensity and T2 hypointensity (characteristic of blood products) 1
  • Decreasing in size compared to previous imaging 1
  • Possibly representing resolving hemorrhagic cysts or endometriomas 1
  • Showing a punctate focus with T1 hyperintensity and mild diffusion restriction in the left ovary, likely related to blood products 1

What These Findings Mean

Hemorrhagic Cysts

• These are common, benign ovarian cysts that contain blood 1
• They typically show:
  • Internal reticular pattern (network-like appearance) 1
  • Concave margins where blood is retracting 1
  • No blood flow within the cyst on Doppler imaging 1
• Hemorrhagic cysts usually resolve on their own within 8-12 weeks 1

Endometriomas

• These are cysts formed from endometrial tissue growing outside the uterus 2
• They contain old blood products that give them their characteristic appearance 3
• They tend to persist longer than hemorrhagic cysts 1
• They can range from 1-3 cm (small) to 20+ cm (large) 2

Recommended Management Approach

For Likely Hemorrhagic Cysts

• If these are hemorrhagic cysts:
  • Since they are small (less than 5 cm) and decreasing in size, they likely require no further management 1
  • However, follow-up is recommended to confirm resolution 1

For Possible Endometriomas

• If these are endometriomas:
  • They typically require surveillance even when small 1
  • Annual follow-up is generally recommended for endometriomas 1

Recommended Follow-up Protocol

• Ultrasound is the first-line imaging modality for follow-up 1, 4

  • Transvaginal ultrasound provides the best visualization 1
  • Color Doppler should be included to evaluate for any developing vascularity 1

• MRI can be used if:

  • The lesions cannot be adequately assessed by ultrasound 1
  • There are concerning changes in appearance 1
  • MRI with contrast is superior for evaluating any developing enhancing components 1

Important Considerations

• The small size (1.7 cm) and decreasing trend are reassuring features 1
• The presence of free fluid in the pelvis is common and often physiologic 1
• The risk of malignancy in classic benign-appearing lesions is less than 1% 1

Follow-up Timeline

• For likely hemorrhagic cysts: Follow-up ultrasound in 8-12 weeks to confirm resolution 1
• For possible endometriomas: Initial follow-up in 8-12 weeks, then annual surveillance if stable 1
• If the lesions persist or enlarge, additional evaluation by a specialist may be warranted 1

Common Pitfalls to Avoid

• Don't confuse retracted blood clots with solid components - blood clots will not show blood flow on Doppler 1
• Remember that endometriomas can change in appearance over time, sometimes mimicking other conditions 3
• Avoid unnecessary interventions for small, stable or decreasing lesions that appear benign 1