From the Guidelines
Hemorrhagic ovarian cysts less than or equal to 5 cm in premenopausal women require no further management, while those greater than 5 cm but less than 10 cm should be followed up in 8-12 weeks. According to the O-RADS US risk stratification and management system, a consensus guideline from the ACR Ovarian-Adnexal Reporting and Data System Committee 1, typical hemorrhagic cysts in premenopausal women that are less than or equal to 5 cm can be managed conservatively. For larger cysts, between 5-10 cm, follow-up ultrasound in 8-12 weeks is recommended to assess for resolution or change in size. Key considerations for management include:
- Cyst size: less than or equal to 5 cm requires no further management, while greater than 5 cm but less than 10 cm requires follow-up
- Patient age: hemorrhagic cysts are uncommon in postmenopausal women and may require further evaluation if present
- Symptoms: severe pain, fever, or other concerning symptoms may require immediate medical attention If a hemorrhagic cyst persists or enlarges, referral to a specialist or further imaging with MRI may be necessary, as suggested by the guideline 1. In postmenopausal women, any hemorrhagic cyst, regardless of size, should be further evaluated due to the low likelihood of such cysts occurring in this age group.
From the Research
Definition and Presentation
- A hemorrhagic ovarian cyst is a functional cyst resulting from bleeding into a follicular or corpus luteum cyst 2.
- It is a common gynaecological condition that often presents with acute pelvic pain, typically localized to one side, and may be accompanied by menstrual irregularities 2.
- Diagnosis is usually made via pelvic ultrasound, which typically reveals a complex cyst with characteristic features such as a reticular or 'lace-like' pattern 2.
Complications and Management
- While most haemorrhagic cysts resolve spontaneously and require only conservative management, complications such as rupture or significant hemorrhage may necessitate surgical intervention 2, 3.
- Ruptured hemorrhagic ovarian cysts can lead to hemoperitoneum, which can create a risk of further adverse events including hypovolemic shock 3.
- Surgical management, such as laparoscopic ovarian cyst wall removal, may be necessary to treat ruptured hemorrhagic ovarian cysts 3, 4.
Epidemiology and Risk Factors
- The epidemiology of ovarian cysts is unclear due to the lack of consistent reporting and a high likelihood of spontaneous resolution 5.
- Ovarian cysts are common in premenopausal women, and the incidence of ovarian cysts in postmenopausal women is around 18% over a 15-year period in the USA 5.
- Women on oral anticoagulation are at risk of ovarian vascular accidents, which can present as acute pelvic pain 4.
Diagnostic Considerations
- Pelvic ultrasound is the primary diagnostic tool for hemorrhagic ovarian cysts, and transvaginal ultrasonography (TVU) can be used for follow-up examinations 5.
- The American College of Obstetricians and Gynecologists (ACOG) recommends conservative management for simple ovarian cysts, and surgical intervention may be necessary for complicated cases 5.
Surgical Management
- Laparoscopic surgery is a minimally invasive approach that can be used to treat benign ovarian cysts, and it causes minimal activation of stress hormones 6.
- Minilaparotomy and laparotomy are other surgical approaches that can be used to treat ovarian cysts, but they may be associated with more postoperative pain and stress response 6.