What is the management plan for a patient with a 37*45 mm right ovarian hemorrhagic cyst found on ultrasound (USG)?

Management of 37×45 mm Right Ovarian Hemorrhagic Cyst

For a premenopausal woman with a typical hemorrhagic ovarian cyst measuring 37×45 mm, follow-up ultrasound in 8-12 weeks is recommended; if the cyst persists or enlarges, refer to a gynecologist, ultrasound specialist, or obtain MRI for further characterization. 1, 2

Initial Assessment Required

Before determining management, confirm the following ultrasound features to ensure this is a classic hemorrhagic cyst 2, 3:

• Reticular pattern (fine thin intersecting lines representing fibrin strands) 2
• Retracting clot (avascular echogenic component with angular, straight, or concave margins) 2
• Peripheral vascularity only with absence of internal blood flow on color Doppler 2
• Thin, smooth wall (<3 mm thickness) 3
• No solid components or papillary projections 3

Menopausal Status Determines Management

If Premenopausal:

Since this cyst is >5 cm but <10 cm, schedule follow-up ultrasound in 8-12 weeks, ideally during the proliferative phase (first half of menstrual cycle after menstruation). 4, 1, 2

• No immediate intervention needed if the patient is hemodynamically stable and pain is manageable 2, 5
• The vast majority of hemorrhagic cysts resolve spontaneously 5, 6
• At follow-up, if the cyst has resolved or is decreasing in size, no further management is required 2
• If the cyst persists, enlarges, or changes morphology (develops vascular components or solid areas), refer to gynecologist or obtain pelvic MRI with contrast 4, 1, 2

If Postmenopausal:

Hemorrhagic cysts should not typically occur in postmenopausal women; immediate referral to ultrasound specialist, gynecologist, or MRI is required regardless of size. 1, 2

• Postmenopausal status significantly increases concern for underlying malignancy 1
• Further characterization is mandatory before conservative management 2

O-RADS Risk Classification

This cyst falls into O-RADS 2 category (almost certainly benign, <1% malignancy risk) if it demonstrates classic hemorrhagic features 4, 3. However:

• Any cyst ≥10 cm automatically becomes O-RADS 3 (1-10% malignancy risk) regardless of appearance 3
• Presence of solid components, thick irregular septations, or papillary projections would elevate to O-RADS 4 or 5, requiring immediate gynecologic referral 4, 3

Red Flags Requiring Immediate Referral

Refer immediately to gynecology or gynecologic oncology if any of the following are present 1, 3:

• Solid components with internal vascularity (color score ≥4) 3
• Papillary projections (≥4 projections indicates O-RADS 5) 3
• Ascites or peritoneal nodules 1
• Rapid growth between imaging studies 1
• Hemodynamic instability or signs of rupture with significant hemoperitoneum 7, 6

Common Pitfalls to Avoid

• Do not perform fine-needle aspiration of ovarian cysts—this is contraindicated 2
• Do not assume all cysts in premenopausal women are functional—follow appropriate guidelines for persistent masses 2
• Do not operate without proper characterization unless there is hemodynamic compromise 6
• Do not underestimate size—cysts ≥10 cm have substantially higher cancer risk and require more aggressive evaluation 3
• Ensure color Doppler is performed to evaluate for internal vascularity, which would suggest a solid component rather than hemorrhagic content 4, 2, 3

If Surgical Intervention Becomes Necessary

If the cyst persists and requires surgery 4, 1:

• General gynecologist can manage O-RADS 2-3 lesions 4
• O-RADS 4 lesions warrant consultation with gynecologic oncology prior to removal 4
• O-RADS 5 lesions should be directly referred to gynecologic oncology 4
• Only 33% of ovarian cancers are appropriately referred initially, yet oncologist involvement is the second most important prognostic factor after stage 3