Diagnostic Ultrasound - Abdomen and Pelvis

Hemorrhagic Cyst
Diagnoses: Female Pelvis
TERMINOLOGY
• Hemorrhage into cystic space in ovarian parenchyma
IMAGING
• Avascular hypoechoic ovarian "mass" with fine lacy
interstices
○ Lacy interstices due to fibrin strands → acute clot
• Majority resorb quickly and leave no sequela on 6-12 week
follow-up scans
• May appear as mixed echogenicity mass
○ Color Doppler shows clot is avascular
• Hemorrhagic cyst (HC) may rupture
○ Adjacent echogenic free fluid
TOP DIFFERENTIAL DIAGNOSES
• Endometrioma
○ Uniform low-level internal echoes from blood
breakdown products rather than lacy fibrin strands in
clot
KEY FACTS
○ Will not change much on follow-up
• Solid ovarian mass
○ Papillary projections more likely than angular fragments
• Torsion
CLINICAL ISSUES
• May be asymptomatic and incidentally seen, or present
with acute pelvic pain
• Majority resolve spontaneously
• Larger cysts more likely to cause acute pain/presentation
with acute abdomen
• Surgical treatment for severe symptoms
○ Ovarian torsion
○ HC rupture with significant intraperitoneal hemorrhage
DIAGNOSTIC CHECKLIST
• 90% of hemorrhagic ovarian cysts will exhibit fibrin strands
or retracting clot
(Left) In this patient
presenting with pelvic pain,
there is a septated cystic mass
in the left adnexa, which
appears anechoic ſt on
transabdominal grayscale US.
(Right) When further
evaluated with transvaginal
US, the typical hypoechoic and
lace-like echoes are seen with
retracted clot st, confirming a
hemorrhagic cyst in a
premenopausal patient. In
general, a hemorrhagic cyst <
5 cm does not require
additional follow-up US
according to the Society of
Radiologists in Ultrasound
(SRU) recommendations.
(Left) Endovaginal US shows a
hemorrhagic cyst (HC), with
areas of more echogenic clot
. These should not be
confused with papillary
projections in ovarian
neoplasms, which generally
have more convex margins and
internal vascularity. (Right)
Endovaginal grayscale US
shows typical areas of
reticular or lacy internal
echoes are due to fibrin
strands within the
hemorrhagic cyst ſt.
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