haemorrhagic ovarian cyst

Hemorrhagic ovarian cysts (HOCs) usually result from hemorrhage into a corpus luteum or other functional cyst. Radiographic features are variable depending on the age of the hemorrhage. They typically resolve within eight weeks.

Clinical presentation

Patients may present with sudden-onset pelvic pain, pelvic mass, or they may be asymptomatic and the hemorrhagic ovarian cyst is an incidental finding .  A hemorrhagic or a ruptured ovarian cyst is the most common cause of acute pelvic pain in an afebrile, premenopausal woman presenting to the emergency room . They can occur during pregnancy.


Hemorrhagic ovarian cysts typically develop as a result of ovulation. Secondary to a hormone response the stromal cells surrounding a maturing Graafian follicle become more vascular, and after the oocyte has been expelled, the Graafian follicle develops into a corpus luteum with a highly vascular and fragile granulosa layer, which ruptures easily, forming a hemorrhagic ovarian cyst .

Radiographic features


Hemorrhagic ovarian cysts can have a variety of appearances depending on the stage of evolution of the blood products and clot.

  • lace-like reticular echoes or an intracystic solid clot
    • a fluid-fluid level is possible.
  • thin wall
    • clot may adhere to the cyst wall mimicking a nodule, but has no blood flow on Doppler imaging
    • retracting clot may have sharp or concave borders, mural nodularity does not
  • posterior acoustic enhancement
    • may be less noticeable if harmonics or compounding is used
  • there should not be any internal blood flow
    • circumferential blood flow in the cyst wall is typical

If there is rupture of a hemorrhagic cyst, other findings may be present.


Relatively well defined cystic lesion in association with the ovary. Signal characteristics can vary depending on the age of the hemorrhage.

  • T1: high signal
  • T2: high signal
    • "T2 shading" is suggestive of chronic blood products and is more typical of endometrioma
  • hemorrhage evolves from the center of the cyst and then extends peripherally (i.e. the center may show chronic stage of hemorrhage while the periphery is more subacute)
  • T1 C+ (Gd): no enhancement

Treatment and prognosis

Most hemorrhagic cysts resolve completely within two menstrual cycles (8 weeks).

Cysts with a typical appearance of a hemorrhagic cyst should lead to follow-up ultrasound or MRI imaging in 6-12 weeks if:

  • the cyst is > 5 cm in diameter if the patient is pre-menopausal
  • any size of a hemorrhagic cyst if the patient is perimenopausal  

In the postmenopausal patient, surgical evaluation is warranted.

A cystic structure that does not convincingly satisfy the criteria for a benign cyst cannot be considered a cyst and should be evaluated with a short interval follow-up ultrasound or MRI

Differential diagnosis

Differential considerations on ultrasound include:

  • cystic ovarian neoplasm: the most helpful feature in distinguishing ovarian neoplasms from hemorrhagic cysts are
    • papillary projections
    • nodular septae
    • color Doppler flow in the cystic structure
  • endometrioma
    • typically contains uniform low-level internal echoes with a hypervascular wall on Doppler ultrasound.
    • more often multiple
    • on MRI, endometrioma shows high signal in T1 and low signal in T2 (shading sign), although there is overlap in appearance with hemorrhagic cysts

See also

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