HEMORRHAGIC OVARIAN CYST

Hemorrhagic ovarian cysts   (HOCs) usually result from hemorrhage from the corpus luteum or other functional cyst. The radiographic features vary according to the age of the bleeding. They usually resolve within eight weeks. However, Dawasanté experts offer you a HERBAL TEA to treat hemorrhages caused by ovarian cysts.

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Clinical presentation

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

Pathology

HOCs usually develop as a result of ovulation. Secondary to a hormonal response, the stromal cells surrounding a maturing Graafian follicle become more vascular and, after expulsion of the oocyte, the Graafian follicle develops into a corpus luteum with an extremely vascularized and fragile granulosa layer, easily rupturing , forming a HOC. 

Radiographic features

Ultrasound

HOCs can have different appearances depending on the stage of development of the blood products and the clot. 

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

If a hemorrhagic cyst ruptures, other findings may be present.

Pelvic MRI

Relatively well-defined cystic lesion in association with the ovary. The characteristics of the signal may vary depending on the age of the bleeding.

• T1:   high signal
• T2:   high signal
  • The "T2 shade" suggests chronic blood products and is more typical of endometrioma
• the bleeding progresses from the center of the cyst and then spreads to the periphery (the center may show a stage of chronic bleeding while the periphery is more subacute)
• T1 C + (Gd):   no improvement

Treatment and prognosis

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

Cysts with the typical appearance of a hemorrhagic cyst should receive a follow-up ultrasound or MRI within 6 to 12 weeks if:

• the cyst is> 5 cm in diameter if the patient is premenopausal
  or
• any size of a hemorrhagic cyst if the patient is perimenopausal  ² 

In postmenopausal patients, surgical evaluation is warranted.

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

Differential diagnosis

Differential considerations on ultrasound include:

• cystic ovarian tumor: the most useful feature in distinguishing ovarian tumors from hemorrhagic cysts is
  • papillary projections
  • nodular septa
  • color Doppler flow in the cystic structure
• endometrioma
  • usually contains uniform low-level internal echoes with a hypervascular wall on Doppler ultrasound.
  • more often multiple
  • On MRI, the endometrioma shows a high signal in T1 and a low signal in T2 (shaded sign), although the appearance of hemorrhagic cysts overlaps.

The hemorrhagic ovarian cyst  (COH) is an adnexal mass formed due to the occurrence of bleeding in a follicular cyst or corpus luteum. Hemorrhagic cysts are commonly seen in clinical practice because hemorrhages from a cyst are usually painful, prompting the patient to see her doctor. They can present with varying symptoms and clinical signs ranging from no symptoms to acute abdomen.

HOCs are usually detected by grayscale ultrasound, but they are often misdiagnosed due to their varying ultrasound appearance. mimicking other organic adnexal masses. Most HOCs are functional, few can be neoplastic, but they are universally benign. Surgical intervention should be postponed in the management of COH, as most of them resolve spontaneously with follow-up. Therefore, safe clinical and ultrasound diagnosis should be attempted to avoid exposing the patient to unnecessary surgery.

cm in diameter, severe persistent abdominal pain, failure of spontaneous resolution of the cyst, masses that cannot be confirmed by ultrasound criteria, and ultimately complications such as rupture Surgical intervention may be indicated in cases of large cysts larger than 5 ovarian torsion.

Intracystic hemorrhage can occur in different types of functional cysts, against a background of acute pelvic pain. The appearance varies depending on the time between the bleeding and the time of the ultrasound. Appearance, therefore, can sometimes be confusing and the course over time is important for a positive diagnosis. It is sometimes necessary to resort to other explorations. The differential diagnosis in young women should be made with the ectopic pregnancy. The other diagnoses to be evoked will above all be endometrioma, tumor hemorrhage and torsion infarction.

FUNCTIONAL CYSTS

We have seen, it develops in the ovary every month a follicle 20 to 25 mm, which will break the 14 ^th day of the cycle to allow ovulation and transformation of the follicle into the corpus luteum. This phenomenon can be painful or exceed the usual sizes to reach 30 to 50 mm. The corpus luteum can also be large, hemorrhagic, and bleed in the stomach. Faced with this pain, the ultrasound will often reveal a cyst called “functional”, ie linked to the functioning of the ovary. These cysts are common, especially if you do not take the pill or if you are taking treatment to stimulate ovulation. Even though they are painful, these cysts should not be operated on. They go away spontaneously in two or three months. It is the ultrasound which will show their disappearance. If these cysts occur very frequently, the woman may be suggested to take a pill to block ovulation and avoid these problems.
Finally, functional cysts can be seen during pregnancy, or even after stopping menopause. They have particular characteristics on ultrasound and you have to know how to wait for their disappearance. It is only in case of persistence that we can discuss removing them by laparoscopy.

Organic cysts

This is a pathology and cysts that do not disappear but, on the contrary, can grow, twist, rupture. Their ultrasound characteristics can lead to the diagnosis of:

➢ Endometriotic cyst if it contains old blood. It is endometriosis;
➢ Dermoid cysts if they contain hair, teeth, fatty tissue. They develop from germ cells intended to donate eggs. These cysts are seen in young women and can be bilateral;
➢ Mucinous cysts that contain mucus, a fluid that runs like egg white;
➢ Serous cysts that contain a fluid like water.

This organic cyst must be operated either urgently if they cause ovarian torsion and acute pain, or cold. The operation will generally be performed laparoscopically. Only the cyst will be removed, leaving the ovary (cystectomy), especially as the woman is young. However, it is always necessary to be warned that an intervention planned in laparoscopic surgery can turn into open belly surgery (laparotomy), either for reasons of surgical technique (difficulty of dissection, bleeding, etc.) or because the diagnosis that had been mentioned during the laparoscopy is not that which one discovers by looking in the belly. We must never forget that if the radiologists have made a lot of progress (ultrasound, scanner, MRI) allowing the exact diagnosis to be made most often before the operation, the images are only the images and not always the reality that we discover in the womb. An apparently benign cyst can turn out to be malignant upon surgery.