Haemorrhagic Ovarian Cyst

A haemorrhagic ovarian cyst forms when bleeding occurs into a functional cyst, most commonly a corpus luteum cyst (follicular cysts bleed less often). It is common in women of reproductive age, typically in the luteal phase of the menstrual cycle, and is a leading cause of acute pelvic pain in premenopausal women.

Risk factors include anticoagulant therapy, bleeding disorders (von Willebrand disease, thrombocytopenia), ovulation induction, and trauma or intercourse. It is distinct from endometrioma, which contains old blood from endometriosis. Cysts are usually 3 to 8 cm and resolve spontaneously over 4 to 8 weeks, though rupture with haemoperitoneum can happen.

• Sudden onset unilateral lower abdominal or pelvic pain, often after intercourse or exercise, in the second half of the cycle; may follow a delayed period.
• Nausea, vomiting; a low grade fever is possible.
• Signs of haemoperitoneum in rupture: peritonism, shoulder tip pain, tachycardia, hypotension, and syncope.
• Adnexal tenderness and fullness on bimanual examination; peritoneal signs in rupture.
• Pain may mimic ectopic pregnancy, torsion, appendicitis and a tubo ovarian abscess.

• Urine or serum hCG to exclude ectopic pregnancy (always).
• Transvaginal ultrasound: a thick walled cyst with a "lace like" or "reticular" pattern of internal fibrin strands or a retracting clot (a solid appearing component with concave margins, no internal flow on colour Doppler), with a ring of fire at the periphery (corpus luteum), and posterior acoustic enhancement; free fluid with echoes in the pouch of Douglas with rupture. Doppler shows no flow within the clot, and flow is preserved in ovarian tissue (unless torsion).
• Full blood count (haemoglobin, haematocrit), group and save or crossmatch if haemodynamically unstable, and a coagulation screen if on anticoagulants or there is a history of bleeding.
• Follow up ultrasound in 6 to 12 weeks to confirm resolution; persistent cysts need further evaluation (MRI, and tumour markers CA-125 when the cyst is complex, in postmenopausal women).
• CT or MRI may be used when the diagnosis is uncertain.

• Stable patient with no haemoperitoneum or a small amount: conservative management with analgesia (paracetamol 1 g every 6 hours, ibuprofen 400 to 600 mg every 8 hours, with a short course of codeine or tramadol if needed), rest, and avoidance of strenuous activity and intercourse until resolved. Observation for 24 to 48 hours in hospital if there is significant pain or doubt, with serial haemoglobin and clinical review.
• Follow up ultrasound at 6 to 8 weeks. Resolution is expected in 8 to 12 weeks; no treatment is needed for resolved cysts.
• Oral contraceptive pills do not hasten resolution of existing cysts but prevent new cysts, and are used to suppress ovulation in recurrent cases (ethinylestradiol 30 micrograms with levonorgestrel 150 micrograms daily).
• Unstable patients (haemodynamic compromise, large haemoperitoneum, falling haemoglobin): resuscitation with intravenous crystalloid and blood, followed by laparoscopy for evacuation of haemoperitoneum and haemostasis (cystectomy with ovarian sparing technique, bipolar coagulation of the bleeding site, or suture of the ovary, with oophorectomy only when no ovarian tissue can be saved). Tranexamic acid 1 g intravenously can be given.
• Anticoagulated patients: reversal or temporary interruption of the drug may be needed according to bleeding severity; vitamin K, prothrombin complex concentrate or protamine, depending on the drug, with specialist input.
• Suspected torsion (severe pain, enlarged ovary with reduced Doppler flow): laparoscopy and detorsion, preserving the ovary.
• Rupture in a woman with a bleeding disorder requires correction of the disorder (desmopressin or factor replacement) in addition to surgery.
• Complete resolution is expected; recurrence is possible. Advise to return urgently for worsening pain, fainting or fever.