Hemorrhagic Ovarian Cyst - 5 Interesting Facts, Causes, Symptoms, Diagnosis & Treatment

Hemorrhagic Ovarian Cyst in short

A hemorrhagic ovarian cyst is formed from an ovarian cyst or follicle that bleeds into itself, typically at the time of ovulation.
Hemorrhagic ovarian cyst (HOC) is an adnexal mass formed because of occurrence of bleeding into a follicular or corpus luteum cyst.
Hemorrhagic cysts are commonly seen in clinical practice because hemorrhage into a cyst is usually painful, triggering the patient to consult her physician.
They can present with variable clinical symptoms and signs ranging from no symptoms up to acute abdomen.

Synonym

Hemorrhagic corpus luteal cyst

ICD-10CM CODES
N83.20	Unspecified ovarian cyst

Epidemiology & Demographics

Predominant Sex & Age

Women of reproductive age.

Peak Incidence

Reproductive age.
Hemorrhagic cysts are almost exclusively encountered in menstruating and ovulating adolescent females.

What are the Risk Factors?

Reproductive age, ovulation

Physical Findings & Clinical Presentation

•Asymptomatic or acute onset of lower abdominal pain
•Rupture of this cyst may cause intraabdominal bleeding, peritoneal signs
•Can occur during pregnancy

What causes Hemorrhagic Ovarian Cyst?

When an ovarian cyst or follicle ruptures, bleeding into the ruptured cyst wall causes irritation and pain.

1. Ovulation (Functional Cyst Formation)

During a normal menstrual cycle, the ovary forms a follicle that may rupture and release an egg.
If bleeding occurs into the follicle or corpus luteum after ovulation, a hemorrhagic cyst forms.

2. Vascular Fragility or Rupture

The corpus luteum is highly vascular. Minor trauma or hormonal stimulation can cause small blood vessels to rupture, leading to internal bleeding into the cyst.

3. Hormonal Imbalance

Increased estrogen or gonadotropin stimulation can lead to excessive follicle growth and cyst formation prone to bleeding.

4. Trauma or Physical Activity

Strenuous exercise, sexual activity, or abdominal trauma can cause a fragile cyst to rupture and bleed.

5. Anticoagulant Therapy or Clotting Disorders

Patients on blood thinners or with bleeding disorders (e.g., hemophilia, von Willebrand disease) are more likely to develop hemorrhagic cysts due to impaired clotting.

6. Reproductive Age

Hemorrhagic cysts are most common in premenopausal women, especially between 20–40 years, due to active ovulatory cycles.

7. Polycystic Ovary Syndrome (PCOS)

PCOS may lead to irregular ovulation and persistent cysts, increasing the chance of hemorrhagic events, though it’s not a direct cause.

What are the Differential Diagnosis

Ectopic pregnancy
Endometrioma
Tubo-ovarian abscess
Neoplasm
Dermoid cyst
Ovarian torsion
Appendicitis
Pelvic inflammatory disease
Diverticulitis
Urolithiasis
Adnexal masses

Workup – How is Hemorrhagic Ovarian Cyst diagnosed?

Hemorrhagic Ovarian Cysts are commonly detected by gray-scale ultrasound, but they are often misdiagnosed due to their variable sonographic appearance; mimicking other organic adnexal masses.

Laboratory Tests

CBC, urinalysis
Serum human chorionic gonadotropin (hCG) or urine pregnancy test

What are the Imaging Studies?

Transvaginal ultrasound (US): The sonographic appearance of hemorrhagic cysts is highly variable. Most hemorrhagic cysts have a thin outer wall, demonstrate posterior acoustic through-transmission, and can be variable in size but often measure 3 to 3.5 cm in diameter. Fine, reticular septations resembling a fishnet pattern are a common finding on US. ¹ ^, 2
Pelvic MRI.

How is Hemorrhagic Ovarian Cyst treated?

Acute General treatment

•Observation, pain management, supportive care ³
1Ibuprofen, Tylenol, heating pads
•Surgical intervention is rarely needed

Disposition

•If stable can be discharged home
•If vitals unstable or if concern for ongoing bleeding either through clinical worsening or decreasing hemoglobin/hematocrit, may require diagnostic laparoscopy

Referral

•General gynecology
- 1.Symptomatic cysts greater than 6 cm in premenopausal patients
•Gynecology oncologists
- 1.Image findings concerning for cancer ³

Pearls & Considerations

If the diagnosis of hemorrhagic cyst is uncertain, a 6-wk follow-up US can be obtained.
Hemorrhagic cysts change throughout the menstrual cycle and typically will resolve or decrease in size at follow-up.

Prevention

Hormonal contraceptives can decrease ovarian cyst formation. ⁴

Most ovarian cysts occur unnoticed and symptomless, however serious complications such as ovarian torsion and cystic rupture can happen. Dermoid cysts and cystadenomas can become large and cause the ovary to move out of position increasing the chances of the ovary becoming twisted; this can lead to a complete lack of blood flow to the ovary.

Many ovarian cysts do not rupture, and amongst those that do, many ruptures without symptoms. However, at times, a ruptured ovarian cyst can lead to severe pain and hemoperitoneum, a possibly life-threatening condition. This occurs when cystic rupture leads to a release of fluid and blood into the abdomen or pelvis. Hemoperitoneum can result in hypovolemic shock, organ failure, organ damage, and even death.

Summary

Ovarian cysts can also be hemorrhagic.
Hemorrhagic ovarian cyst (HOC) rupture can release blood and fluid into the surrounding abdomen and pelvis, presenting several risks to the patient including hemoperitoneum, less blood flow to vital organs, and sepsis.
If the bleeding is severe, the patient may need to undergo laparoscopic surgery to control the bleeding or remove the cyst, as well as treatment to replace lost blood.
Despite the relatively high incidence of ovarian cysts, particularly in premenopausal women, cyst rupture may on occasion present painfully and require surgical intervention to resolve.
Particularly in the case of ruptured hemorrhagic ovarian cysts, resulting hemoperitoneum can create a risk of further adverse events including hypovolemic shock; proper identification and management of such cases are therefore critical.

Sources

Hemorrhagic ovarian cysts: Clinical and sonographic correlation with the management options
Mantecon O, George A, DeGeorge C, McCauley E, Mangal R, Stead TS, Peplinski B, Ganti L. A Case of Hemorrhagic Ovarian Cyst Rupture Necessitating Surgical Intervention. Cureus. 2022 Sep 20;14(9):e29350. doi: 10.7759/cureus.29350. PMID: 36284799; PMCID: PMC9583282.https://pmc.ncbi.nlm.nih.gov/articles/PMC9583282/
Abbas A.M., et al.: Hemorrhagic ovarian cysts: clinical and sonographic correlation with the management options . Middle East Fertil Soc J 2016; 21 (1): pp. 41-45.
Jain K.A., et al.: Sonographic spectrum of hemorrhagic ovarian cysts . J Ultrasound Med 2002; 21 (8): pp. 879-886.
Ross E.K., Kebria M.: Incidental ovarian cysts: when to reassure, when to reassess, when to refer . Cleve Clin J Med 2013; 80 (8): pp. 503-514.
Grimes D.A., et al.: Oral contraceptives for functional ovarian cysts . Cochrane Database Syst Rev 2014; 4: pp. CD006134.

Hemorrhagic Ovarian Cyst – 5 Interesting Facts, Causes, Symptoms, Diagnosis & Treatment