The Common Vein Copyright 2008
Ovarian cysts (follicles) are normal evolutions of the menstrual cycle but in certain instances the cyst physiology is altered for unknown reasons, causing the cyst to enlarge unusually, rupture in a different manner, or become hemorrhagic, resulting in a pain syndrome.
A variety of situations manifest structurally including;
Follicular rupture – mittelschmerz
Enlargement of the follicle without rupture
Hemorrhage into the follicle/cyst without rupture
Hemorrhage into the follicle/cyst with rupture
Hemorrhage into an endometrioma simulating hemorrhage into a follicle usually without rupture
The common result is a pain syndrome that commonly occurs in midcycle.
Physiologically, during each menstrual cycle, a normally functioning ovary produces multiple cysts called graafian follicles. During the middle of the cycle, one cyst dominates and releases an egg. The follicle then becomes the corpus luteum, which can mature to measure up to 2 cm. If fertilization does not occur, the corpus luteum fibroses and is resorbed. If fertilization does occur, the corpus luteum matures and enlarges initially, but later shrinks during pregnancy. Ovarian cysts can be either follicular or luteal, and may respond to gonadotropins (including FSH).
Clinically the pain is different from mittelschmerz in that it may be more severe, prolonged, or with a different character. Sometimes the pain can simulate peritonitis. Most importantly from a diagnostic standpoint, is that a mass is usually felt on clinical examination.
The diagnosis is confirmed by ultrasound which usually shows a cystic mass in the adnexa. The cyst is either larger than the usual follicle, contains hemorrhage, or hemorrhage and large amounts of fluid are noted free in the pelvic cavity. When the patient presents with peritonism, a CTscan is usually indicated and in the case of a ruptured cyst, induration of the greater omentum or proximity of the bleed to the anterior peritoneum is recognized together with the hemorrhagic cyst. When an ovarian cyst ruptures, there is usually minimal blood loss.
Treatment depends on several factors. In most patients, the treatment is conservative with pain management being central to the care. Surgery may be indicated if the cyst does not go away after several periods or is enlarging. In a post menopausal woman, when complex cysts are identified cyclical disease is not a consideration and malignant disease must be suspected.
Add hemorrhagic cyst of the ovary have a fishnet appearance
ovary pain cysts discomfort nrmal variant enlarged normal follicles USscan ultrasound copyright 2008 Courtesy Ashley Davidoff MD 83269c.8s
ovary cyst hemorrhage clot fibrin pain midcycle USscan ultrasound Courtesy Ashley Davidoff MD copyright 2008 83279c02.8s
pain ovary mittelschmerz hemorrhage rupture right lower quadrant pain RLQ peritonism peritonitis CTscan Courtesy Ashley Davidoff MD copyright 2008 83268c02.8c
24480c01 27 year old female presented with lower abdominal pain pelvic pain ovary fx cyst cul de sac blood free blood hyperdense corpus luteum cyst greater ometum congested fx enhancing dx hemorhagic ovarian cyst CT scan C- CTscan Courtesy Ashley DAvidoff MD