KEY FACTS
Terminology
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Hemorrhage into functional cyst in ovarian parenchyma
Imaging
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Avascular hypoechoic ovarian “mass” with fine, lacy interstices due to fibrin strands
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Majority resorb quickly and leave no sequela on 6- to 12-week follow-up US scan
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May appear as mixed echogenicity mass depending on age of blood
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Color Doppler shows clot is avascular
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Adjacent echogenic free fluid suggests ruptured hemorrhagic cyst (HC)
Top Differential Diagnoses
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Endometrioma
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Uniform, low-level internal echoes from blood breakdown products
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Will not change much on follow-up
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Solid ovarian mass
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Internal vascularity on color Doppler
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Ovarian/adnexal torsion
Clinical Issues
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May be asymptomatic or symptomatic with acute pelvic pain
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Larger HCs more likely to cause acute pain
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Majority resolve spontaneously
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Rarely, may be associated with significant intraperitoneal hemorrhage requiring surgical treatment
Scanning Tips
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Look for stretched ovarian parenchyma around HC
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HC will be avascular on color Doppler
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Small clot along cyst wall may mimic mural nodule but will be avascular
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Follow-up US in 6-12 weeks if > 5 cm to ensure resolution
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HC < 5 cm does not require follow-up imaging
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on transabdominal grayscale US.
. Stretched ovarian parenchyma 
around the periphery is also characteristic of a hemorrhagic cyst.
due to the acute nature of a hemorrhagic cyst. Fibrin strands 
and stretched ovarian parenchyma 
around the periphery are helpful clues this is a hemorrhagic cyst.
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