Images in GYN Ultrasound

Telltale sonographic features of simple and hemorrhagic cysts

First of 4 parts on cystic adnexal pathology

Author and Disclosure Information

Myriad sonographic features characterize cystic adnexal pathology. Here, three cases of benign, resolving cysts, including when to follow-up.



Pelvic ultrasonography remains the preferred imaging method to evaluate most adnexal cysts, given its ability to accurately characterize their various aspects:

  • Simple cysts are uniformly hypoechoic, with thin walls and no blood flow on color Doppler (FIGURE 1).
  • Hemorrhagic cysts produce lacy/reticular echoes and clot with concave margins
    (FIGURE 2).
  • Mature cystic teratomas produce hyperechoic lines and dots, sometimes known as “dermoid mesh,” acoustic shadowing, and a hyperechoic nodule (FIGURE 3).
  • Endometriomas produce diffuse, low-level internal echoes and a “ground glass” appearance (FIGURE 4).

In the first of this 4-part series on the sonographic features of cystic adnexal pathology, we focus on simple and hemorrhagic cysts. In the following parts we will highlight:

  • mature cystic teratomas and endometriomas (Part 2)
  • hydrosalpinx and pelvic inclusion cysts (Part 3)
  • cystadenoma and ovarian neoplasia (Part 4).

An earlier installment of this series entitled “Hemorrhagic ovarian cysts: one entity with many appearances” (May 2014) also focused on cystic pathology.

Figure 1: Simple cyst

A simple cyst in a 32-year-old patient.

Figure 2: Hemorrhagic cyst

Note the lacy/reticular internal echoes and lack of internal blood flow on color Doppler.

Figure 3: Cystic teratoma

This cyst exhibits the “dermoid mesh” and hyperechoic lines that correspond with hair.

Figure 4: Endometrioma

Note diffuse low-level internal echoes (“ground glass”) and no “ring of fire” on color Doppler.

Characteristics of simple cysts
A simple cyst typically is round or oval, anechoic, and has smooth, thin walls. It contains no solid component or septation (with rare exceptions), and no internal flow is visible on color Doppler imaging.

Levine and colleagues observed that simple adnexal cysts as large as 10 cm carry a risk of malignancy of less than 1%, regardless of the age of the patient. In its 2010 Consensus Conference Statement,1 the Society of Radiologists in Ultrasound recommended the following management strategies for women with simple cysts:

Reproductive-aged women

  • Cyst <3 cm: No action necessary; the cyst is a normal physiologic finding and should be referred to as a follicle.
  • 3–5 cm: No follow-up necessary; the cyst is almost certainly benign.
  • 5–7 cm: Yearly imaging; the cyst is highly likely to be benign.
  • >7 cm: Additional imaging is recommended.

Postmenopausal women

  • <1 cm: No follow-up necessary; the cyst is almost certainly benign.
  • 1–7 cm: Yearly imaging; the cyst is likely to be benign.
  • >7 cm: Additional imaging is recommended.

Characteristics of hemorrhagic cysts
These cysts can be quite variable in appearance. Among their sonographic features:

  • reticular (lacy, cobweb, or fishnet) internal echoes, due to fibrin strands
  • solid-appearing areas with concave margins
  • on color Doppler, there may be circumferential peripheral flow (“ring of fire”) and no internal flow.

In its 2010 Consensus Conference Statement, the Society of Radiologists in ­Ultrasound recommended the following management strategies1:

Premenopausal women

  • ≤5 cm: No follow-up imaging unless the diagnosis is uncertain.
  • >5 cm: Short-interval follow-up ultrasound (6–12 weeks).

Recently menopausal women

  • Any size: Follow-up ultrasound in 6–12 weeks to ensure resolution.

Later postmenopausal women

  • Any size: Consider surgical removal, as the cyst may be neoplastic.

Share your thoughts on this article! Send your Letter to the Editor to Please include your name and the city and state in which you practice.

Next Article:

ACIP votes on incorporating 9-valent HPV vaccine into recommendations

Related Articles