67. Hemorrhagic cyst in a chronological and bone age 10 year old female with pre-menarchal vaginal bleeding

Abstract

<h3>Background</h3> A Hemorrhagic ovarian cyst forms due to bleeding into a corpus luteal cyst. Development of a hemorrhagic cyst assumes the prior occurrence of ovulation and a pathologic signaling error in the hypothalamic pituitary axis that prevent normal involution of the corpus luteum. While functional simple follicular cysts have been reported, hemorrhagic cysts have not been reported to date in girls far from menarche. Imaging of an ovary with complex features in a pre-menarchal girl raises the concern for ovarian neoplasm. This impacts decision making about whether expectant management is appropriate. The objective here is to present a unique case of a hemorrhagic cyst in a pre-menarchal girl as a cause of vaginal bleeding. <h3>Case</h3> TA is a 10-year old Tanner III pre-menarchal female with a bone age of 10, who presented with vaginal bleeding and an episode of intense pelvic pain with syncope. History, physical exam, and laboratory testing ruled out trauma, endocrine disorders and dermatology pathology. All blood tumor markers were negative, and her estradiol level was 19 pg/ml. Bone age of 10 ruled out early menstruation. The first ultrasound (US) showed a 5.4 × 4.6 × 3.3 cm right ovary containing a 4.7 cm cyst that appeared hemorrhagic. The second US, two weeks later, measured the cyst at 5.0 cm and stated there was a bit less debris. Both ultrasounds saw no evidence of torsion. An MRI done 7 weeks later showed a uterus that looked early pubescent and an unremarkable left ovary measuring 1.5 × 0.7 cm. The right ovary measured 4.1 × 3.1 × 4.2 cm and contained a 3.7 × 3.0 well circumcised cystic structure that demonstrated homogeneous internal T1 shortening with layering of T2 consistent with blood products similar to that seen in an endometrioma. It was lined with several sub centimeter daughter cysts with thin peripheral enhancement. After the MRI, surgical evaluation with vaginoscopy was offered to the parents, but was declined by them. Serial follow up ultrasounds showed a measurable decline in cyst size by 10 weeks and it was about 50% smaller by 20 weeks. Final US done 7 months after the initial US showed a normal right ovary measuring 1.6 × 1.5 × 0.7 cm. She never experienced any further vaginal bleeding. <h3>Comments</h3> Pre-menarchal females with complex ovarian cysts and vaginal bleeding have been diagnosed with torsion, germ cell tumors, and granulosa-theca cell tumors. In such cases, hemorrhagic cysts should now be on the differential. This case report also highlights that it can take months for regression of a hemorrhagic ovarian cyst in a pre-menarchal female during which time close monitoring for torsion and potential malignancy is paramount.