What is the next step in managing a persistent simple ovarian cyst in a 42-year-old woman with Paroxysmal Supraventricular Tachycardia (PSVT) and Abnormal Uterine Bleeding (AUB) who has been taking ormeloxifene (centchroman) 60mg per week?

Management of Persistent Simple Ovarian Cyst in a Patient with PSVT and AUB on Ormeloxifene

Transvaginal ultrasound follow-up in 8-12 weeks is the most appropriate next step in management for this persistent simple ovarian cyst. 1, 2

Assessment of the Current Situation

• The patient is a 42-year-old premenopausal woman with a simple ovarian cyst that has persisted for more than 3 cycles while on ormeloxifene therapy for AUB 3
• Ormeloxifene (a selective estrogen receptor modulator) has been associated with ovarian cyst formation in approximately 28% of patients treated for abnormal uterine bleeding 3
• Simple cysts in premenopausal women, even when persistent, carry an extremely low risk of malignancy (<1%) if they maintain simple features 1, 2

Risk Stratification

• According to the O-RADS US risk stratification system, simple cysts without concerning features are classified as O-RADS 2 (almost certainly benign with <1% risk of malignancy) 1
• The presence of PSVT (Paroxysmal Supraventricular Tachycardia) does not significantly alter the management approach for ovarian cysts 1
• For premenopausal women with simple cysts >3 cm but <10 cm, follow-up ultrasound in 8-12 weeks is the standard recommendation 2, 1

Management Algorithm

1. First step: Transvaginal ultrasound follow-up in 8-12 weeks 1, 2

   • This allows time to determine if the cyst will resolve spontaneously
   • Timing should ideally be during the proliferative phase after menstruation 2

2. If cyst persists without change in characteristics after follow-up:

   • Continue surveillance with ultrasound at 6-month intervals for up to 1 year 1
   • As long as the cyst maintains simple features (unilocular, anechoic, smooth thin wall, no internal elements), continued observation is appropriate 1

3. If cyst shows concerning changes during follow-up:

   • Development of solid components, irregular walls, or papillary projections
   • Significant increase in size
   • Development of symptoms
   • Referral to gynecologist for further evaluation and possible surgical intervention 1

Medication Considerations

• Ormeloxifene and ovarian cysts:

  • Ovarian cyst formation is a known side effect of ormeloxifene therapy, occurring in approximately 28% of patients 3
  • Consider discussing with the patient whether to continue ormeloxifene therapy or switch to alternative treatment for AUB 3
  • Unlike combined oral contraceptives, there is no evidence that discontinuing ormeloxifene will hasten cyst resolution 3, 4

• PSVT considerations:

  • No specific contraindications to standard management of ovarian cysts in patients with PSVT 1
  • If surgical intervention becomes necessary, anesthesia consultation should be obtained 1

Important Caveats and Pitfalls

• Avoid unnecessary surgical intervention for simple cysts, as the vast majority are benign even when persistent 2, 5
• Do not rely on combined oral contraceptives to treat functional ovarian cysts, as evidence shows they do not hasten resolution 4
• Ensure high-quality imaging with transvaginal ultrasound by an experienced sonographer for accurate assessment 2, 6
• Remember that most simple cysts in premenopausal women will resolve spontaneously or remain unchanged without clinical significance 5
• If the cyst cannot be adequately visualized by ultrasound, MRI pelvis without and with contrast may be considered as an alternative imaging modality 1